Beachwood Post-acute & Rehab

F-F759

Findings:

A review of Resident 9's admission record indicated Resident 9 was admitted originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included Hypotension (lower than normal blood pressure) bradycardia (lower than normal heart rate), shortness of breath, rheumatoid arthritis (a chronic autoimmune disease that affects the joints), and muscle weakness.

A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 5/27/2024, indicated Resident 9's cognition ((the mental ability to understand and make decisions of daily living) was severely impaired and the resident required supervision or touching assistance with eating, partial to moderate assistance with oral hygiene and upper body dressing, was dependent for toileting hygiene, lower body dressing and putting on/taking off footwear.

During an initial tour on 6/25/2024 at 10:20 AM Resident 9's bedside table was observed to have 2 tubes of Diclofenac Sodium topical gel 1% and a box with 7 Salonpas Lidocaine 4% patches on Resident 9's bedside drawer in a visible open unsecured area as she (Resident 9) lay asleep in bed.

During a concurrent interview and record review on 6/25/2024 at 10:34 AM licensed vocational nurse 9 (LVN9) stated Resident 9's family brought the medications and they (family) applied the Diclofenac Sodium topical gel 1% and a box with 7 Salonpas Lidocaine 4% patches on the resident. A review of Resident 9's electronic medical administration (emar) record indicated Resident 9 did not have a physician's order for the Diclofenac Sodium topical gel 1% and a box with 7 Salonpas Lidocaine 4% patches. LVN9 stated the risks of having medication without a physician's order in a visible unsecured open area at bedside included: poisoning if ingested by a wandering confused resident, overdose, drug interactions, and allergic reactions that could lead to unnecessary hospitalization and even death.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 31 056334 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056334 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 A review of Resident 9's emar on 6/27/2024 at 12:46 PM indicated Resident 9 had a physician's order for and was receiving: Level of Harm - Minimal harm or potential for actual harm 1. Orencia solution 125mg/ml, 1ml subcutaneously every Monday for rheumatoid arthritis pain.

Residents Affected - Few 2. Tramadol 50mg x2 tablets every 8 hours for severe pain.

3. Tylenol extended release 650mg every 12 hours for mild pain as needed.

During an interview on 6/27/2024 at 2:51 PM Resident 9's daughter/responsible party (RP), stated she applied the Diclofenac Sodium topical gel 1% on Resident 9 on Resident 9 foot and joint during RP's visit every other day. The RP stated she placed the Salonpas Lidocaine 4% patch on Resident 9's back when Resident 9 did not have the patch on the back.

During an interview on 6/28/2024 at 9:55 AM, Resident 9's doctor indicated he received a text message from

the facility 7-10 days prior from staff regarding the use of Diclofenac Sodium topical gel 1% and Salonpas Lidocaine 4% patch and he approved it. The doctor stated the facility staff licensed staff was supposed to apply the medication on the Resident and not the Family.

During an interview on 6/28/2024 at 4:30PM, the director of nursing (DON) stated Resident 9 and/or the pesponsible party did not have an order for self-administration and/or to administer medication to the Resident. The DON was unable to provide text from staff to and from doctor indicating an order for approval of the use of both medications on Resident 9. The DON stated leaving Diclofenac Sodium topical gel 1% and

a box with 7 Salonpas Lidocaine 4% patches at bedside and using the Diclofenac Sodium topical gel 1% and

a box with 7 Salonpas Lidocaine 4% patches on Resident 9 without a physician's order placed the Resident at risk for overdosing, dependency, and possible poisoning if ingested by a wandering confused patient.

A review of facility policy titled Identifying and Managing Medication Errors and Adverse Consequences dated 1/2024 indicated, the staff and practitioner shall strive to minimize adverse consequences by:

a) Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration and monitoring of the medication

b) Defining appropriate indications for use; and

c) Determining that the resident:

1. Has no known allergies to a medication.

2. Is not taking other medications, nutritional supplements including herbal products or good that would be incompatible with the medication and

3. Has no condition, history, or sensitivities that would preclude use of that medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 31 056334 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056334 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46843 Residents Affected - Some Based on observation, interview, and record review the facility failed ensure medications were discarded as per facility policy and procedure titled, Discarding and Destroying Medications dated 2001. By failing to:

1. Check the expiration date, remove, and discard from use, one box of BD Vacutainer Safety-Lok Blood Collection Set (tubing and needle used to collect blood specimens).

