Other·October 19, 2017

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 Department of Public Health during the investigation of an Entity Self Reported incident (ERI). ERI #: CA00538447- Substantiated Representing the Department of Public Health: Evaluator ID #: 36394, RN, HFEN Evaluator ID #: 34396, RN, HFEN The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Highest Scope: L

F225 SS=B INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, 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: R4P411 Facility ID: CA910000075 If continuation sheet 1 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 2 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record reviews, the facility failed to timely report an injury of unkown source, for one of 35 sampled residents, (Resident 1), who was found unresponsive on the floor, face down, lying in a pool of blood, which was oozing from her forehead and resulted in death, to the State Agency, and to thoroughly investigate the injury. The State Survey agency recieved the report report 12 days later after the incident had occured. This resulted in a delay in ascertaining what caused the resident's injury and placed other residents at risk for harm. Findings: On 6/7/2017 at 11:40 a.m., an unannounced visit was made to the facility to investigate an incident involving Resident 1, who was found on the floor, face down, next to the corner of the night stand in her room, unresponsive, lying in a pool of blood that was oozing from her head. The resident was pronounced dead by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 3 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 the Emergency Response Team on 5/26/2017. The Director of Nursing (DON) and the assistant Administrator were both informed of the nature of the visit. On 6/7/17 at 11:40 a.m., during an interview the DON stated on 5/26/17 at 7:35 a.m., she received a text message on her cell phone from Licensed Vocational Nurse (LVN 1) stating the facility was in an emergency situation. According to the DON, the content of the message was "Resident 1 was found on the floor face down, unresponsive, next to her night stand, with a lot of blood oozing from her head." The DON stated when she arrived at the facility, the local police department was in there conducting an investgation with a Certified Nursing Attendant (CNA 1) who found the resident on the floor. The DON stated the resident was unresponsive, with a lot of blood oozing from her head, blue in color, cold and stiff. The DON stated upon arrival to the facility, she observed the resident's right siderail was down. She further stated the siderail may not have been raised while the resident was in bed asleep and that may have caused her to fall out of bed. The DON stated LVN 2 told her the resident was last observed at approximately 5 a.m., sitting on her bed looking into the night stand's upper drawer. The DON also stated he told her the resident was observed sitting on her bed, changing from her night gown to street clothes. The DON was asked if a resident is found unresponsive and had been pronounced dead what would she do? DON stated she will report immediately to the police, Ombudsman and the Depatment of Health or the State Department. When asked if she investigated or reported the death of Resident 1 to the Department of Health? The DON stated a verbal investigation was done with the facility's staffs and a text message was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 4 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 sent to the administrator. She stated as a patient advocarte, she should have reported the incident to the Health Department. According to the admission record, Resident 1 was an 89 year old female who was admitted to the facility on 11/18/14, with diagnoses that included dementia (a decline in mental ability severe enough to interfere with daily life). A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/25/17 indicated Resident 1 had decreased ability to make self understood or to understand others, had impaired cognitive skills for daily decision making, needed minimum assistance from staff for transferring, dressing, toilet use and used assistive device such as cane for ambulation. The MDS further revealed the resident was incontinent (loose control) of bowel and bladder functions. On 6/12/2017, at 12: 43 p. m., during and interview with the administrator, he stated he received a text message on his cell phone from the DON on 5/26/2017, at 8: 00 a.m. stating resident 1 was found on the floor, unresponsive, in a pool of blood, oozing from her head and was pronounced dead by the paramedics. The Administrator was asked why it took him eight (8) business days before he notified the Department? The administrator stated the police department was already notified, and the facility was still conducting its own investigation, and the probable cause of death was known because resident fell and hit her head at the corner of the night stand next to her bed and died. When a copy of the facility's investigative report was requested, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 5 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 Admenistrator stated he does not have a documented report but verbal investigation was conducted with the facility's staff. He further stated he was still waiting for the police report before notifying the Depatment of Public Health. When asked if he was aware of the protocol for investigating and reporting incident of unusual occurrences? He stated yes! and he while Resident 1's who fell in his facility and died was not thoroughtly investigated and reported to the Department of health in a timely manner. On 6/7/2017 at 1: 45 p. m., during an interview with CNA1 stated she went to resident 1's room on 5/26/2017 at 7: 15 a. m., opened resident 1's privacy curtain to offer her milk and coffee because resident always drink coffee and milk in the morning. She stated resident was found on the floor with her head raised on the metal bar part of the over bed table, Resident was not breathing and she was laying in a pool of blood that was oozing from her head. She said she ran out out the resident room and yelled LVN 1' name. She futher stated she had been instructed by the director of staff development not to touch any resident who is down but to leave and get help from licensed nurses.When CNA 1 was asked who else did she report to? CNA 1 stated she did not report it to the Ombudsman. A follow up question was asked , who is a mandetory repoter? CNA 1 stated everyone. When asked why did she not report? CNA 1 did not answere. On 6/7/2017 at 2: 07 p. m., during an interview with LVN 1, he stated on 5/26/27, CNA 1 called him by his name at the top of her voice "karim... come ... come" around 7: 10 a. m. or 7:15 a. m., he was not sure of the time. He said, he ran from the nursing station to room FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 6 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 3C and LVN2 who worked night shift followed him to the room. He said, while in the room, both found Resident 1 on the floor unresponsive, face down