Western Conv. Hospital

F-F688.

Findings:

During a review of the active physician's orders for residents on RNA services dated 3/19/2025, the physician's orders indicated 81 residents had physician's orders for the RNA to provide treatments and services including but not limited to, ROM exercises to upper extremities (UE, shoulder, elbow, wrist, hand) and lower extremities (LE, hip, knee, ankle, foot), application of splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) or braces (an external device to support, align, or correct a movable part of the body), and ambulation (walking).

During a review of the facility's 2/2025 and 3/2025 Nursing Staffing Assignment and Sign-in Sheet for Nurse Assistants, the Sign-in Sheet indicated the following RNA staff assignments for the 7 a.m. to 3:30 p.m. shift:

-2/28/2025: one (1) RNA

-3/3/2025: two (2) RNAs

-3/8/2025: zero (0) RNA

-3/16/2025: 0 RNA

-3/17/2025: 2 RNAs

During an interview on 3/19/2025 at 8:31 a.m., with Restorative Nursing Aide (RNA 1), RNA 1 stated sometimes she was reassigned from RNA duty to have certified nursing assistant (CNA) duties.

During an interview on 3/19/2025 at 9:23 a.m., with Restorative Nursing Aide (RNA 2), RNA 2 stated she sometimes was reassigned as a CNA and tried to see as many residents as possible for RNA after her CNA duties. RNA 2 stated if she had CNA assignments, then it was difficult to see all the residents for RNA.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0725 During an interview with the Director of Staff Development, and concurrent record review of the Nursing Staff Assignments and Sign-In Sheets on 3/19/2025 at 2:31 p.m., the Director of Staff Development (DSD) stated Level of Harm - Minimal harm or on weekends, there should be one RNA staffed each day, and on weekdays there should be at least three to potential for actual harm four RNAs. The DSD reviewed the daily 2/2025 and 3/2025 Nursing Staff Assignment and Sign-In Sheets and confirmed there were not enough RNA staff on the following days: 2/28/2025, 3/3/2025, 3/8/2025, Residents Affected - Some 3/16/2025, and 3/17/2025. The DSD stated the facility was short of CNA staff, and so many times the RNAs were pulled from their RNA duties and given CNA duties. The DSD stated it was important for residents on RNA to receive their RNA treatments as ordered, because the purpose of RNA was to help residents stay mobile, prevent any more contractures, and restore their strength and ADLs. The DSD stated if residents missed their RNA treatments frequently, then residents could revert back to more contractures and become weaker.

During an interview on 3/20/2025 at 11:09 a.m., with the Director of Nursing, the Director of Nursing (DON) stated it was important to have sufficient RNA staffing to ensure residents on RNA programs received their RNA treatments. The DON stated the RNA program was to help prevent contractures and keep the resident's joint mobility stable.

During a review of the facility's policies and procedures (P&P) revised 8/2022, titled, Staffing, Sufficient and Competent Nursing, the P&P indicated our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and facility assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm 49131

Residents Affected - Some 48712

Based on interview and record review, the facility failed to ensure two Licensed Vocational Nurses (LVN) knew what the purpose of checking orthostatic hypotension (a condition where blood pressure drops significantly when a person stands up from a sitting or lying position or sits up from a lying position) was for and how to obtain blood pressure readings, to determine if a resident had orthostatic hypotension.

This deficient practice had the potential to place residents at risk for a delay in care and services which could result in falls or injury.

Findings:

During an interview on 3/19/2025 at 3:02 p.m. with LVN 4, LVN 4 stated orthostatic blood pressure is ordered for residents who are taking psychotropic (drugs that affect a person's mental state) medications. LVN 4 stated the purpose is to determine if the resident on psychotropic medication had hypotension (low blood pressure). LVN 4 stated the procedure for taking orthostatic blood pressure is done by taking the resident's blood pressure in the lying position first, and if necessary, would take the sitting blood pressure immediately after. LVN 4 stated if the blood pressure in the lying position did not show the resident was hypotensive, then

they did not have to take another blood pressure reading in the sitting position and can use the blood pressure in the lying position for the sitting.

During an interview on 3/20/2025 at 12:51 p.m. with LVN 6, LVN 6 stated orthostatic blood pressures are done for the resident on the day and shift it was ordered for. LVN 6 stated if ordered for lying and sitting, the staff would take it in both of those positions at the resident's convenience. LVN 6 stated if the resident happened to be sitting up in their wheelchair or eating, they could take the blood pressure in the sitting position then and later if they are lying down resting, they could take it then. LVN 6 stated the two blood pressure readings do not need to be taken in a particular timeframe but just that is it done on the shift.

During an interview on 3/20/2025 at 1:54 p.m. with the Director of Staff Development (DSD), the DSD stated

the nurses would take an orthostatic blood pressure to determine orthostatic hypotension in the positions it was ordered for. The DSD stated that could be lying to sitting or lying to standing but usually it is just lying to sitting. The DSD stated the procedure is to have the resident lie down first and take the blood pressure in that position, then they would have the resident sit, wait about 5 minutes and then taking another blood pressure in that position. The DSD stated that if there was a change of 20 millimeter of mercury (mmHg- unit of measurement) in the systolic (top number in a blood pressure reading) and or 10 mmHG in the diastolic (bottom number in the blood pressure reading) value, that would indicate the resident is positive for orthostatic hypotension and the nurse would need to notify the doctor to see if there are new orders that would need to be done.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0726 During a review of the facility's Job Description for LVN, dated 3/7/2024, the Job Description indicated the position is responsible for assuring physicians' orders are followed and quality care is provided on each shift Level of Harm - Minimal harm or in a skilled care facility. potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40994 potential for actual harm Based on interview and record review, the facility failed to monitor blood pressure related to the use of Residents Affected - Some amlodipine (a medication used to treat high blood pressure) with hold parameters (instructions in the medication order to hold the medication if the blood pressure reading is too low) between 3/23/24 and 3/31/24.

The deficient practice of failing to monitor blood pressure related to the use of amlodipine increased the risk that Resident 83 could have experienced adverse effects related to receiving amlodipine when her blood pressure was too low possibly resulting in dizziness and falls with injury.