2. Remove one box of expired Bisacodyl (laxative- medication that prevents/treats constipation) 10 milligrams.

These deficient practices had the potential to cause a mechanical failure of the expired blood collection set

during an attempt to collect blood from a resident and affect medication efficacy (the power to produce the desired effect) and reduce the therapeutic (intended to treat diseases or disorders) effects of medications administered.

Finding:

During observation of the 4th floor medication storage area at the nursing station on 06/27/24 at 3:42 p.m., a half-used box of Safety-Lok Vacutainers were observed on the counter in the medication room open and ready for use and available for staff to use by staff to draw blood from residents. The half-used box of Safety-Lok Vacutainers was observed to have an expiration date of 4-30-2023.

During an interview on 6/27/24 at 3:45 p.m., Registered Nurse Supervisor 1 (RNS 1) worked at the facility for [AGE] years and stated she was not aware the expired Safety-Lok Vacutainers were in the medication room. RNS 1 was not aware if anyone that had recently used the expired vacutainer; RNS1stated that she would dispose of the expired Safety-Lok Vacutainers immediately. RNS 1 stated expired equipment should not be used due to the possibility of potential contamination, or mechanical failure due to the expiration date being 4-30-23.

During an interview on 06/27/24 at 4:05 p.m., Director of Nursing (DON) stated no expired medications or equipment were to be kept in the medication storage area. The DON stated expired medication or equipment kept in the medication storage area could have been by mistake. The DON stated medication areas were inspected and checked for expired medication and equipment every month by staff.

During medication storage and labeling observation on 06/27/24 at 2:37 p.m., licensed vocational nurse 2 (LVN 2) observed and noted 1 box of house supply Bisacodyl 10 milligrams with an expiration date of 4-24. LVN 2 stated if residents received expired medication the residents could get sick. LVN 2 stated she did not administer any Bisacodyl to any resident on the date of observation (6/27/2024).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 31 056334 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056334 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 During an interview on 6/27/24 at 3:50 pm, the DON Stated the licensed nurses were supposed to check medication carts daily to ensure there were no expired medications in the medication carts. The DON stated Level of Harm - Minimal harm or the residents could get sick if expired medications were consumed. potential for actual harm

A review of the facility policy and procedures titled, Discarding and Destroying Medications dated 2001 Residents Affected - Some indicated, Policy Statement Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, and hazardous waste.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 31 056334 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056334 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 45037

Residents Affected - Some REVIEWED

Based on oservation, interview, and record review, the facility failed to ensure safe and sanitary food storage, food labeling practices in accordance with professional standards and facility policy to ensure food service safety and ensure routine maintenance of kitchen pipes was performed.

These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses and other toxins) and corrosion to the pipes, safety hazards in 211 of 211 medically compromised residents who received food and have food prepared from the kitchen, staff getting injured due to large puddles of water on the floor, and large industrial fan blowing in kitchen while food is being prepared.

Findings:

During an initial tour and observation of the facility kitchen with the Dietary Supervisor (DS) on 6/25/2024 at 7:50 AM. Two blocks of yellow sliced cheese were observed labeled with an expiration date of 2/23/24, one large plastic container with food in it was observed without a label indicating the contents, open date, or expiration date, one loaf of whited bread was observed with an expiration date of 3/18/24, one large container of ranch dressing was observed with an expiration date of 2/7/24, one large plastic container was observed labeled jelly with an expiration date of 6/20/24 . A large amount of water was observed on the floor underneath the sink and near the sink where the dishes were washed. A pipe under the sink where dishes were washed was observed to have a greenish color on the pipes and a large amount of dust was observed under the sink where the dishes were washed.

During an observation of resident food storage refrigerator on the facility's 5th floor with licensed vocational nurse 1 (LVN 1) on 6/25/2024 at 8:40 AM, 15 food items in plastic containers (unable to identify food items) were not labeled with expiration dates.

During an observation of food storage refrigerator on 4th floor with LVN 1 on 06/25/24 08:43 AM, 11 food items in plastic containers (unable to identify food items) were observed without expiration dates on them.

During an observation of food storage refrigerator on 3rd floor with LVN 1 on 06/25/24 09:03 AM, 2 food items in plastic containers (unable to identify food items) and 4 drinks (labeled Beautiful) were not labeled with expiration dates.

