Santa Monica Conv Ctr I

F-F760.

Findings:

A review of Resident 1 ' s GACH History and Physical dated 2/8/2025 indicated, Resident 1 has a history of atrial fibrillation (Afib-an irregular heartbeat that can lead to blood clots and increases the risk of stroke and other heart complications) on Eliquis.

A review of Resident 1 ' s GACH physicians medication order dated 2/14/2025 indicated apixaban [Eliquis] 5 milligram (mg, unit of measurement) tablet take 1 tablet by mouth 2 times daily.

A review of Resident 1 ' s Nursing Progress Notes dated 2/14/2025 at 3:23 PM indicated, all orders with verified with medical doctor (MD), all orders noted and carried out.

A review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool) dated 2/17/2025 indicated, Resident 1 ' s cognitive skills (ability to think and process information) for daily decision making was moderately impaired. Resident 1 ' s mediation assessment for high-risk drug classes for anticoagulant (blood thinner), not assessed.

A review of Resident 1 ' s History and Physical dated 2/17/2025 indicated, Resident 1 can make needs known but cannot make medical decisions.

A review of Admissions Record dated 4/22/25indicated, Resident 1 was initially admitted to the facility on [DATE REDACTED] with a diagnosis of not limited to generalized muscle weakness (a lack of strength in the muscles), atherosclerotic heart disease (narrowing of the vessels that carry blood to your blood), cerebral infarction (a stoke or a disrupted blood flow to the brain due to problems with the blood vessels that supply blood), hyperlipidemia (high levels of cholesterol in the blood), presence of cardiac pacemaker (a battery-powered device implanted in the chest to help control heart rate).

A review of Resident 1 ' s Order Summary Report active orders as of 4/22/2025 indicted, no orders entry for

the medication apixaban/Eliquis.

A review of Resident 1 ' s Medication Administration Record (MAR) for the period of February 2025 schedule indicated, no documentation of the medication apixaban/Eliquis being transcribed or administered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 555786 Department of Health & Human Services Printed: 08/28/2025 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 555786 B. Wing 04/22/2025

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

Ocean Park Healthcare 2828 Pico Boulevard Santa Monica, CA 90405

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 0842 During an interview on 4/22/2025 at 11 AM with Licensed Vocational Nurse (LVN) 1 stated, for residents with blood thinners, staff reviews physician ' s orders, assesses the resident for bleeding, bruising, and signs of Level of Harm - Minimal harm or blood clots. During new admissions, admitting nurse is responsible to review a medication list from potential for actual harm transferring facility, no medication should be missed. LVN1 was assigned to care for Resident 1 for a day, does not remember the resident having a blood thinner medication ordered and did not administer one. Residents Affected - Few LVN1 stated, the likely outcome for missing a blood thinner medication, the resident will have blood clots and complications that risks Resident 1 ' s life.

During an interview on 4/22/2025 at 12 PM with LVN2 stated, during new admissions, emergency medical technicians bring a transfer packet with residents. The transfer packets usually include medication list, history and physical, lab results, and code status. During admissions, medications are notified to attending physicians right away for review and approvals. Medication reconciliations is done by admitting nurse. Registered Nurse supervisors or Director of Nursing (DON) conduct medication reconciliations review after each admission. Transfer records are uploaded in the care system by medical records for licensed staff to carry out orders.

During a telephone interview on 4/22/2025 at 12:27 PM with Pharmacy supervisor (PharmD2) stated, the process for medication to be dispensed, the facility obtains medication order lists from transferring hospital, facility staff gets approval by attending physician, then staff sends the medication orders to pharmacy. Pharmacy reviews order and dispenses medications within same day of admission, usually between four to six hours from admission time. PharmD2 confirmed Resident 1 was admitted to the facility on [DATE REDACTED]. PharmD2 stated, the pharmacy did not receive an order for apixaban/Eliquis. Pharmacy cannot dispense without orders. This was the response from the pharmacist. I can rephrase it - Pharmacy does not dispense medications without MD orders.