Findings:

During a review of Resident 83's Admission Record, dated 3/20/25, the Admission Recordindicated she was admitted to the facility on [DATE REDACTED] with diagnoses including hypertension (high blood pressure.)

During a review of Resident 83's available Care Plans (a resident-centered plan of care developed to address a resident's unique health care needs), dated 3/13/24, revised 3/27/24, the care plan indicated Resident 83 was at risk for elevated BP (blood pressure) and to Monitor pulse rate and BP as ordered.

During a review of Resident 83's available Care Plans, dated 3/13/24, the care plan indicated she was as risk of falls/injury related to the use of antihypertensive medications and to Assess resident's medication for possible adverse effects .

During a review of Resident 83's Order Audit Report (a report with information about a previous medication order), dated 3/20/25, the order summary report indicated Resident 83 received amlodipine 5 mg by mouth one time a day for hypertension - hold for SBP (systolic blood pressure - the top number in a blood pressure reading) less than 120 between 3/15/24 and 1/28/25.

During a review of Resident 83's Medication Administration Record (MAR - a record of all medications administered, and monitoring recorded for a resident), for March 2024, the MAR indicated between 3/23/24 and 3/31/24, there were no blood pressure readings documented corresponding to the administrations of amlodipine.

During an interview on 3/20/25 at 12:21 PM with the Director of Nursing (DON), the DON stated the facility failed to monitor Resident 83's blood pressure related to her use of amlodipine between 3/23/24 and 3/31/24.

The DON stated, although there are some BP readings in the progress notes, the BP would need to be documented consistently in the MAR to be relevant to the hold parameters on Resident 83's order for amlodipine. The DON stated, without the blood pressure readings recorded there, it cannot be determined if

the licensed nurses gave Resident 83 the amlodipine within the hold parameters specified by the physician's order.

The DON stated this increased the risk that the resident could have consequences of receiving amlodipine when her blood pressure was too low possibly leading to dizziness and falls with injury.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0757 During a review of the facility's policy and procedure (P&P) titled, Specific Medication Administration Procedures, dated April 2008, the P&P indicated .Obtain and record any vital signs as necessary prior to Level of Harm - Minimal harm or medication administration . potential for actual harm

During a review of the facility's P&P Documentation of Medication Administration, revised March 2023, the Residents Affected - Some P&P indicated The facility shall maintain a medication administration record to document all medication administered .Documentation must include, as a minimum: .specific medication parameters (e.g. blood pressure .).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48712 Residents Affected - Some 40994

Based on interview and record review, the facility failed to:

1. Ensure one of six sampled residents (Resident 1) was not prescribed Seroquel (a drug used to treat a mental health condition) without an appropriate diagnosis.

2. Define and monitor behaviors related to the use with lorazepam (a medication used to treat mental illness) for one of five residents sampled residents (Resident 83).

These deficient practices placed Resident 1 and Resident 83 at risk of adverse effects (bad outcome).

Findings:

A. During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE REDACTED] with diagnoses including hypotension (low blood pressure), diabetes ([DM]

a disorder characterized by difficulty in blood sugar control and poor wound healing), and asthma (a chronic lung condition characterized by recurrent episodes of wheezing, shortness of breath, and coughing).

During a review of Resident 1's History and Physical (H&P), dated 11/4/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P did not indicate Resident 1 had a mental illness.

During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 1/2/2025, the MDS indicated Resident 1's cognitive (process of thinking and reasoning) skills for daily decision making were moderately impaired. The MDS indicated Resident 1 did not have a mood disturbance. The MDS indicated Resident 1 did not have potential indicators of psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). The MDS indicated Resident 1 did not have a psychiatric/mood disorder. The MDS indicated Resident 1 was dependent on staff for toileting, showering, and dressing.

During a review of Resident 1's Psychiatric Evaluation dated 3/10/2025, the evaluation indicated Resident 1 had a diagnosis of Anxiety NOS. Rule out psychosis.

During a review of Resident 1's Order Summary Report dated 3/20/2025, the report indicated the physician entered an order on 2/7/2025 to give Seroquel 50 milligrams ([mg] a unit of measure in drug dosing) two times a day for psychosis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0758 During a review of Resident 1's Preadmission Screening and Resident Review ([PASARR] a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities Level of Harm - Minimal harm or are placed in facilities that can provide the appropriate care) dated 3/20/2024, the PASARR indicated potential for actual harm Resident 1 did not have a serious mental disorder or symptoms of psychosis.

Residents Affected - Some During a concurrent interview and record review on 3/21/2025 at 9:26 a.m. with Registered Nurse (RN) 1, Resident 1's electronic medical record (EMR) was reviewed. RN 1 could not find evidence of a diagnosis of psychosis in the EMR. RN 1 stated a resident should not be taking Seroquel without a mental health diagnosis. RN 1 stated a resident taking Seroquel without an indication could cause drowsiness and decreased function.

During a review of the facility's policy and procedure (P&P) titled, Psychotropic (medications that affect brain activities associated with mental process and behavior) Medication Use dated 3/2023, the P&P indicated psychotropic medications are not prescribed or given to residents unless it is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record.

B. During a review of Resident 83's Admission Record, the Admission Record indicated Resident 83 was admitted to the facility on [DATE REDACTED] with diagnoses including vascular dementia (a condition involving memory loss and thinking problems caused by loss of blood flow to the brain) and anxiety (excessive worry about everyday situations strong enough to interfere with daily activities).

During a review of Resident 83's Order Audit Report dated 3/20/25, the Report indicated Resident 83 received lorazepam 0.5 mg. by mouth every four hours as needed for moderate anxiety between 3/15/24 and 4/19/24.

During a review of Resident 83's Care Plan dated 3/27/24, the Care Plan indicated Resident 83 was at risk for adverse effects related to the use of lorazepam to treat anxiety. The Care Plan indicated nursing interventions included to monitor and record episodes of behaviors per psychotropic policy.