by the side of her bed with pool of blood, no sign of live (unresponsive). LVN 1 said he shook the resident toe but she was cold and clammy looks blue. LVN 1 was asked if he reported to the Ombudman office or to the department of Health? LVN 1 stated he did not report to any authorized legal agency except to the DON and the police. When LVN 1 was asked who is a mandetory reporter, he responded everyone. He further stated he should have reported to the department of health but failed to do so. On 6/9/2017 at 10 a. m. to 12 p.m., LVN 2 stated on 5/26/2017 at 7:05 a. m, CNA 1 who worked morning shift found Resident 1's on the floor when she went to the room to offer her breakfast but unfortunately, found the resident unresponsive laying on the floor in a pool of blood, oozing from the right corner of her head in the proximity of the night stand metal plate that was attached to the drawer as a hand holder. LVN2 was asked when resident is found down unresponsive and breathless what should be done? LVN 2 he checked resident's vital signs. when asked if blood pressure machine was used? When asked what the vital sign readings were, LVN 1 was unable to provide and staed Blood pressure cuff/ machine was not used it as throught his visual observation. He further stated resident sustained 3 by 3 centimeter laceration (skin tear) on her right forehead. When asked if measurement was done with calibrated tape, he said he used his visual sight for the measurement. He stated 911 was called and police department was notified. When asked if the department of state was notified? He stated no, except for the incident report that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 7 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 was done on 5/26/2017. LVN 2 stated he is aware of been a mandetory reporter, regreted while he did not inform the department of stated. On 6/9/2017 at 1:10 p. m., during an interview with CNA 4 stated he should have called the office of the Omudsman to report resident's death because that is what the director of staff development taught during abuse training and in- service. On 6/14/17 at 3:20 p.m., during an interview with the DON stated she asked the assistant Administrator if the incident involving Resident 1 had been reported to the DPHS, but she was told not to worry, that Administrator said he reported the incident to the police. When DON was asked who is a mandetory reporter? DON said everyone. When asked why did she not report? DON had no comment. On 6/15/2017, at 4:20 p. m., a question wasto the administrator if that was the proper way of investigation and reporting or is thgat what is on the facility's policy? Administrator stated unusual occurances shall be report by the facility within twenty (24) hours either by telephone to the local heath officer and the Department of State. Administator further stated he knew he did not follow the facility's policy in reporting and investigating a sentil incident (death) that happened in his facility on 5/26/2017. He stated he promised to correct the deficient practice and prevent and protect the current residents in the facility. According to an undated facility's policy and procedures titled "Accident and Incident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 8 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 Report" indicated, the facility shall accurately and completedly report, investigate and analyze all accidents/incident or unusual occurences (death from unnatural causes, safety or health of patients, personnel or vitors) invoving resident, visitors or volunteer by the facility withing twenty-four (24), either by telephone to the local health officer and the department of health and human services.

F281 SS=L SERVICES PROVIDED MEET PROFESSIONAL STANDARDS CFR(s): 483.21(b)(3)(i)

F281 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on interview and record reviews, the facility failed to ensure cardiopulmonary resuscitation (CPR [an emergency procedure performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 9 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 and breathing]), was provided for one of 35 sampled residents (1). The facility failed to; 1. Ensure Resident 1, who was a Full code status (when the resident requests in writing that CPR and other lifesaving measures be given) was not provided with CPR when she was found unresponsive by a Certified Nursing Assistants (CNA 1) Even though Licensed Vocational Nurse (LVN 1) wrote in a deleration that "on the first instance noted resident is moving," when lying on the floor, face down in a pool of blood, CPR was not initiated, 2. Ensure CNA 1 and LVN 1, provided CPR immediately when Resident 1 was found unresponsive, deprived the resident the possibility of survival, 3. Ensure their CPR training was not contrary to American Heart Association (AHA) CPR guidelines by advising unlicensed staff not to start CPR when a resident was found unresponsive, and 4. Ensure CNA 1, CNA 2, CNA 3, CNA 4 and the Director of Nursing (DON) were able to demonstrate knowledge regarding the proper protocol for the initiation of CPR. These deficient practices also had the potential to adversely affect 22 of 35 residents identified on Full code status and placed them at risk for potential harm or loss of lives. Because of the facility's failure to; ensure CPR was provided in accordance to the resident's request, the facility's implementation of a policy which contradicts AHA CPR guidelines, along with the nursing staffs failure to demonstrate knowledge of professional standards regarding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 10 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 proper CPR guidelines and protocols, an Immediate Jeopardy (IJ) was called on 6/13/2017 at 2:07 p.m. The Administrator, assistant Administrator and the DON were informed of the IJ. Findings: a. On 6/7/2017 at 11:40 a. m., an unannounced visit was made to the facility to investigate an Entity Reported Incident involving Resident 1 who was found on 5/26/17 at around 7 a.m., unresponsive in the room, lying on the floor. The resident was found on her right side next to the corner of the night stand, lying in a pool of blood oozing from her head. The resident was pronounced dead by the emergency response team (EMS) upon arrival on the same day at 7:20 a.m. The Director of Nursing (DON) and the assistant Administrator were advised of the visit. During an interview with the DON and the assistant Administrator on 6/7/2017 at 11:40 a.m., the DON stated Resident 1 may have hit her head on the night stand which had a sharp metal handles located on each drawer or she hit her head on the over bed table that was next to the head of the bed. On the same day at 11:55 a.m., the DON stated she received a text message on her phone, sent by LVN 1, who was the 11-7 nurse, indicating the facility had an emergency. The DON stated she arrived at the facility at 7:35 a.m., and met two police officers who were questioning CNA 1, who worked the 7-3 shift, regarding the resident's cause of death. The DON stated she saw the resident lying on the floor unresponsive, bluish in