Other·August 3, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of two complaints during an Abbreviated survey. Complaint number: CA00582805 and CA00582038 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 38309 The inspection was limited to the specific two complaints investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of complaint investigation CA00582038. No deficiencies were written as a result of complaint investigation CA00582805.

F622 SS=D Transfer and Discharge Requirements CFR(s): 483.15(c)(1)(i)(ii)(2)(i)-(iii)

F622 §483.15(c) Transfer and discharge§483.15(c)(1) Facility requirements(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SIXL11 Facility ID: CA910000073 If continuation sheet 1 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 07/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE would otherwise be endangered; (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. (ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. §483.15(c)(2) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. (i) Documentation in the resident's medical record must include: (A) The basis for the transfer per paragraph (c) (1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SIXL11 Facility ID: CA910000073 If continuation sheet 2 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 07/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE receiving facility to meet the need(s). (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. (iii) Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident. (B) Resident representative information including contact information (C) Advance Directive information (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals; (F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the transfer or discharge was appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility and verify all special instructions or precautions for ongoing care, was appropriate, including: 1. Failure to ensure Resident 1 was discharged after treated and the pneumonia (lung infection) had resolved. 2. Failure to ensure Resident 1 was assisted to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SIXL11 Facility ID: CA910000073 If continuation sheet 3 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 07/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE find alternatives to afford remaining in the facility and to apply for MediCal benefits. 3. Failure to ensure the facility's policy on Transfer and Discharge by not permitting Resident 1 to remain in the facility and not transfer or discharge except under the circumstances including, transfer/discharge is appropriate because the resident's health has improved sufficiently so that the resident no longer needs the services provided by the facility. As a result, Resident 1's respiratory condition deteriorated requiring emergency transfer to General Acute Care Hospital 1 (GACH 1) Emergency Department (ED) for shortness of breath and lower leg swelling and was hospitalized. Findings: On 4/24/18 an unannounced visit was made to the facility to investigate a complaint regarding Resident 1's Transfer and Discharge Rights A review of the Admission Record indicated Resident 1 was admitted to the facility, on 2/19/18, with diagnoses including ovarian cancer, pneumonia and pulmonary embolism (blockage in one of the pulmonary arteries in your lungs). A review of the Minimum Data Set (MDS standardized assessment and care planning tool) dated 2/26/18, indicated Resident 1 was cognitively intact, able to communicate needs, required extensive assistance with bed mobility, transfer and ambulation. A review of the physical therapy (PT) Discharge Summary, dated 3/19/18, indicated Resident 1 walked 150 feet approximately one FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SIXL11 Facility ID: CA910000073 If continuation sheet 4 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 07/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to two weeks prior, but at the time of discharge from PT Resident 1 was walking 20-40 feet A review of the Physician's Discharge Summary, dated 3/28/18, indicated Resident 1 had cough for three days with mild intermittent shortness of breath; chest x-ray showed possible pneumonia (lung infection) and elevated white blood cells (WBC) 13,000 per microliter, which was indicative of infection (normal range 4,500 to 11,000). A review of the Interdisciplinary Team (IDT group of professionals from different healthcare fields), notes dated on 3/23/18, indicated Resident 1 was private pay and she expressed being unable to afford the payment for her stay at the facility and it was best for her to be discharged to a Board and Care (B&C). A review of the Discharge Summary indicated Resident 1 was discharged to a lower level of care, a Board and Care (B&C) facility on 3/28/18. The discharge was necessary due to Resident 1's improved health and no longer needed the facility's services. A review of the facility's Post Discharge Plan of Care indicated a completion date of 3/24/18 prior to Resident 1's discharge dated 3/8/18. During an interview with Certified Nursing Assistant 1 (CNA 1), on 4/24/18, at 2:40 p.m., she stated Resident 1 was continent but had accidents is could not make it to the bathroom on time. CNA 1 stated Resident 1's legs were swollen. During an interview with the Social Services Director (SSD) on 4/24/18, at 3:40 p.m., she stated Resident 1 was discharged because there was a physician's discharge order. When asked about the follow up for Resident 1's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SIXL11 Facility ID: CA910000073 If continuation sheet 5 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 07/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE discharge, SSD stated she called the B&C and no one answered and did not do further follow up. A review of the ED Record Report from GACH 1, dated 3/29/18, indicated Resident 1 had shortness of breath, leg swelling, and a heart rate of 131 beats per minute (normal 60-100 bpm). The History of Present Illness form dated 3/29/18, indicated Resident 1 had lower extremities (pitting) edema (accumulation of fluid in the feet and lower legs) measured as four plus [4+ equivalent to 6 to 8 millimeters (mm) indentation when applying pressure to the swollen area (such as by depressing the skin with a finger) and over 30 seconds to rebound]. During an interview with business office staff on 4/24/18 at 4:30 p.m., he stated Resident 1's friend stated she did not have access to Resident 1's account and could not find Resident 1's checks. On 5/29/18 at 2:30 p.m., during an interview, the Rehabilitation Director stated Resident 1 was able to walk about 20-40 feet and towards the end Resident 1 did not make progress. On 5/29/18 at 3:40 p.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) stated he went through her medications with Resident 1 on the day of her discharge, but he did not know the place where Resident 1 went. On 5/29/18 at 5:15 p.m., during an interview, the Director of Nursing (DON) she stated she heard from Resident 1's physician that Resident 1 was admitted to hospital after her discharge. A review of the facility's policy and procedure titled Transfer and Discharge revised on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SIXL11 Facility ID: CA910000073 If continuation sheet 6 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055711 (X3) DATE SURVEY COMPLETED 07/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HEALTH CARE CENTER 1321 Franklin St Santa Monica, CA 90404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 4/29/04 indicated the facility must permit each resident to remain in the facility and not transfer or discharge the resident from the facility except under the following circumstances including: transfer/discharge is appropriate because the resident's health has improved sufficiently so that the resident no longer needs the services provided by the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SIXL11 Facility ID: CA910000073 If continuation sheet 7 of 7