During a review of Resident 83's Medication Administration Record (MAR) dated 3/2024, the MAR did not indicate behaviors were defined or monitored and documented between 3/23/24 and 3/31/24 related to the administration of lorazepam.

During an interview on 3/20/25 at 12:21 p.m. with the Director of Nursing (DON), the DON stated the facility failed to monitor or define Resident 83's behaviors between 3/23/24 and 3/31/24. The DON stated the order indicated lorazepam was for moderate anxiety but did not specify any behavioral manifestation that could be objectively monitored and documented by licensed staff. The DON stated the MAR from 3/2024 indicated there was no monitoring of any behaviors related to the use of lorazepam done during that time. The DON stated monitoring and defining behaviors related to psychotropic medication use was important to help the facility and prescribers to assess whether the medication was effective at controlling behaviors and adequately treating the condition for which they were indicated. The DON stated failing to monitor for behaviors increased the risk that Resident 83 could have experienced adverse effects of lorazepam or experienced untreated symptoms of anxiety possibly leading to a decline in the resident's quality of life.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0758 During a review of the facility's P&P titled, Psychotropic Medication Use dated 3/2023, the P&P indicated Residents, families, and/or the representative are involved in the medication management process. Level of Harm - Minimal harm or Psychotropic medication management includes adequate monitoring for efficacy. potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40994 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure its medication error rate was Residents Affected - Some less than five percent (%). Two medication errors out of 33 total opportunities contributed to an overall medication error rate of 6.06 % affecting two of six residents observed for medication administration (Residents 4 and 83). The facility failed to:

1. Administer the correct strength of cranberry (a supplement) supplement to Resident 4.

2. Administer the correct formulation of multivitamins (a vitamin supplement) to Resident 83.

The deficient practices of failing to administer medications in accordance with the physician's orders increased the risk that Residents 4 and 83 may have experienced medical complications possibly resulting in hospitalization .

Findings:

1). During a review of Resident 4's Admission Record, dated 3/20/25, the Admission Record indicated she was admitted to the facility on [DATE REDACTED] and most recently readmitted on [DATE REDACTED] with diagnoses including personal history of traumatic brain injury (an injury to the head causing difficulty in everyday activities.)

During a review of Resident 4's History and Physical (H&P - a record of a comprehensive physician's assessment), dated 9/17/23, the H&P did not indicate whether she had the capacity to understand and make decisions.

During a review of Resident 4's Order Audit Report (a report with information about a previous medication order), dated 3/25/25, the order audit report indicated Resident 4 was prescribed cranberry 425 milligrams (mg - a measure of unit for mass) between 3/2/25 and 3/19/25.

During an observation on 3/19/25 at 8:05 AM with the Licensed Vocational Nurse (LVN 4), LVN 4 was observed preparing Cranberry 450 mg supplement for Resident 4 by crushing the tablet and mixing it with a small amount of applesauce.

During an observation on 3/1/25 at 8:30 AM, Resident 4 was observed taking the Cranberry 450 mg by mouth by spoon feeding herself the crushed medication and applesauce mixture.

2). During a review of Resident 83's Admission Record, dated 3/20/25, the Admission Record indicated she was admitted to the facility on [DATE REDACTED] with diagnoses including hypertension (high blood pressure.)

During a review of Resident 83's Order Audit Report, dated 3/25/25, rhe order audit report indicated Resident 83 was prescribed Centrum Oral Liquid (a liquid multivitamin formulation) to take 15 milliliters (ml - a unit of measure for volume) by mouth one time a day between 3/15/24 and 3/19/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0759 During an observation on 3/19/25 at 9:01 AM, LVN 4 was observed preparing one tablet of multivitamins with minerals for Resident 83 by crushing the tablet and mixing with a small amount of applesauce. Level of Harm - Minimal harm or potential for actual harm During an observation on 3/19/25 at 9:17 AM, LVN 4 was observed spoon feeding the crushed multivitamin with minerals tablet and applesauce mixture to Resident 83. Residents Affected - Some

During an interview on 3/19/25 at 12:07 PM with LVN 4, LVN 4 stated she failed to give the correct dose of Cranberry to Resident 4 by administering a 450 mg tablet when the order was for 425 mg. LVN 4 stated she failed to ensure the dose of the product she administered matched the physician's order. LVN 4 stated she should have clarified the order with the physician to allow for administering the product on hand before administering a different strength. LVN 4 stated she administered the incorrect formulation of multivitamins to Resident 83 by administering the tablet instead of the liquid formulation specified in the physician's order. LVN 4 stated she thought they were substitutable but didn't realize they contain a completely different formulation and strengths of the vitamins. LVN 4 stated following the physician's order is important to ensure residents received exactly what they were prescribed. LVN 4 stated failing to follow the physician order regarding medication strength or formulation could have increased the risk that Residents 4 and 83 could have experienced medical complications from receiving medications incorrectly.

During a review of the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, revised October 2017, the P&P indicated .Medications are administered in accordance with the written orders of the attending physician .

During a review of the facility's P&P titled, Specific Medication Administration Procedures, dated April 2008,

the P&P indicated To administer medication in a safe and effective manner . read medication label before administering .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40994 potential for actual harm Based on interview and record review, the facility failed to ensure its residents were free from significant Residents Affected - Few medication errors by administering amlodipine (a medication used to treat high blood pressure) outside of the hold parameters (instructions in the medication order to hold the medication if the blood pressure reading is too low) a total of 81 times between 4/1/24 and 1/28/25 affecting one of five residents sampled for unnecessary medications (Resident 83.)

The deficient practice of failing to administer amlodipine in accordance with hold parameters as specified in

the physician order contributed to two falls resulting in injuries to Resident 83's face and hands on 4/10/24 and 6/20/24 and increased the risk that Resident 83 may have experienced other adverse effects of low blood pressure such as dizziness, possibly resulting in a decline in her quality of life.

Findings:

During a review of Resident 83's Admission Record, dated 3/20/25, the Admission Record indicated Resident 83 was admitted to the facility on [DATE REDACTED] with diagnoses including hypertension (high blood pressure.)