color, cold and stiff, in a lot of blood that had been oozing from her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 11 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 head. The DON stated the coroner's office (inquire into and determine the circumstances, manner, and cause of all violent, sudden, or unusual deaths) was informed by the police department about the resident's death. The DON stated the resident's right side rail was down and she might had dropped from the bed to the floor in her sleep. The DON stated CPR was not initiated by the staff, but 911 (emergency dispatch) was called. When questioned if the staff had been trained how to initiate CPR, the DON stated "Yes." The DON stated the staff were aware of the resident's Full code status. She further stated the facility's protocol was for CNAs not to touch any of the resident's who were on the floor, instead they had to leave and obtain help from a licensed nurse. According to the admission records Resident 1 was a 89 year old female, who was admitted to the facility on 11/18/14. The resident had diagnoses that included dementia (a decline in mental ability severe enough to interfere with daily life), major depressive disorder (a brain disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and late effect of stroke (a decreased supply of blood to the brain). A review of the POLST, dated 11/18/14, indicated Resident 1 was Full code status which included CPR and full treatment to prolong life by all medically effective means. A review of the Minimum Data Set (MDS), a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 12 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 standardized assessment and care screening tool, dated 2/25/17, indicated Resident 1 had decreased ability to make self understood or to understand others, had impaired cognitive skills for daily decision making, needed minimum assistance from staff for transferring, dressing, toilet use, and used assistive device such as cane for ambulation. The MDS further revealed the resident was incontinent (loose control) of bowel and bladder functions. A review of the licensed nurses progress notes, dated 5/26/17 at 2:30 a.m., documented by LVN 2, 11-7 nurse, indicated Resident 1 was in bed asleep, and was offered assistance to the bathroom but did not need any assistance at that time. The notes also indicated at 7 a.m., (4 1/2 hours later) LVN 2 was called to the resident's room. The resident was found unresponsive, lying on her right side with her head on the proximity of the night stand corner. The notes indicated on examination, the resident was not responsive or breathing, there was no pulse or no breathing. The notes indicated the resident was lying in moderate amount of blood which was oozing from the right side of her head which measured 3 by 3 centimeters laceration (a deep cut or tear in skin). The notes indicated 911 was called and upon examination, they pronounced the resident had expired. There was no documented evidence indicating CPR was initiated by any of the facility staff. On 6/7/17 at 12:30 p.m., during an interview with the Administrator, stated on 5/26/17 at approximately 8 a.m., he received a text message on his phone from the DON indicating Resident 1 was found on the floor next to the night stand, unresponsive, in a pool of blood oozing from her head. The Administrator FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 13 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 stated the resident was pronounced dead by the paramedics. The Administrator was asked what was their CPR protocol when a resident was found unresponsive, he stated the staff should check the clinical records to determine if the resident was a Full code, then to get the crash cart and initiate CPR. On 6/7/2017 at 1:45 p.m., in an interview with CNA 1, stated she went to Resident 1's room on 5/26/2017 at approximately 7:15 a.m., opened the resident's privacy curtain to offer her milk and coffee because she drank them in the morning. CNA 1 stated she found the resident face down on the floor with her face on the metal part of the over bed table, lying in a pool of blood oozing from her head. CNA 1 stated she ran out of the room and shouted LVN 1's name. When asked what else did she do, CNA 1 stated she continued to pass the breakfast trays for the rest of the residents. When asked what is the protocol when a resident was found unresponsive, CNA 1 stated she was instructed by the Director of Staff Development (DSD) not to touch the resident, instead leave the resident and get help from a charge nurse. CNA 1 also stated she did not observe LVN 1 or LVN 2 obtain the vitals or perform CPR on the resident. On 6/7/2017 at 2:07 p.m., during an interview with LVN 1, stated on 5/26/27 at 7:10 a.m. or 7:15 a.m., but not sure of the exact time, CNA 1 called him by his name at the top of her voice " k.... come ... come. " LVN 1 stated he ran to Resident 1's room. LVN 1 stated LVN 2 followed him and found the resident on the floor unresponsive, face down next to her bed, lying in a lot of blood that was oozing from the head. LVN 1 stated he shook the resident's leg while saying, "are you ok" but the resident did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 14 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 respond. LVN 1 instructed LVN 2 to call the EMS while he stayed with the resident. When asked how long he stayed with the resident, LVN 1 stated he was not sure. LVN 1 stated after 911 was called, LVN 2 came back to the room and stayed with the resident so he could resume his morning assignments. When asked why he did not initiate CPR, LVN 1 stated CPR was not provided because the resident was unresponsive and did not have a pulse (a rhythmical throbbing of the arteries as blood is propelled through them, typically as felt in the wrists or neck). LVN 1 further stated when he felt the resident with his gloves, the resident was cold, blue and stiff. When asked if he was aware of resident's Full code status, LVN 1 responded yes but there was "no signs of life." During a review of LVN 1's declaration notes, dated 6/7/17 it revealed when CNA 1 shouted for assistance, both LVN 1 and LVN 2 found Resident 1 on the floor, lying face down in a pool of blood. The notes by LVN 1 revealed "On the first instance noted resident is moving." LVN 1 wrote he stayed with the resident but instructed LVN 2 to call 911. Even though LVN 1 noted the resident "is moving," there was no indication her vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate and blood pressure that indicate the state of a patient's essential body functions) were obtained and no documentation as to CPR had been initiated. On 6/9/2017 at 10 a.m., during an interview with LVN 2, stated on 5/25/17 at 11 p.m., Resident 1 was observed in her room lying in bed. On the same dat at 1 a.m., he saw the resident in bed. At 3 to 3:30 a.m., he offered the resident a trip to the bathroom but she refused and stated she was ok. LVN 2 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 15 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 the last time he did rounds around 5 a.m., he saw the