During a concurrent interview and record review on 4/22/2025 at 12:53 AM with Registered Nurse supervisor (RN), Resident 1 ' s GACH Physician Transfer Order dated 2/14/2025 was reviewed. RN stated the admitting nurse is the responsible person to review and reconcile medications. RN supervisor or DON will review the medication reconciliation the same day or next day to ensure interfacility transfer medication list is accurately reconciled. RN stated, Resident 1 was admitted to the facility on a Friday afternoon. RN started basic assessment and endorsed the admission process to the evening shift charge nurse. RN did not review the medication (the RN did not get a chance to complete revision of meds, he endorsed to the charge nurse), did not complete reconciliation because the resident was admitted after the RN ' s end of shift. RN not aware if Resident 1 ' s medication was reviewed by another RN supervisor or DON. The resident was transferred to a sister facility within two days. (RN reviewed and acknowledged Physician Transfer Order indicated apixaban/Eliquis 5mg tablet was part of the list of medications. Resident 1 ' s MAR indicated, apixaban/Eliquis is not included in the medication orders. RN agreed apixaban/Eliquis was not ordered and administered to Resident 1. RN stated, It is a deficiency and harm risk for the resident.

During a telephone interview with on 4/22/2025at 1:25 PM with attending physician (MD) stated, he is the provider for the facility. Resident 1 was randomly assigned to him during admission. Facility staff had called him and reviewed the medication and approved the existing mediations. MD stated, Resident 1 was on anticoagulant (blood thinner), I do know he was supposed to be on anticoagulant. MD had provided telephone order to facility staff for approval of existing transfer medications from GACH.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 555786 Department of Health & Human Services Printed: 08/28/2025 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 555786 B. Wing 04/22/2025

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

Ocean Park Healthcare 2828 Pico Boulevard Santa Monica, CA 90405

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 0842 During a concurrent interview and record review on 4/22/2025 at 2:45 PM with LVN3, Resident 1 ' s GACH Physician Transfer Order dated 2/14/2025 and MAR for February 2025 was reviewed. LVN3 stated, I Level of Harm - Minimal harm or remember going through the medication lists and I have called the attending physician for order approvals potential for actual harm and entered the medication lists in Point Click Care (PCC- electronic resident care system). LVN3 acknowledged apixaban/Eliquis 5mg tablet was part of Resident1 ' s list of medications in the GACH transfer Residents Affected - Few order. Apixaban/Eliquis is not transcribed in Resident 1 ' s MAR. LVN3 does not recall if apixaban/Eliquis is entered in PCC. LVN3 stated it might be an honest mistake omitting the apixaban/Eliquis from Resident 1 ' s MAR and the reason the resident was not administered the medication. LVN3 stated blood thinners are high-risk medications, there is a potential harm and complications from missing the prescribed doses.

During a concurrent interview and record review on 4/22/2025 at 3:24 PM with the DON, Resident 1 ' s GACH Physician Transfer order dated 2/14/2025 was reviewed. DON confirmed the medication apixaban/Eliquis should have been included in Resident 1 ' s MAR and administered according to the physician ' s order. The medication is possibly omitted due to a failure to transcribe and medication reconciliation.

A review of the facility ' s policy and procedures (P&P), titled Medication Reconciliation Policy revised 4/10/2024, the P&P indicated, Medication reconciliation is the process of identifying the most accurate list of all medications that the resident is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from:

1. A resident/representative from home - copy and verify home medication list

2. Hospital - copy and verify hospital discharge medication list

3. Other Provider (SNF, Lower level of care, etc.) - copy and verify Provider ' s Medication list.

It is the process of reviewing the complete medication and comparing the medication lists received on admission with the facility admission medication orders during a resident's admission.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 555786

F-F842.

Findings:

A review of Resident 1 ' s GACH History and Physical dated 2/8/2025 indicated, Resident 1 has a history of atrial fibrillation (Afib-an irregular heartbeat that can lead to blood clots and increases the risk of stroke and other heart complications) on Eliquis.

A review of Resident 1 ' s GACH physicians medication order dated 2/14/2025 indicated apixaban [Eliquis] 5 milligram (mg, unit of measurement) tablet take 1 tablet by mouth 2 times daily.

A review of Resident 1 ' s Nursing Progress Notes dated 2/14/2025 at 3:23 PM indicated, all orders with verified with medical doctor (MD), all orders noted and carried out.