During a review of Resident 83's available Care Plans, dated 3/13/24, revised 3/27/24, the care plan indicated Resident 83 was at risk for elevated BP (blood pressure) and to monitor pulse rate and BP as ordered.

During a review of Resident 83's available Care Plans, dated 3/13/24, the care plan indicated she was as risk of falls/injury related to the use of antihypertensive medications and to assess resident's medication for possible adverse effects .

During a review of Resident 83's available Care Plans, dated 4/10/24, the care plan indicated Resident 83 had actual falls on 4/10/24 and 6/20/24 related to antihypertensive medication, cognitive impairment, history of falls, and unsteady gait but contained no interventions specific to antihypertensive medications.

During a review of the consultant pharmacist's recommendation, dated 12/30/24, concerning Resident 83's order for amlodipine, the recommendation indicated please consistently acknowledge SBP hold parameter .

During a review of Resident 83's Order Audit Report (a report with information about a previous medication order), dated 3/20/25, the order audit report indicated Resident 83 received amlodipine 5 mg by mouth one time a day for hypertension - hold for SBP (systolic blood pressure - the top number in a blood pressure reading) less than 120 between 3/15/24 and 1/28/25.

During a review of Resident 83's Medication Administration Record (MAR - a record of all medications administered, and monitoring recorded for a resident), between 4/1/24 and 1/28/25, the MAR indicated licensed staff administered Resident 83's amlodipine when her SBP was less than 120 a total of 81 times including on 4/10/24 and 6/20/24 (the days Resident 83 experienced falls with injuries.)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 review of Resident 83's Change of Condition (COC - a record of a change in a resident's health due to a new illness, fall, unusual behavior, or worsening of an existing condition form, dated 4/10/24, the COC Level of Harm - Minimal harm or indicated on 4/10/24 at 3:30 PM, Resident 83 was found lying on the floor with a small cut on her forehead potential for actual harm and pain in her left wrist.

Residents Affected - Few During a review of Resident 83's COC, dated 6/23/24, the COC indicated on 6/20/24 at 10:30 AM, Resident 83 was found on the floor with right side facial swelling.

During an interview on 3/20/25 at 12:21 PM with the Director of Nursing (DON), the DON stated hold parameters on blood pressure medications are added so the residents do not receive blood pressure lowering medication when their blood pressure is already too low. The DON stated giving blood pressure medication to a resident with low blood pressure increases the risk of dizziness and falls which may result in injury. The DON stated the facility failed to ensure licensed staff observed the hold parameters for Resident 83's amlodipine 81 times between 4/1/24 and 1/28/25 by administering the medication with a systolic blood pressure reading lower than 120. The DON stated the licensed nurses might not have carefully checked the hold parameter on Resident 83's amlodipine order as it seems like they were usually holding the medication when the SBP was less than 110. The DON stated Resident 83's care plan for falls indicated she was at increased risk of falls related to her use of antihypertensive medication and giving amlodipine outside of the medication's hold parameters could have contributed to her falls on 4/10/24 and 6/20/24. The DON stated on 4/10/24 amlodipine was administered outside of parameters and on 6/19/24, 6/20/24, and 6/21/24 amlodipine was also administered outside of

parameters. The DON stated the timing of these administrations could have contributed to Resident 83's falls and injuries around those times.

During a review of the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, revised October 2017, indicated .Medications are administered in accordance with the written orders of the attending physician .

During a review of the facility's P&P titled, Specific Medication Administration Procedures, dated April 2008, indicated To administer medication in a safe and effective manner . read medication label before administering .

During a review of the facility's P&P titled, Hypertension - Clinical Protocol, revised March 2023, indicated

The staff and physician will monitor for complications of blood pressure treatments such as .dizziness .falling . Over-treating blood pressure may increase the risk of significant side effects and complications, such as falling and fractures, especially in compromised or frail individuals .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49131 potential for actual harm Based on interview, and record review, the facility failed to ensure one of four sampled residents (Resident Residents Affected - Some 8) had the correct laboratory tests done as ordered by the physician.

This deficient practice had the potential to result in Resident 8 to experience a delay in services due to incomplete laboratory results.

Findings:

During a review of Resident 8's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 8 was originally admitted on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included hyperlipidemia (high levels of fats in the blood), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).

During a review of Resident 8's Care Plan, dated 9/20/2019, the Care Plan indicated Resident 8 was a risk for dehydration due to the use of medications for bipolar disorder and interventions included to perform laboratory tests as ordered and to notify the doctor for abnormal values.

During a review of Resident 8's History and Physical (H&P), dated 5/15/2024, the H&P indicated Resident 8 did not have the capacity to understand and make decisions.

During a review of Resident 8's Minimum Data Set (MDS - a resident assessment tool), dated 2/12/2025, the MDS indicated Resident 8 had no limitations to their upper extremities (related to the arms) and had limitations to their lower extremities (related to the legs).

During a review of Resident 8's Consultant Pharmacist's Medication Regimen Review (CPMRR-an assessment of a patient's current medication list to identify potential drug interactions, adverse effects, and opportunities for optimization ), dated 1/2025, the CPMRR indicated to follow up with the doctor to consider a thyroid panel (a group of blood test to assess the function of the thyroid gland [a gland that makes and releases hormones]) for the next convenient laboratory tests.

During a review of Resident 8's Order Summary Report, dated 1/28/2025, the Order Summary Report indicated a thyroid panel was ordered per the pharmacist's recommendation.

During a review of Resident 8's Laboratory Results Report, dated 1/30/2025, the Laboratory Results Report indicated that a thyroid peroxidase (an enzyme found in the thyroid gland) and thyroglobulin antibody (an antibody [proteins produced by the immune system in response to foreign substances] that targets a protein produced by the thyroid gland) test was performed.