resident sorting magazine from her night stand top drawer. LVN 2 stated at 7:05 a.m., CNA 1 who worked morning shift found the resident on the floor when she went to the room to offer her breakfast. LVN 2 stated CNA 1 found the resident unresponsive lying on the floor, in a pool of blood, oozing from the right corner of her head in the proximity of the night stand metal drawers handles. When asked what was the facility's protocol when a resident was found unresponsive, LVN 2 stated he would check the resident's vital signs, call a code blue (requiring a team to rush to the specific location and begin immediate resuscitative efforts), call for help, review the medical records to ensure if the resident was a do not resuscitate (no CPR) or a Full code and then start CPR. When questioned why he did not initiate CPR when he found the resident unresponsive, LVN 2 stated CPR was not immediately initiated due to the color on her face indicating she had expired for quite sometime. When asked how he knew that, LVN 2 stated there was no sign of circulation and the resident's body was cold and stiff. LVN 2 stated at 7:30 a.m., he was instructed by LVN 1 to call 911 but when the paramedics arrived at 7:35 a.m., they pronounced the resident dead. On 6/9/2017 at 1:10 p.m., during an interview with CNA 4 stated when the round was made on 5/26/2017 at 11:30 p.m., he saw Resident 1 in bed. CNA 4 stated but the last time he saw the resident was at 4 a.m., as she was sitting on the bed with her legs on the floor. CNA 4 stated he left the facility at 6:55 a.m., and was not aware of the incident involving the resident. CNA 4 stated the resident usually used the restroom by herself and even dressed herself but used a cane when walking. CNA 4 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 16 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 the resident held objects like bed or over the bed table when attempting to go from sitting to standing position. On 6/12/2017 at 6:02 a.m., during an interview with CNA 4 when asked what was the facility protocol when a resident was found unresponsive, CNA 4 stated he was instructed by DSD not to touch the resident and go and get help from the charge nurse. When asked how to perform CPR, CNA 4 stated "twenty chest compressions, give oxygen and remove tight clothes and open the mouth." Because of the facility's failure to; 1. Ensure Resident 1, who was a Full code status (when the resident requests in writing that CPR and other lifesaving measures be given) was not provided with CPR when she was found unresponsive by a Certified Nursing Assistants (CNA 1) and a Licensed Vocational Nurse (LVN 1), while lying on the floor, face down in a pool of blood, 2. Ensure CNA 1 and LVN 1, provided CPR immediately when Resident 1 was found unresponsive, deprived the resident possibility of survival, 3. Ensure their CPR training was not contrary to American Heart Association (AHA) CPR guidelines by advising unlicensed staff not to start CPR when a resident was found unresponsive, and 4. Ensure CNA 1, CNA 2, CNA 3, CNA 4 and the Director of Nursing (DON) were able to demonstrate knowledge regarding the proper protocol for the initiation of CPR. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 17 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 These deficient practices also had the potential to adversely affect 22 of 35 residents identified on Full code status and placed them at risk for potential harm or loss of lives an IJ was called. The facility provided an acceptable plan of correction which included the following: 1. CPR Course provided for CNAs. 2. A lecture held to demonstrate and return demonstration CPR 3. The Inservice consisted of immediate response to someone/resident found unresponsive on the floor 4. Life and Safety Guide- included eight signs of abuse, immediate response for unresponsive resident, codes for disasters-which will be placed on the back of name tags. 5. Skilled testing checklist from American Heart Association (AHA)-Demonstrated with return demonstration which includes but not limited to immediate cardiopulmonary resuscitation. Handouts which include skill description 6. Emergency crash cart-Placed an order for crash cart for Unit. The immediate jeopardy was lifted on June 15, 2017, at 5:15 p.m. The facility administrator and director of nursing was notified. b. During an interview on 6/12/17 at 7:05 a.m., Restorative Nurse Assistant (RNA 1) was asked when what to do when a resident was found unresponsive, RNA 1 stated to call the License Vocational Nurse (LVN 1), or the Director of Nursing (DON), do not touch or move them. RNA 1 stated that was what they told us to do. When asked to explain how they performed CPR, RNA 1 stated " push ten times FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 18 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 on chest bring head back pinch nose blow thru the mouth three to four times and repeat. " During an interview on 6/12/17 at 7:25 a.m., CNA 1 was asked what to do when a resident was found unresponsive, stated call the charge nurse, check the resident to see if alive and call 911. CNA 1 further stated the Designated Staff Developer (DSD) told them not to move or touch the resident. When asked to explain how they performed CPR, CNA 1 stated " chest compression five times two breaths and repeat. " During an interview on 6/12/17 at 7:45 a.m., CNA 2 was asked what to do when a resident was found unresponsive, CNA 2 stated call for help, not allowed to move the resident instructed by DSD to call 911. When asked to explain how to perform CPR, CNA 2 stated " ten chest compressions listen for breath five breaths and repeat. " During an interview on 6/12/17 at 7:50 a.m., CNA 3 was asked what to do when a resident was found unresponsive, CNA 3 stated call the charge nurse and do not move the resident. When asked to explain how to perform CPR, CNA 3 stated " pressing hands spread apart not sure ten compressions and three breaths and repeat. " On 6/12/2017 at 8: 10 a.m., during an interview with the Director of Nursing (DON) when asked what to do a resident was found unresponsive, stated to assess for pulse and respiration, check full code order, initiate CPR and call for help. When asked if DON knew how to perform CPR, DON stated she would if performed by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 19 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 one staff they had to give 100 compression and two breaths but if performed by two staff, 60 compressions and one breath would be given. DON was asked how did the nursing staff determine which resident was DNR (to withhold CPR) or Full code status during an emergency. The DON stated the nursing staff would have to look in the resident' medical records to check for a code status before performing CPR. The DON was asked what would happen if a resident did not have a code status in their medical records, DON stated the resident was automatically considered a Full code status. The DON further stated if a licensed nurse was unable to locate a resident's code status the nurse would call the family and instruct another licensed