During an observation of food storage refrigerator on 2nd floor with LVN 1 on 06/25/24 09:08 AM, 2 food items in plastic containers (unable to identify food items) were not labeled with expiration dates.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 31 056334 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056334 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During a follow up observation of the facility kitchen on 06/27/24 07:18 AM, three puddles of water we observed on the floor. A large orange industrial fan was blowing in the kitchen and a pipe under the sink was Level of Harm - Minimal harm or observed leaking water into the green bucket. potential for actual harm

During an interview on 06/25/24 at 8:18 AM, the DS stated the staff did not clean underneath the sink where Residents Affected - Some the dishes were washed. The DS stated the residents could get sick if the kitchen was not cleaned regularly.

The DS stated she reported the leaking pipe underneath the kitchen sink a week prior to the date of

observation to the maintenance supervisor (MS).

During an interview on 06/25/24 10:40 AM, the MS stated the plumbing/pipes were last serviced approximately one year prior.

During a follow up interview on 6/25/24 11:20 AM, the MS stated he did not have any invoices on hand for

the last time the leaking pipe in the kitchen was repaired or serviced. The MS stated the leaking pipe could lead to corrosion of the pipes and someone could slip and fall and get injured.

During an interview on 06/27/24 07:18 AM, SA asked the MS/HS how long the pipe has been leaking and he said he did not know. SA asked MS/HS what could happen to the staff with puddles of water on the floor, MS/HS stated the staff could slip and fall and hurt themselves.

A review of the facility policy and procedures (P&P) titled Maintenance Service with a revised date of January 2024, indicated 1. Maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. F. establish priorities in providing repair services. I. providing routinely scheduled maintenance services to all areas. 8. The maintenance Director is responsible for maintaining the following records/reports. L. Work order request. M. Maintenance schedules records shall be maintained in the Maintenance Director's office.

A review of the facility P&P titled Food Receiving and Storage with a revised dated of January 2024, indicated 8. All food stored in the refrigerator or freezer will be covered, labeled, and dated. 14. Food items and snacks kept on the nursing units must be maintained as indicated: b. All foods belonging to residents must be labeled with the resident's name, the item, and the use by date. d. beverages must be dated when opened and discarded after twenty-four hours. f. Partially eaten food may not be kept in the refrigerator.

A review of the facility P&P titled Food for Residents from Outside Sources (undated), indicated 2. The dietary department is not responsible for keeping food for residents. a. Such food must be eaten within one (1) hour of receiving. b. Any food not eaten must be taken home or disposed of that day.

A review of the facility P&P titled Food brought by Family/Visitors with a revised date of January 2024, indicated 6. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item, and the use by date. 7. The nursing staff is responsible for discarding perishable foods on or before the use by date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 31 056334 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056334 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beachwood Post-Acute & Rehab 1340 15th Street Santa Monica, CA 90404

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46843 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure call lights (device with a Residents Affected - Few button or touch pad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) were within reach for one of seven sampled residents (Resident 165).

This deficient practice had the potential to result in a delay in meeting Resident 165's needs for hydration, toileting, and activities of daily living.

Findings:

A review of Resident 165's Admission Record indicated Resident 165 was admitted to the facility on [DATE REDACTED], with medical diagnoses that included: Paraplegia (a chronic condition that causes the loss of muscle function and feeling in the lower half of the body, including both legs), major depressive disorder (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), and muscle weakness (a lack of physical or muscle strength, throughout the body).

A review of Resident 165's Minimum Data Set (MDS - a standardized assessment and care screening tool) indicated Resident 165's cognition (the mental ability to make decisions of daily living) was intact.The MDS indicated the resident required maximum assistance from staff for toileting, hygiene, bathing, lower body dressing, and personal hygiene.

During observation in Resident 165's room on 6/25/2024 at 8:54 a.m., Resident 165 was observed lying in bed with the call light hanging off the bed and out of reach of Resident 165.

During an interview on 6/25/2024 at 9:04 a.m., Resident 165 asked if someone could get the call light from under the bed because Resident 165 could not reach the call light.

During an interview on 6/25/2024 at 9:09 a.m., Certified Nurse Assistant (CNA1) stated Resident 165 did not have the call light within reach; however, it was okay because CNA1 was always checking on CNA1's assigned residents. CNA1 stated not having the call light within reach could result in the resident needing help and not being able to call for help because the call light was not within reach.

During an interview on 6/27/2024 at 2:22 p.m., the Director of Nursing (DON) stated call lights were to remain within reach of the residents. The DON stated staff were to perform room checks periodically to ensure resident safety was maintained and call lights were within reach of each resident.

A review of the facility's policy and procedures titled, Answering the Call Light dated 2001, indicated, The purpose of this procedure is to respond to the resident's requests and needs. General Guidelines 4. When

the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 31 056334