During a concurrent interview and record review on 3/20/2025 at 2:15 p.m. with Registered Nurse (RN) 2, Resident 8's Laboratory Results Report, Order Summary Report, and CPMRR was reviewed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0770 RN 2 stated a thyroid panel laboratory test was recommended by the pharmacist in the CPMRR, and a thyroid panel laboratory test was ordered on 1/28/2025 as indicated on the Order Summary Report. RN 2 Level of Harm - Minimal harm or stated a thyroid panel was ordered for Resident 8 because she was taking Seroquel (a medication that treats potential for actual harm several kinds of mental health conditions such as bipolar disorder), and Seroquel can cause a decrease in thyroid function. Resident 8's Laboratory Test Results were reviewed on 1/30/2025 and RN 2 stated a thyroid Residents Affected - Some peroxidase and thyroglobulin antibody was done and a thyroid panel was not done. RN 2 stated the thyroid panel will test for triiodothyronine (T3- a thyroid hormone that plays a role in growth, and development), thyroxine (T4- another thyroid hormone that plays a role in growth, and development), and thyroid stimulating hormone (TSH- a hormone that regulates the function of the thyroid gland). RN 2 stated a thyroid panel was not done and a thyroid peroxidase and thyroglobulin are not the same as a thyroid panel and therefore would not produce the same results as a thyroid panel. RN 2 stated this could cause the doctor to not know if Resident 8 had issues with the thyroid gland.

During a review of the facility's policy and procedure (P&P), titled Lab and Diagnostic Test Results - Clinical Protocol, dated 3/2024, the P&P indicated the physician will identify and order lab testing based on the resident's diagnostic and monitoring needs and the staff will process and arrange for tests to be done. Physician and nurses who have concerns about how test results had been handled or reported should communicate concerns to the Director of Nursing or Medical Director.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm 38740

Residents Affected - Some Based on observation, interview and record review, the facility failed to ensure the standardized recipes for

the lunch menu was followed on 3/18/2025 by failing to:

1. Ensure Eighteen (18) residents on a soft and bite size diet (Diet for people who are not able to bite off pieces of food safely but are able to chew bite sized pieces down into little pieces that are safe to swallow/Bite sized pieces no bigger than 1/2 x 1/2 inches) did not receive whole bread instead of bread that is cut into smaller pieces.

2. Ensure the menu included the texture modified diet (diets that are altered in texture to accommodate resident chewing or swallowing problems includes diets such as Soft and Bite size and Minced and Moist) that was ordered for residents. The menu did not indicate the serving guide for the bread at each meal.

These Deficient practices had the potential to result in meal dissatisfaction, decreased nutritional intake and increased choking risk in 18 residents on a soft and bite size diet.

Findings:

According to the facility lunch menu on 3/18/2025, the following items would be served on a regular diet: BBQ chicken, Potato Salad, Fresh carrots, wheat Roll with Margarine, Strawberry Gelatin and milk.

During an observation in the kitchen on 3/18/2025 at 11:42 a.m., Cook1 stated for residents on a soft and bite size diet we serve them a mechanical soft diet per our menu.

During an interview with the Dietary Supervisor (DS) on 3/18/2025 at 11:45 a.m., the DS stated our menu is still following old standards for diet textures and the menu does not have Soft and bite size diet, but the physician diet orders are based on new IDDSI (Internation dysphagia Diet standardization Initiative-Standards developed to facilitate safe consumption of food and drinks by people with eating and drinking difficulties (dysphagia). It describes the characteristics of foods and drinks and is accompanied with testing methods to determine if the food or drink conforms to the IDDSI standards). The DS stated for residents who are on a soft and bit size diet we use the mechanical soft diet menu. The DS stated a mechanical soft diet and a soft and bite size diet is the same.

During an observation of the tray line service for lunch (a system of food preparation, in which trays move along an assembly line) on 3/18/2025 at 11:50 a.m. Cook1 served residents who were on a soft and bite size diet order, a whole piece of wheat bread roll following the mechanical soft diet menu and serving guide.

During a concurrent interview and review of the menu with Cook1, Cook1 stated whole wheat bread roll is ok for the residents on a soft and bite size diet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0803 During an interview with Registered Dietitian (RD1) and (RD2) on 3/18/2025 at 2p.m., RD1 stated the facility menu is transitioning into the new IDDSI menu. RD1 stated diet orders have already transitioned into the Level of Harm - Minimal harm or IDDSI but not the menu. RD1 stated the facility has a clarification letter that explains the mechanical soft diet potential for actual harm (foods that are easily chewed. Foods are modified in texture by chopping, dicing and grinding) is equivalent to the soft and bite size diet. RD1 stated we are following the menu which has not changed yet to include the Residents Affected - Some soft and bite size diet. RD stated the facility does not have the recipe to make the soft and bite size diet bread. RD1 stated the physician diet orders are not matching the diets that are on the menu. RD 1 stated the diet orders should match the diet on the menu to provide the correct food texture. RD stated the diet manual does not have the new IDDSI diets.

During an interview with the Speech and Language Therapist (ST) on 3/19/2025 at 12 p.m. the ST stated a soft and bite size diet is for residents who cannot bite but can chew. The ST stated the size is the real importance here. The ST said the food should be cut to about 1.5 centimeters (cm) or 1/2 inch. The ST stated the facility menu is currently in transition and the menu is still on old dysphagia diet such as the mechanical soft diet. The ST stated the diet orders have changed to reflect the new terminology of IDDSI but menus have not changed. The ST stated he orders diets based on IDDSI.

During the same interview the ST stated for a soft and bite size diet the bread has to be cut to smaller pieces. The ST stated the diet order is soft and bite size, and the kitchen should provide the food in the soft and bite size diet texture. The ST stated the diets should be ordered consistent with the approved diet manual and menu. The ST stated the facility diet manual does not include IDDSI terminology. (The Diet manual serves as a guide in prescribing diets, helps in planning regular and therapeutic diet menus, and as a reference for developing recipes and preparing diets. Diet manuals are reviewed annually).

During a review of facility's undated policy titled Menu indicated, The menus will be prepared as written using standardized recipes. The Dietary supervisor and cooks are trained and responsible for the preparation and service of therapeutic diets prescribed.

During a review of the facility undated policy titled Diet Orders, the policy indicated, The physician will prescribe diets in accordance with the approved Diet Manual. A written order must appear on the medical records before the resident may be served. The physician will be asked to order diets in accordance with the approved diet manual.