nurse to perform CPR. Due to the facility's failure to ensure LVN 1, LVN 2 and CNA 1 responded immediately to begin CPR for Resident 1 who was unresponsive, in need of immediate emergent care and was full code. The , and to ensure CNAs 1, 2, 3, 4 and DON were properly trained in when and how to initiate CPR according to professional standards which entails to respond to life threatening medical emergency situations in a timely and effective manner. An immediate jeopardy was called on 6/13/2017 at 2:07 p.m., with the Administrator, Assistant administrator and the Director of Nursing. On 6/15/2017 at 4:55 p.m., the administrator, DON and assistant Administrator presented an acceptable plan of correction action which consisted of the following: LVN 1, LVN 2, CNA 1 who did not respond immediately to begin CPR for Resident 1 were provided one-to-one inservice by the DON on emergency procedures in accordance with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 20 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 facility's policy. The insevice began immediately on 6/13/2017 and was completed on 6/15/2017, which will be repeated on a bimonthly basis. CNAs 1, 2, 3, 4 and DON were retrained on how to properly respond when a resident was found unresponsive. The staff also obtained a new CPR Cards. The admission licensed nurse will verify and clarify the residents code status, license nurses will conduct daily rounds to assess each resident's condition and making sure the proper code status identification was in place. On 6/15/2017 at 5:15 p.m., the Surveyor team met with the Administrator, assistant Administrator and the DON, informed them the IJ was lifted. c. During an interview and review of the clinical records for 35 sampled residents indicated 22 residents had a Full code status. The DON on 6/12/2017 at 12 p.m., stated the facility does not have a crash cart (supplies for CPR) and promised to order one and educate staff on how to use it. A review of the employees files indicated the following employees possed the cards but did not perform CPR on Resident 1 when she was found unresponsive, face down on the floor in a pool of blood; LVN 1 CPR Card issued on 3/1/2016 with a recommenced renewal date 3/20/2018 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 21 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 LVN 2 CPR Card issued on 2/17/2016 with a recommenced renewal date 2/20/2018 CNA 1 CPR Card issued on 3/1/2016 with a recommenced renewal date 3/20/2018 CNA 2 CPR Card issued on 6/24/2014 with a recommenced renewal date 6/24/2016 (EXPIRED) CNA 3 CPR Card issued on 1/9/2017 with a recommenced renewal date 1/9/2019 CNA 4 CPR Card issued on 224/2016 with a recommenced renewal date 2/24/2018 The facility's policy and procedure revised April 2011 titled " Emergency Procedure Cardiopulmonary Resuscitation " indicated CPR is immediately initiated in case of recognized cardiac and or pulmonary arrest until medical emergency personnel are available to take over the resuscitation efforts. The first certified CPR staff to arrive and find a resident unresponsive and breathless and pusleless will identify whether there is cardiopulmonary or respiratory arrest by shaking the person and calling his or her name. The policy indicated to respond to the resident immediately and send available staff to call 911, and return for help. According to the Vocational Practice Act 2518.6 Performance Standards; a licensed vocational nurse shall safeguard the patient's health and safety by actions that include maintaining current knowledge and skill for safe and competent practice. A review of the American Heart Association FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 22 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 CPR guidelines, dated 2015 revealed the first thing to recognize cardiac arrest (a sudden, unexpected loss of heart function, breathing and consciousness) was to check for responsiveness. If there was an unwitnessed collapse; where there was no breathing or only gasping for breath, no definite pulse felt within 10 seconds, the instructions were to send someone for help and to begin CPR immediately.

F309 SS=G PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 23 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide cardiopulmonary Resuscitation (CPR) for Resident 1, who was a full code and found by certified staff unresponsive (without a heart beat and without respiration), laying face down in her room, with blood oozing from her head. Failure to follow Resident 1's Physician's Order for lifesustaining Treatment and failure to follow the facility's policy and procedure titled "Emergency Procedure- Cardiopulmonary Resuscitation" and failure to follow the American Heart Association Adult Basic Life Support for Healthcare providers. This deficient practice resulted in Resident 1 not being FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 24 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 afforded the opportunity to survive and receive the full benefit of CPR per her request. Consequently, Resident 1 expired at the facility. Findings: On 6/7/2017 at 11:40 a. m., an unannounced visit was made to the facility to investigate an Entity Reported Incident involving Resident 1 who was found on 5/26/17, at around 7 a.m., unresponsive in the room, lying on the floor. The resident was found on her right side next to the corner of the night stand, lying in a pool of blood oozing from her head. The resident was pronounced dead by the emergency response team (EMS) upon arrival on the same day at 7:20 a.m. The Director of Nursing (DON) and the assistant Administrator were advised of the visit. On 6/7/2017, at 11:40 a. m., unannounced visitation was made to the facility to investigate a complaint / Entity Reported Incident (ETI) for a resident who was found on the floor on her right side next to the corner of the night stand in her room unresponsive, laying in a pool of blood oozing from her head. Resident was pronounced death by the Emergency Response Team on 5/26/2017. Surveyor met with the Director of Nursing (DON) and the assistant administrator at the nurses' station one. During an interview with the DON and the assistant in the resident's room, she stated the resident may have hit her head on the night stand that had a sharp oval metal handle on each drawer, that was closer to the be,d or the over head table that was next to the head of the bed. At 11: 55 a. m. on the same date, DON stated she received a text message on her phone sent by Licensed Vocational Nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 25 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 1(LVN) noting the facility has an emergency. The DON stated she arrived at the facility at 7:35 a.m and met two police officers questioning CNA 1 regarding the resident's cause of death. The DON stated she saw the resident laying on the floor unresponsive, in a lot of blood oozing from her head. The DON stated the resident looked bluish, cold and stiff. DON stated the CONER Office was informed by the Police Department (). The DON stated the resident's right bedside rail was down