A review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool) dated 2/17/2025 indicated, Resident 1 ' s cognitive skills (ability to think and process information) for daily decision making was moderately impaired. Resident 1 ' s mediation assessment for high-risk drug classes for anticoagulant (blood thinner), not assessed.

A review of Resident 1 ' s History and Physical dated 2/17/2025 indicated, Resident 1 can make needs known but cannot make medical decisions.

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.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 7 555786 Department of Health & Human Services Printed: 08/28/2025 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 555786 B. Wing 04/22/2025

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

Ocean Park Healthcare 2828 Pico Boulevard Santa Monica, CA 90405

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 Admissions Record dated 4/22/25 indicated, Resident 1 was initially admitted to the facility on [DATE REDACTED] with a diagnosis of not limited to generalized muscle weakness (a lack of strength in the muscles), Level of Harm - Minimal harm or atherosclerotic heart disease (narrowing of the vessels that carry blood to your blood), cerebral infarction (a potential for actual harm stoke or a disrupted blood flow to the brain due to problems with the blood vessels that supply blood), hyperlipidemia (high levels of cholesterol in the blood), presence of cardiac pacemaker (a battery-powered Residents Affected - Few device implanted in the chest to help control heart rate).

A review of Resident 1 ' s Order Summary Report active orders as of 4/22/2025 indicted, no orders entry for

the medication apixaban/Eliquis.

A review of Resident 1 ' s Medication Administration Record (MAR) for the period of February 2025 schedule indicated, no documentation of the medication apixaban/Eliquis being transcribed or administered.

During an interview on 4/22/2025 at 11 AM with Licensed Vocational Nurse (LVN) 1 stated, for residents with blood thinners, staff reviews physician ' s orders, assesses the resident for bleeding, bruising, and signs of blood clots. During new admissions, admitting nurse is responsible to review a medication list from transferring facility, no medication should be missed. LVN1 was assigned to care for Resident 1 for a day, does not remember the resident having a blood thinner medication ordered and did not administer one. LVN1 stated, the likely outcome for missing a blood thinner medication, the resident will have blood clots and complications that risks Resident 1 ' s life.

During an interview on 4/22/2025 at 12 PM with LVN2 stated, during new admissions, emergency medical technicians bring a transfer packet with residents. The transfer packets usually include medication list, history and physical, lab results, and code status. During admissions, medications are notified to attending physicians right away for review and approvals. Medication reconciliations is done by admitting nurse. Registered Nurse supervisors or Director of Nursing (DON) conduct medication reconciliations review after each admission. Transfer records are uploaded in the care system by medical records for licensed staff to carry out orders.

During a telephone interview on 4/22/2025 at 12:27 PM with Pharmacy supervisor (PharmD2) stated, the process for medication to be dispensed, the facility obtains medication order lists from transferring hospital, facility staff gets approval by attending physician, then staff sends the medication orders to pharmacy. Pharmacy reviews order and dispenses medications within same day of admission, usually between four to six hours from admission time. PharmD2 confirmed Resident 1 was admitted to the facility on [DATE REDACTED]. PharmD2 stated, the pharmacy did not receive an order for apixaban/Eliquis. Pharmacy cannot dispense without orders. This was the response from the pharmacist. I can rephrase it - Pharmacy does not dispense medications without MD orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 7 555786 Department of Health & Human Services Printed: 08/28/2025 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 555786 B. Wing 04/22/2025

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

Ocean Park Healthcare 2828 Pico Boulevard Santa Monica, CA 90405

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 During a concurrent interview and record review on 4/22/2025 at 12:53 AM with Registered Nurse supervisor (RN), Resident 1 ' s GACH Physician Transfer Order dated 2/14/2025 was reviewed. RN stated the admitting Level of Harm - Minimal harm or nurse is the responsible person to review and reconcile medications. RN supervisor or DON will review the potential for actual harm medication reconciliation the same day or next day to ensure interfacility transfer medication list is accurately reconciled. RN stated, Resident 1 was admitted to the facility on a Friday afternoon. RN started basic Residents Affected - Few assessment and endorsed the admission process to the evening shift charge nurse. RN did not review the medication (the RN did not get a chance to complete revision of meds, he endorsed to the charge nurse), did not complete reconciliation because the resident was admitted after the RN ' s end of shift. RN not aware if Resident 1 ' s medication was reviewed by another RN supervisor or DON. The resident was transferred to a sister facility within two days. (RN reviewed and acknowledged Physician Transfer Order indicated apixaban/Eliquis 5mg tablet was part of the list of medications. Resident 1 ' s MAR indicated, apixaban/Eliquis is not included in the medication orders. RN agreed apixaban/Eliquis was not ordered and administered to Resident 1. RN stated, It is a deficiency and harm risk for the resident.