During a review of the facility's diet manual dated 2020, the diet manual did not have a soft and bite size diet description or plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 38740

Residents Affected - Some Based on observation, interview and record review, the facility failed to ensure safe and sanitary food preparation practices were followed in the kitchen when one can opener blade was dirty with dry brown sticky residue and when the blade was worn with the potential to spread harbor harmful bacteria.

This deficient practice had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in 47 out of 109 residents who received food from the facility.

Findings:

During an observation in the kitchen food preparation area on 3/18/2025 at 9:30 a.m. one can opener blade was noted to be dirty and worn out. The blade was stained, covered with brown residue.

During a concurrent observation and interview with the Dietary Supervisor (DS) on 3/18/2025 at 9:35 a.m.,

the DS verified that there is only one can opener in the kitchen. The DS verified that the blade had brown sticky residue. The DS did not know what the dark brown color residue was. DS stated it could be removed with washing. The DS did not know when the last time the blade was washed.

During a review of the facility's undated policy and procedure (P&P) titled, Sanitizing Equipment and surfaces, the P&P indicated, Dietary staff should ensure that all equipment, shelves, serving utensils and surface areas are clean and in good condition.

During a review of the 2022 U.S. Food and Drug Administration Food Code titled, Good Repair and proper adjustment Code # 4-501.11(C), indicated, Cutting or piercing parts of Can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened.

During a review of 2022 Food Code titled, Can Openers Code# 4-202.15, indicated, Once can openers become pitted or the surface in any way becomes uncleanable, they must be replaced because they can no longer be adequately cleaned and sanitized.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Minimal harm or 38740 potential for actual harm Based on observation, interview, and record review, the facility's policy on food from outside and brought by Residents Affected - Some family-visitors did not address how to store and reheat food to ensure safe and sanitary food storage, handling and consumption. For residents who have leftover food brought from outside the facility, the facility policy does not have a procedure for safe food handling. This had the potential to cause food borne illness in residents in the facility who were served the food brought by family or visitors.

Findings:

During an interview with Dietary Supervisor (DS) on 3/18/2025 at 10:30 a.m. the DS stated resident's families are encouraged not to bring anything that needs to be stored. The DS stated residents can have food from outside for one meal because there is no space to store the resident's leftover food from visitors.

The DS stated anything leftover will be discarded per our policy.

During an interview with charge nurse (LVN2) on 3/18/2025 at 11a.m., LVN2 stated there is no refrigerator for residents at the nursing station. LVN2 stated there are some residents who receive food from outside but there is no refrigerator for residents to store leftover perishable food.

During an interview with the treatment nurse (LVN5) on 3/18/2025 at 11:15 a.m. LVN5 stated she has not seen any resident refrigerator in the facility.

During an interview with the DON on 3/19/2025 at 9:34 a.m., the DON stated our policy is that no outside food for residents will be stored. The DON stated the facility does not have a refrigerator to store residents' food from family or visitors. The DON stated the facility only allows family to bring enough food to consume for one meal and the family needs to discard or take leftovers back. The DON stated she is not aware of any residents who request for food to be stored for later consumption or have food from outside. The DON stated if residents want to store the food, the facility does not have the policy and procedure that address how and where to store food safely.

During an interview with Adminstrator (ADM) on 3/19/2025 at 10 a.m., the ADM stated the facility policy does not have a procedure on how and where to store resident food brought from outside.

During a review of the facility's policy and procedure (P&P) titled, Food From Outside Sources, undated, the P&P indicated, Food from outside sources is discouraged due to concerns with food safety and infection control and maintaining control of therapeutic diet orders .If outside food is brought in, the facility is not liable for any food safety and infection control . The charge nurse must be notified if any outside food is brought in .

The staff will discard any leftover.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48712 potential for actual harm Based on observation, interview, and record review, the facility failed to implement its infection control Residents Affected - Many program by failing to:

1. Ensure the Laundry Aide (LA) performed hand hygiene, changed gown and gloves after sorting dirty linen and prior to handling clean linen. This deficient practice put all the residents at risk for cross contamination (movement of bacteria from one place to another) and infection.

2. Refrigerate opened food item, as indicated in the bottle container, for one of three sampled residents (Resident 93). This deficient practice had the potential for Resident 93 to experience foodborne illnesses (food poisoning).

Findings:

1. During a concurrent observation and interview on 3/19/2025 at 11:54 a.m. with the LA in the laundry room,

the LA was observed sorting dirty linen from the laundry chute. The LA then went to the clean area and rolled

a large cart containing clean linen to the middle of the floor, without performing hand hygiene and removing contaminated gloves and gown, after sorting the dirty linens. The LA stated she should have changed her gown and gloves after touching the dirty linen. The LA stated touching dirty linen, then clean linen can cause cross contamination and lead to infection.

During an interview on 3/19/2025 at 12:49 p.m. with the Infection Prevention Nurse (IPN), the IPN stated

after sorting the dirty linen and loading dirty linen in the washer, the LA should have changed her gown/gloves, before touching the clean linen to prevent cross contamination. The IPN stated, urine and feces from the dirty linen can be transferred to the clean linen and can lead to infection.

During a review of the facility's undated policy and procedure (P&P) titled, Laundry Route & Process, the P&P indicated staff should wash hands after handling soiled linens. The P&P indicated, infection control techniques should be used to prevent cross-contamination of linen and to protect the spread of infection.

49131

2. During a review of Resident 93's Admission Record, the Admission Record indicated Resident 93 was admitted to the facility on [DATE REDACTED] with diagnoses including hyperlipidemia (elevated levels of fats in the blood), and hypertension (high blood pressure).

During a review of Resident 93's History and Physical (H&P), dated 6/26/2024, the H&P indicated Resident 93 had the ability to understand and make decisions.

During a review of Resident 93's Minimum Data Set (MDS- a resident assessment tool), dated 12/26/2024,

the MDS indicated Resident 93 did not have any limitations to the upper and lower extremities (arms and legs).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0880 During an observation on 3/18/2025 at 9:38 a.m. in Resident 93's room, Resident 93 had a bottle of opened and halfway used, bottle of strawberry jam on the bedside table. The label on the strawberry jam stated to Level of Harm - Minimal harm or Refrigerate After Opening. potential for actual harm

During a concurrent observation and interview on 3/19/2025 at 12:19 p.m. with Licensed Vocational Nurse Residents Affected - Many (LVN) 4, LVN 4 observed Resident 93's used bottle of strawberry jam on the bedside table. LVN 4 stated the facility did not have a refrigerator to store the resident's personal food items. LVN 4 read the label on the bottle of strawberry jam, and LVN 4 stated the label indicated to refrigerate the bottle of strawberry jam after opening. LVN 4 stated it was not known when the strawberry jam was brought in or when it was opened. LVN 4 stated not refrigerating the product after opening and consuming it later, had the potential to cause food poisoning.

During a review of the facility's undated P&P, the P&P indicated food from outside sources is discouraged due to concerns with food safety and infection control.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 48 555069

F-F725.

Findings:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0688 During a review of Resident 15's Admission Record (AR), the AR indicated Resident 15 was admitted to the facility on [DATE REDACTED] with diagnoses including but not limited to hemiplegia (weakness to one side of the body) Level of Harm - Minimal harm or and hemiparesis (inability to move one side of the body) following nontraumatic intracerebral hemorrhage potential for actual harm (bleeding in the brain) affecting right dominant side.

Residents Affected - Some During a review of Resident 15's CP revised on 8/24/2022, the CP indicated Resident 15 had limitations in bed mobility, ADLs, gait (walking), and balance. The CP goal indicated Resident 15 will develop no complications related to decreased mobility or contractures (loss of motion of a joint). The CP interventions indicated restorative nursing treatment and right UE (RUE) passive range of motion (PROM, movement at a given joint with full assistance from another person) followed by RUE hand and elbow splint two to four hours once a day five times a week or as tolerated.

During a review of Resident 15's care plan (CP) revised on 9/4/2023, the CP indicated Resident 15 had an alteration in joint mobility. The CP goal indicated Resident 15 will minimize the risk for further ROM loss daily. The CP interventions indicated to provide RNA program as ordered.

During a review of Resident 15's Minimum Data Set (MDS, a resident assessment tool) dated 2/6/2025, the MDS indicated Resident 15 required modified independence for daily decision making. The MDS indicated Resident 15 had functional limitations in ROM on one side of the upper extremity (UE, shoulder, elbow, wrist/hand) and one side of the lower extremity (LE, hip, knee, ankle/foot). The MDS indicated Resident 15 was independent in sit to lying and rolling left and right. The MDS indicated Resident 15 required set up assistance for eating, and personal hygiene. The MDS indicated Resident 15 required supervision assistance for dressing, sit and stand, and chair to bed transfers.

During a review of Resident 15's Order Summary Report (OSR) dated 3/19/2025, the OSR indicated the following orders:

-RNA to perform ambulation (walking) using hemi walker (type of walking support device used with one hand) with ankle foot orthosis (AFO, an orthotic device designed to correct or address problems with the ankle and foot) on RLE once a day five times a week or as tolerated ordered 12/5/2022.

-RNA to perform PROM to RUE in all places as tolerated five times a week ordered 2/6/2025.

-RNA program for application of right elbow splint for four hours or as tolerated seven times a week ordered 2/25/2025.

-RNA program for application of right resting hand splint for four hours or as tolerated seven times a week ordered 2/25/2025.

1) a. During an observation on 3/19/2025 at 8:23 a.m., Resident 15 was sitting up in a wheelchair in the hallway. Resident 15 was wearing a right resting hand splint and a right elbow splint.

During an observation on 3/19/2025 at 2:06 p.m., Resident 15 was sitting up in a wheelchair and was wearing a right resting hand splint and a right elbow splint.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0688 During a review of Resident 15's 2/2025 and 3/2025 RNA Documentation Survey Report (DSR), the DSR indicated RNA applied right elbow splint and right resting hand splint for six hours on 2/25/2025, 2/26/2025, Level of Harm - Minimal harm or 3/3/2025, 3/4/2025, 3/5/2025, 3/6/2025, 3/7/2025, 3/9/2025, 3/10/2025, 3/11/2025, 3/12/2025, 3/13/2025, potential for actual harm 3/14/2025, 3/17/2025, 3/18/2025, and 3/19/2025.

Residents Affected - Some During an interview on 3/19/2025 at 12:52 p.m., the Director of Rehabilitation (DOR) and the Occupational Therapist (OT 1) stated RNA was a maintenance program to help prevent resident's decline in function, ROM, and prevent worsening of contractures. DOR and OT 1 stated if a resident required a splint or brace, then an RNA order was written for the type of splint and the hours the resident should wear the splint. The DOR and OT 1 stated only therapists had the training to determine the maximum time a resident could safely wear a splint and the risks of wearing a splint for too long. OT 1 stated if a resident wore a splint for longer than the determined maximum and safe wearing time, then the resident could sweat, cause skin issues, and cause pain. OT 1 stated Resident 15 could have decreased sensation on the right upper extremity and if staff allowed Resident 15 to wear the splint for longer than the determined maximum wearing time, then Resident 15 was at risk for harm. DOR and OT 1 stated residents should not wear a splint or brace for longer than the time therapy determined was the maximum safe wearing time.

During an interview on 3/20/2025 at 11:09 a.m., the Director of Nursing (DON) stated the RNA program required a specific physician's order and RNAs were to follow the physician's order for RNA as the order was written and ordered.

During a review of the facility's undated policy and procedures (P&P) titled, Splinting, the P&P indicated contraindications for splinting included, prolonged immobility from splint can produce limitations in joint ROM and delicate skin that cannot tolerate pressure of a splint without causing skin breakdown. The P&P also indicated when the therapist has determined that the splint has reached maximum benefit to the resident, the therapist will Inservice nursing staff on the proper application and wearing schedule.