and the resident might have dropped from the bed to the floor in her sleep. The DON stated CPR was not initiated by the staff, but 911 was called. When questioned if the facility's staff had been trained on CPR, the DON stated "Yes." The DON was asked if staffs were aware of the resident's full code status to which she responded "Yes" and stated staffs are not to touch any resident on the floor, instead, they had to leave and get help from other licensed staffs. According to the admission record, Resident 1 was an 89 year old female, who was admitted to the facility on 11/18/14. The resident had diagnoses which included dementia (a decline in mental ability severe enough to interfere with daily life). A review of the Minimum Data Set (MDSstandardized assessment and care screening tool) dated 02-25-17, indicated Resident 1 had decreased ability to make self-understood or to understand others. Resident 1 had slow or minimal cognitive skills for daily decision making, required minimum assistance from staff for transferring, dressing, toilet use and personal hygiene,and was decline in continence (control) of bowel and bladder functions due to dementia FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 26 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 Physician Orders for LifeSustaining Treatment (POLST is a physician order that outlines a plan of care reflecting a resident's wishes concerning care at life's end) dated 11-18-14, indicated Resident 1 wished an attempt of (CPR) and full treatment for prolonging life by all medically effective means. A review of the nurse's noted dated 6/26/2017 at 2: 30 a. m., indicated Resident 1 was noted in bed asleep, offered assistance to the bathroom, no assistance needed at this time. Progress notes also indicated at 7 a. m., found resident unresponsive, lying on her right side with head on the proximity of the night stand corner, no pulse and no breathing, lying in moderate amount of blood oozing from the right side of resident's head. Resident sustained 3 centimeters by 3 centimeters laceration to the forehead. At 7: 30 a. p m., 911 was called for assistance. 911 arrived after 35 minutes and pronounced resident dead. There was no documented evidence indicating the resident's vital signs were assessed, or CPR was initiated and or code blue was called. Delete: Failure to initiate CPR immediately after the facility's staff realized that Resident 1 was breathless and pulseless, resulted in insufficient of oxygen to the resident's brain. A review of the clinical records of 35 sampled residents indicated 22 residents were identified as a full code status per the physician's orders. However, upon interview with the DON on 6/12/2017, at 12 p. m., she stated the facility does not have a crash cart, but promised to order one and educate staff on how to use it. On the same date at 12:30 p. m., during and interview with the administrated in room (3c), he stated he received a text message on his phone from the DON approximately 8 a.m. stating that resident 1 was found on the floor, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 27 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 unresponsive, in a pool of blood oozing from her head and was pronounced death by the paramedics. In an interview with the administrator, he was asked when a resident is found unresponsive and breathless what should be done? he stated CPR was not necessary at the time resident was found because she had expired for quite sometime. The Administrator further stated, staff failed to call code blue, get the crash cart and then, initiate CPR. On 6/7/2017 at 1: 45 p. m., in an interview CNA 1 stated she went to resident 1's room on 5/26/2017 at 7: 15 a. m., opened the privacy curtain to offer her milk and coffee because the resident preferred coffee and milk in the morning. CNA 1 stated Resident 1 was found on the floor with her head raised on the metal bar part of the over bed table, breathless and pulseless, laying in a pool of blood oozing from her head. CNA 1 stated she ran out of the room,shouted LVN 1'S name. When CNA 1 was asked what else did she do, CNA 1 stated she continued to pass the breakfast trays to the rest of the resident. CNA 1 was asked when a resident is found unresponsive and pulseless what will she do, CNA 1 stated she was instructed by the director of staff development not to touch the resident, leave the resident and get help from charge nurse. On 6/7/2017 at 2: 07 p. m., during an interview with LVN 1, he was asked, how he assessed Resident 1 when he first saw the resident on the floor unresponsive? LVN 1 stated, he shook the resident's leg, "are you ok", but the resident remained unresponsive. LVN 1 stated he instructed LVN 2 to call Emergency Response Team (911), then he stayed with the resident. He said after 911 was called, LVN 2 came back to the room and stayed with the resident and he left to resume his morning shift assignment, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 28 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 blocked the room and kept all the other residents in the dinning room until fire department arrived at 9 a. m. When asked why didn't he initiates CPR? LVN 1 stated CPR was not provided due to his assessment of unresponsive. LVN 1 was asked how he conducted resident's assessment, LVN 1 stated by visual observation. When asked it vital signs were taken, LVN 1 stated, resident's skin was cold, blue and stiffen when he felt with his gloved hand. When asked if he was aware of resident's full code order, LVN 1 responded yes but was "no sign of live". On 6/9/2017 at 10 a. m. to 12 p.m., during an interview with LVN 2, stated that on 5/25/ 2017 Resident was observed during round at 11 p. m. in her room lying in bed. At 1 a. m .on 5/26/2017 stated he saw resident in bed. At 3 to 3: 30 a. m. stated he offered Resident 1 a trip to the bath room but resident refused and stated she was ok. He stated the last time he did round and saw Resident 1's sorting magazine from her night stand top drawer was at 5 a. m. on 5/26/2017. on 6/9/2017 at 11a. m., LVN 2 was questioned regarding Resident 1's activity prior to her discovered on the flood "death" LVN 2 stated Resident 1 usually had the ability to make self-understood and usually had the ability to understand others. Ambulates to the bath room sometime with assistant but sometimes uses pull- ups. LVN 2 at 12 p. m., stated on 5/26/2017 at 7:05 a. m, CNA 1 who worked morning shift found Resident 1's on the floor when she went to the room to offer her breakfast but unfortunately, found the resident unresponsive lying on the floor in a pool of blood, oozing from the right corner of her head in the proximity of the night stand metal plate that was attached to the drawers as hand holders. LVN2 was asked when a resident found unresponsive and breath less what should be done?LVN 2 stated he would check FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 29 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 the resident's vital signs, call a code blue, call for help, and check resident's medical record to ensure if resident is a DNR or a full code, then start CPR. When questioned why he did not initiate CPR? LVN 2 stated CPR was not immediately initiated due to the color of her face and she had expired for quite sometime. When asked how did he know, LVN 2 stated the was no sign of circulation, body was cold and stiffen. LVN 2 stated, at 7: 30 a.m he was instructed by LVN 1 to call Emergency Respond Team (ERT) that arrived at 7: 35 a. m. and pronounced resident death. LVN2 stated, Santa Monica Police Department (SMPD)was notified and the informed the Corner office and at 10 : 15 a. m. On 6/9/2017 at 1:10 p. m., during an interview with CNA 4 stated rounds were done on 5/26/2017 at 11 : 30 p. m., and she saw the resident in bed. CNA 4 stated the last time he saw Resident 1 was on 5/26/2017 at 4 a. m. sitting on her bed with legs on the floor. He stated resident usually used the restroom by her self and even dresses herself. CNA 4 stated Resident 1 uses a cane when walking and held onto objects like a bed or bed table when sitting to a standing position. CNA 4 stated he left the facility at 6:55 a. m. on 5/26/20217 and he was not aware of Resident 1's death until his return to work. On 6/12/2017 at 6:02 a. m., during an interview with CNA 4 when asked when a resident is found unresponsive what should be done, CNA 4 stated he was instructed by DSD not to touch the resident, go and get help from the charge nurse. When asked if CNA 4 knows how to perform CPR, CNA 4 stated to administer "twenty chest compressions, give oxygen and remove tight clothes and open the mouth. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 30 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 On 6/14/2017 at 3 : 25 p. m., in an interview with the director of nursing, she stated if the resident was found with a change of condition, the staff should have checked the vital signs; if the resident was not breathing, staff should have performed CPR and administered oxygen. The facility policy and procedure revised April 2011 and titled " Emergency Procedure Cardiopulmonary Resuscitation" indicated CPR is immediately initiated in cases of recognized cardiac and or pulmonary arrest until medical emergency personnel are available to take over the resuscitation efforts. The first certified CPR staff to arrive and find a resident unresponsive and breathless and pusleless will identify whether there is cardiopulmonary or respiratory arrest by shaking the person and calling his or her name. Respond to the resident immediately and send available staff to call 911, and return for help. The policy does include the most recent changes from the American Heart Association ( C-A-B- chest compressions, airway, breathing). According to the American Heart Association Adult Basic Life Support for Healthcare Providers Manual dated 2016, when the resident is unresponsive with no breathing or no normal breathing, the first step is to check for alertness, Start compressions, check airway check breathing, check pulse, shout for help/Activate emergency response system. Procedures include to place hand on lower half of the sternum (breast chest area); give 30 compressions in less than 15 and no more than 18 seconds; Compresses at least 2 inches (5 centimeters) and ensure the chest rises that would indicate the resident is receiving the oxygen. Give two breaths with a bag - mask device - a method of delivering rescue breath at one second. Compression should be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 31 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 resumed in less than ten seconds.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 32 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 Based on observation, interview and records reviews, the facility failed to provide adequate supervision and to ensure the environment was free of accident hazards in order to minimize the injuries when a fall occured, resulting in laceration (a deep cut or tear in skin or flesh) to the forehead with massive amount of blood loss for one of 35 sampled residents (1). The paramedics (provide advanced emergency medical care) upon arrival, pronounced the resident had expired. The facility failed to: 1. Ensure Resident 1's siderail was up to prevent a fall while resident was in bed, 2. Ensure Resident 1's over the bed table and the night stand was not placed close to the bed to prevent accidents, 3. Ensure plan of care developed for at risk for falls/injury related to impaired cognition, poor balance and poor safety awareness / judgement was specific about the frequency of visual observation of the resident, 4. Ensure to implement its own policy and procedures for fall prevention and management program that included all residents' environment shall remain as free of accident hazard as possible and all residents shall receive adequate supervision and assistive to prevent accidents. These violations resulted in Resident 1's fall from bed to the floor. The resident sustained laceration to the forehead measuring approximately 3 by 3 centimeters (cm) that caused pain, bleeding and eventually resulted in her death. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 33 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 Findings: During an unannounced visit to the facility on 6/7/17 at 11:40 a.m., was made to investigate an Entity Reported Incident (ERI). The ERI indicated on 5/26/2017 at about 7 a.m., Resident 1 was found face down on the floor, in her room, oozing blood from her head. The resident was pronounced dead. According to the admission records Resident 1 was a 89 year old female, who was admitted to the facility on 11/18/14. The resident had diagnoses which included dementia (a decline in mental ability severe enough to interfere with daily life), insomnia (inability to sleep), carpal tunnel syndrome (numbness, tingling, weakness, in hand due to pressure on the nerve) and right shoulder pain. A review of the Minimum Data Set (MDS), a standardized assesment and care screening tool, dated 2/25/17 indicated Resident 1 had decreased ability to make self-understood or to understand others. The resident had problems with cognitive skills for daily decision making, needed minimum assistance from staff for transferring, dressing, toilet use and personal hygiene. The resident was incontinent (lost control) of bowel and bladder functions. A review of Resident 1's plan of care initiated on 11/15/2014 and revised 5/17/2017, indicated the resident was at risk for falls related to limited mobility, impaired cognition (thinking problem), poor balance and needing limited assistance with care. The goal was to demonstrate preventive measures to minimize injury on a daily basis, keep the environment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 34 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 clear anf free from harzard at all times and monitor the resident when ambulating. The interventions included the following; frequent visual observation of the resident, proper fitting shoes, safe and clutter-free environment and to keep call ligt within easy reach. However, the plan of care did not show frequency of monitoring of visual observations and checks was to be made. A