During a telephone interview with on 4/22/2025 at 1:25 PM with attending physician (MD) stated, he is the provider for the facility. Resident 1 was randomly assigned to him during admission. Facility staff had called him and reviewed the medication and approved the existing mediations. MD stated, Resident 1 was on anticoagulant (blood thinner), I do know he was supposed to be on anticoagulant. MD had provided telephone order to facility staff for approval of existing transfer medications from GACH.

During a concurrent interview and record review on 4/22/2025 at 2:45 PM with LVN3, Resident 1 ' s GACH Physician Transfer Order dated 2/14/2025 and MAR for February 2025 was reviewed. LVN3 stated, I remember going through the medication lists and I have called the attending physician for order approvals and entered the medication lists in Point Click Care (PCC- electronic resident care system). LVN3 acknowledged apixaban/Eliquis 5mg tablet was part of Resident1 ' s list of medications in the GACH transfer order. Apixaban/Eliquis is not transcribed in Resident 1 ' s MAR. LVN3 does not recall if apixaban/Eliquis is entered in PCC. LVN3 stated it might be an honest mistake omitting the apixaban/Eliquis from Resident 1 ' s MAR and the reason the resident was not administered the medication. LVN3 stated blood thinners are high-risk medications, there is a potential harm and complications from missing the prescribed doses.

During a concurrent interview and record review on 4/22/2025 at 3:24 PM with the DON, Resident 1 ' s GACH Physician Transfer order dated 2/14/2025 was reviewed. DON confirmed the medication apixaban/Eliquis should have been included in Resident 1 ' s MAR and administered according to the physician ' s order. The medication is possibly omitted due to a failure to transcribe and medication reconciliation.

A review of the facility ' s Policy and Procedures (P&P), titled Admission Record Audit revised October 2024,

the P&P indicated It is the policy of this facility to audit all new resident admission charts within 72 hours of admission to ensure that documentation is complete, accurate, and compliant with California Title 22, federal regulations, and facility policies. The audit ensures that required clinical, administrative, and legal documentation is present and properly completed to support quality resident care, regulatory compliance, and reimbursement processes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 7 555786 Department of Health & Human Services Printed: 08/28/2025 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 555786 B. Wing 04/22/2025

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

Ocean Park Healthcare 2828 Pico Boulevard Santa Monica, CA 90405

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 the facility ' s P&P, titled Medication Reconciliation Policy revised 4/10/2024, the P&P indicated, Medication reconciliation is the process of identifying the most accurate list of all medications that the Level of Harm - Minimal harm or resident is taking, including name, dosage, frequency, and route, by comparing the medical record to an potential for actual harm external list of medications obtained from:

Residents Affected - Few 1.A resident/representative from home - copy and verify home medication list

2. Hospital - copy and verify hospital discharge medication list

3. Other Provider (SNF, Lower level of care, etc.) - copy and verify Provider ' s Medication list

4. It is the process of reviewing the complete medication and comparing the medication lists received on admission with the facility admission medication orders during a resident's admission.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 555786 Department of Health & Human Services Printed: 08/28/2025 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 555786 B. Wing 04/22/2025

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

Ocean Park Healthcare 2828 Pico Boulevard Santa Monica, CA 90405

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49571

Residents Affected - Few Based on interview and record review, the facility failed to ensure one of three sample residents (Resident 1) medical record was complete and accurate by failing to transcribe the prescribed medication apixaban/Eliquis (an anticoagulant or blood thinner medication used to prevent blood clots to prevent stroke and harmful blood clots in the blood vessels) which was part of Resident 1 ' s General Acute Care Hospital (GACH) physician transfer orders.

This deficient practice resulted in Resident 1's medical record to be incomplete and inaccurate.

Cross Reference: