Other·September 10, 2020

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 a facility reported incident (FRI). FRI number: CA00659851 Representing the Department of Public Health: Health Facilities Evaluator Nurse # 36331 The inspection was limited to the specific FRI investigated and does not represent the findings of a full inspection of the facility. A deficiency was issued for FRI number CA00659851.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to identify and evaluate accident risks and hazards, and did not ensure two staff assistance was provided during Hoyer lift (mechanical lift to transfer resident) transfer, 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: SPMB11 Facility ID: CA910000074 If continuation sheet 1 of 5 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: _______________ 055540 (X3) DATE SURVEY COMPLETED 08/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SANTA MONICA HEALTH CARE CENTER 1320 20th 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 per policy, for one of three sampled Residents (Resident 1). For Resident 1, who had a high fall risk and required full staff performance for transfer, per the comprehensive assessment, the facility failed to develop an initial plan of care for the Hoyer lift with interventions to address the resident's identified risk for falls and failed to implement fall care plan interventions to provide specific approaches to assist Resident 1 to prevent accidents and injuries. These deficient practices resulted in Certified Nurse Assistant 1 (CNA 1) attempted to solely transfer Resident 1 from wheelchair to bed. During the transfer Resident 1 slid off the Hoyer lift sling, landed on the floor, and screamed out. Resident 1 sustained a laceration to left eyebrow, left upper arm, was transferred to the General Acute Care Hospital (GACH) and diagnosed with multiple facial fractures and a fractured left nose. Findings: A review of Resident 1's admission record indicated Resident 1 was re-admitted to the facility on 10/6/18 with diagnoses including altered mental status (a disruption in how your brain works that causes a change in behavior) and unsteadiness on feet. A review of Resident 1's care plan for fall, dated 1/28/19, indicated Resident 1 was at risk for falls/injury due to a balance problem. Nursing interventions included to encourage/remind resident to ask for help when needed if able, provide assistance as identified in transfer and mobility, establish resident physical function, capabilities, and provide measures/approaches to assist resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SPMB11 Facility ID: CA910000074 If continuation sheet 2 of 5 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: _______________ 055540 (X3) DATE SURVEY COMPLETED 08/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SANTA MONICA HEALTH CARE CENTER 1320 20th 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 A review of the Minimum Data Set (MDS-an assessment and care planning tool) dated 7/30/19 indicated Resident 1 had clear speech, limited ability to express ideas and wants, and responds adequately to simple direct communication only. The MDS indicated Resident 1 required full staff performance for transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position) bed mobility, and personal hygiene. A review of Resident 1's Fall Risk Data Collection, dated 8/2/19, indicated a high-risk score of 14, due to medications, gait and balance, and regularly incontinent (having no or insufficient voluntary control over urination or defecation). A review of Resident 1's Progress Notes dated 10/17/19, indicated at 8:05 p.m. Licensed Vocational Nurse (LVN 1) heard screaming and went to Resident 1's room. LVN 1 found Resident 1 lying on the floor, on his left side with his head touching the floor. Certified Nurse Assistant 1 explained she was using a Hoyer Lift with the assistance of Resident 1's wife, while transferring Resident 1 from the wheelchair to the bed. Resident 1 slid off the Hoyer lift sling and landed on the floor. The Progress Note indicated upon body assessment Resident 1 sustained laceration on the left temporal (temple area) and left upper arm. LVN 1 called 911 (an emergency activation system). The Progress Note indicated at 8:20 p.m., Resident 1 was transferred the General Acute Care Hospital (GACH) for further evaluation, per physician's order. A review of the GACH's left facial and head computerized axial tomography (CT scanFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SPMB11 Facility ID: CA910000074 If continuation sheet 3 of 5 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: _______________ 055540 (X3) DATE SURVEY COMPLETED 08/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SANTA MONICA HEALTH CARE CENTER 1320 20th 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 allows doctors to see inside your body) dated 10/17/19, indicated multiple acute facial fractures, an acute mildly displaced fracture (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) of the left maxillary sinus walls (located below the cheeks, above the teeth and on the sides of the nose) and left zygomatic arch (cheek bone) with associated bony fragments posteriorly and extending into the left pterygopalatine fossa (communicates with the nasal and oral cavities), and an acute fracture of the lateral orbital and inferior orbital walls, and left nasal fracture. A review of the GACH's Progress Note dated 10/18/19, indicated Resident 1 fell from Hoyer lift, arrived by ambulance from facility with laceration to left eyebrow and right elbow, admitted to hospital for further evaluation. A review of the GACH's Discharge Summary dated 10/19/19 indicated Resident 1 had plastic surgery evaluation on left facial fractures and the recommendation was conservative treatment. No surgical intervention was recommended and was discharged back to skilled facility. During an interview with Family Member (FM 1), on 10/31/19, at 1:35 p.m., FM 1 stated she sometimes witnessed one or two people using the Hoyer Lift to transfer Resident 1 before the fall incident, due to short staffing. FM 1 further stated herself and her mother did not have Hoyer lift training prior to the incident. During an interview with the Director of Nursing (DON), on 10/31/19, at 2:45 p.m., the DON stated the Hoyer lift was a two-person transfer. The DON further stated a family member was not staff. The DON confirmed and stated the family member did not receive a Hoyer lift FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SPMB11 Facility ID: CA910000074 If continuation sheet 4 of 5 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: _______________ 055540 (X3) DATE SURVEY COMPLETED 08/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SANTA MONICA HEALTH CARE CENTER 1320 20th 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 training. A review of Resident 1's clinical record indicated there was no care plan for the use of a Hoyer lift. During an interview with the DON on 3/19/2020, at 2:45 p.m., the DON stated Resident 1 should have had a care plan regarding the use of the Hoyer lift to maintain safety of Resident 1 and staff. The facility's policy and procedures titled, "Resident Transfer; Mechanical lift," dated 8/15/2002, indicated Manufacturer's instructions and recommendations should always be followed, including the number of staff needed for a safe transfer. Mechanical lifts require at least a 2-person assist. All staff should be in-serviced on use of a mechanical lift and demonstrate his/her competency with the device to his/her supervisor. The facility's policy and procedures titled, "Comprehensive Plan of Care," dated 11/15/2001, indicated the comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SPMB11 Facility ID: CA910000074 If continuation sheet 5 of 5