review of the fall risk assessment, dated 2/17/2017 indicated Resident 1 scored ranged between 17, with a total score of 10 or greater represented a high risk for falls. A review of the facility's incident report, dated 2/20/2016 indicated Resident 1 fell in the hallway when walking with a cane. The report indicated a right hip with pelvis (the large bony structure near the base of the spine) x-ray was done on on the same day which revealed no fracture (broken bone). However, there was no documented evidence in the residet's clinical records indicating interdeciplinary team (experts from several different fields who work together toward a common business goal) meet to revise the interventions on the care plan after the fall. The physician's order dated 4/26/2017, indicated Resident 1 had been on Melatonin (a hormone used to regulate sleep and wakefulness) tablet 5 milligram since 2/24/2015. The order indicated to give 1 tablet by mouth at bedtime for insomnia (inability to sleep) at 8:30 p.m. A review of the Medication Administration Records, dated for the month of January and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 35 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 February, March, April and May 2017 indicated Resident 1 had been taken Melatonin every night at 8:30 p.m. On 6/7/2017 at 11:45 a.m., during an observation of Resident 1's room (3 C) indicated a night stand next to the bed. The night stand had four drawer and each draw had a metal plate with sharpe edges. The bed was unlocked and the over bed table had two wheels that were not locked when pushed to the side. The call light was not within an easy reach of anyone lying in bed and it was tied down to bed B. During an interview with the director of nursing (DON) stated the resident might had fallen out of bed in her sleep since the right upper side rail was in an upright position. The DON stated the resident had poor balance and when reaching the over bed table, the table might had moved because the wheels were broken, causing her to slip and fall. When asked how often does the staff monitor or do rounds, DON stated rounds are made every two hours. The DON further stated the resident fall should have been prevented if the night staff did rounds every two hours per their policy titled "Routine Rounds". On 6/7/2017 at 4:25 p.m., in an interview with Licensed Vocational Nurse (LVN 1) stated Resident 1's goal that addressed the plan of care for falls was revised after the first fall on 2/20/2016. However, he stated the nursing intervention for the fall care plan was not revised to prevent another fall. LVN 1 further stated the right siderail should have been raised to prevent the resident from falling out of bed. During an interview with LVN 2 on 6/9/2017 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 36 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 11:50 a. m., LVN 2 stated he made the last round to Resident 1's room at 1:30 a.m., by peeking through the privacy curtain. He stated the resident was standing next to the night stand, sorting out magazines from the top night stand drawer. LVN 2 stated he believed the resident must had fallen and hidden her head on the night stand's metal handel. When asked if the resident was provided assistance to the bathroom, LVN 2 stated the resident usually used the restroom by herself using a care. When LVN 2 was asked if the resident was wearing proper fitting shocks or shoes, he stated she had no socks or shoes on her feet. LVN 2 stated he failed to provide rounds to the resident per their own facility's policy. He further stated the resident's fall should had been prevented if they provided frequent rounds and more assistance to her. When questioned about the call light, LVN 2 said "residents here do not have the capacity to use call light, call light are jut for formality." When asked if the resident took medication that could enhance sleep, LVN 2 stated she took Melatonin (a hormone used to regulates sleep and wakefulness) every night at 8:30 p.m., for an inability to sleep. LVN 2 stated resident might had fallen due to dizziness or drowsiness of the sleeping medication. On 6/9/2017 at 1 p.m., in an interview with Certified Nursing Assistant (CNA 4) stated he put down the right bedrail in order to enable Resident 1 to get out of bed so she could use the restroom unattended. CNA 2 stated if the right bedrail was in an upward position it should have prevented the resident falling from her bed. On 6/22/2017 at 2:30 p.m., in an interview with DON, stated the bed side tables and over the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 37 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 bed tables would be replaced to prevent further injuries to other residents. The DON stated she believed if this plan of not having the bed side and over the bed table, Resident 1 would not had fallen, sustained head injury and bled to death. A review of the facility's Incident / Accident Report, dated 5/26/2017 at 8 a.m. and a letter by the Administrator addressed to the Department of Public Health (DPHS), dated 6/1/2017, indicated CNA 1 was fetching the residents from her room for breakfast at 7 a.m., when she found Resident 1 lying on the floor. The letter indicated the resident was on her right side next to the corner of the night stand, unresponsive, oozing blood from her head. LVN 2 checked the residet, called 9-1-1 and at 7:20 a.m., paramedics arrived and prononounced the resident had expired. The report concluded the resident must have fallen, hitting the corner of the night stand as she was waiting to be fetched for breakfast. The report indicated the resident fell and sustained a skin tear of 3 by 3 centimeters on the right side of her forehead which was bleeding. The resident was dead. According to an undated facility's policies and procedures titled "Fall Prevention and Management Program" indicated all resident's environment shall remain as free of accident hazard as possible and all resident shall receive adequate supervision and assistive devices to prevent accidents. All resident shall be assessed for being at risk for falls. And resident indentified as "at risk" for fall shall have an individual plan of care that included interventions to prevent falls from occuring. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 38 of 39 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: _______________ 555786 (X3) DATE SURVEY COMPLETED 06/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEAN PARK HEALTHCARE 2828 Pico Blvd Santa Monica, CA 90405 (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 a facility's policy and procedures titled "Patient Rounds" indicated rounds shall be made to promote comfort, and monitor well being of all resident while in the facility. Nursing staff shall make rounds every two hours to check the needs of residents, and address the needs as required. At night, nursing staff shall follow a turning/repositioning program that includes changing of the resident's position and realignment of body. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4P411 Facility ID: CA910000075 If continuation sheet 39 of 39