During a review of the facility's RNA Job Description (JD) dated 8/23/2011, the RNA JD indicated RNA provides residents with routine restorative nursing care and services in accordance with the resident's assessment, care plan and as directed by supervisors.

b. During a review of Resident 15's RNA DSR dated 2/2025, the DSR indicated RNA treatment for ambulation using hemi walker five times a week, PROM to RUE in all planes five times a week, application of right elbow splint seven times a week and application of right

During a review of Resident 15's RNA DSR dated 3/2025, the DSR indicated RNA treatment for application of right elbow splint and application of right resting hand splint seven times a week was not completed on 3/1/2025, 3/8/2025, and 3/16/2025.

During an interview and record review on 3/20/2025 at 9:57 a.m., the Director of Staff Development (DSD) reviewed Resident 15's RNA orders and 2/2025 and 3/2025 RNA DSR and confirmed Resident 15 did not receive RNA treatment as ordered on 2/27/2025, 3/1/2025, 3/8/2025, and 3/16/2025. The DSD stated it was important for residents to receive their RNA treatments as ordered so the resident's contractures did not worsen, or muscles did not weaken. The DSD stated the RNA program was for the residents to improve and thrive and participate in daily activities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0688 During an interview on 3/20/2025 at 11:09 a.m., the Director of Nursing (DON) stated it was important to have sufficient RNA staffing to ensure residents on the RNA programs received their RNA treatments. The Level of Harm - Minimal harm or DON stated the RNA program was to help prevent contractures and keep the resident's joint mobility stable. potential for actual harm

During a review of the facility's P&P revised 7/2017 titled, Resident Mobility and Range of Motion, the P&P Residents Affected - Some indicated residents with limited ROM will receive treatment and services to increase and/or prevent further decrease in ROM.

During a review of the facility's P&P RNA Job Description (JD), the JD indicated RNAs assists with residents with ROM exercises, and ambulation/transfer exercises per the physician's orders.

2). During a review of Resident 2's Admission Record (AR), the AR indicated Resident 2 admitted to the facility on [DATE REDACTED] with diagnosis including but not limited to hemiplegia and hemiparesis following unspecified cerebrovascular disease (disease of the blood vessels, especially blood vessels to the brain) affecting left non-dominant side and contracture, unspecified joint.

During a review of Resident 2's MDS dated [DATE REDACTED], the MDS indicated Resident 2 was severely impaired in cognitive skills (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving) for daily decision making. The MDS indicated Resident 2 had functional limitations in ROM on one side of the upper extremity and one side of the lower extremity. The MDS indicated Resident 2 required supervision assistance with eating and was dependent on staff for bathing, oral hygiene, lower body dressing and bed to chair transfers.

During a review of Resident 2's care plan (CP) revised 1/9/2022, the CP indicated Resident 2 had alteration

in joint mobility. The CP goal indicated Resident 2 will minimize the risk for further loss of ROM daily. The CP interventions indicated initial, quarterly, annual assessment of joint mobility or as needed.

During a review of Resident 2's CP revised 1/9/2022, the CP indicated Resident 2 had limitations in ROM and contractures, bed mobility, ADL, gait, balance and swallowing/feeding. The CP goal indicated Resident 2 will develop no complications related to decreased mobility or contractures. The CP interventions included RNA to do PROM of left LE (LLE) followed by splinting of left knee for four to six hours seven times a week as tolerated and RNA to perform LUE PROM followed by left hand splinting for joint integrity two to four hours seven times a week or as tolerated.

During a review of Resident 2's Order Summary Report (OSR) dated 3/20/2025, the OSR indicated the following orders:

-RNA program for PROM exercises on LUE and LLE in all planes of motion as tolerated five times a week, ordered on 2/25/2025.

-RNA program for application of left knee extension splint for four hours or as tolerated seven times a week, ordered on 2/25/2025.

-RNA program for application of left resting hand splint for four hours or as tolerated seven times a week, ordered on 2/25/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0688 a. During a review of Resident 2's RNA Documentation Survey Report dated 2/2025, the DSR indicated RNA treatment for PROM exercises on LUE and LLE in all planes five times a week, application of left knee Level of Harm - Minimal harm or extension splint seven times a week, and application of left resting hand splint seven times a week were not potential for actual harm completed on 2/27/2025.

Residents Affected - Some During a review of Resident 2's RNA Documentation Survey Report dated 3/2025, the DSR indicated RNA treatment for application of left knee extension splint and application of left resting hand splint seven times a week were not completed on the following dates 3/1/2025, 3/8/2025, 3/16/2025.

During an interview and record review on 3/20/2025 at 10:01 a.m., the Director of Staff Development (DSD) reviewed Resident 2's RNA orders and 2/2025 and 3/2025 RNA DSR and confirmed Resident 15 did not receive RNA treatment as ordered on 2/27/2025, 3/1/2025, 3/8/2025, 3/16/2025. The DSD stated it was important for residents to receive their RNA treatments as ordered so the resident's contractures did not worsen, or muscles did not weaken. The DSD stated the RNA program was for the residents to improve and thrive and participate in daily activities.

During an interview on 3/20/2025 at 11:09 a.m., the Director of Nursing (DON) stated it was important to have sufficient RNA staffing to ensure residents on RNA programs received their RNA treatments. The DON stated the RNA program was to help prevent contractures and keep the resident's joint mobility stable.

During a review of the facility's P&P revised 7/2017 titled, Resident Mobility and Range of Motion, the P&P indicated residents with limited ROM will receive treatment and services to increase and/or prevent further decrease in ROM.

During a review of the facility's P&P RNA Job Description (JD), the JD indicated RNAs assists with residents with ROM exercises, ambulation/transfer exercises per the physician's orders.

b. During a review of Resident 2's Occupational Therapy Joint Mobility Screens (OT JMS), the last OT JMS was completed on 9/13/2021.

During a review of Resident 2's Physical Therapy Joint Mobility Screens (PT JMS), the last PT JMS was completed on 2/4/2022.

During an interview and record review on 3/19/2025 at 12:52 p.m., the DOR and OT 1 reviewed Resident 2's PT and OT JMS and stated there were no PT JMS completed since 2/4/2022 and no OT JMS completed since 9/13/2021. The DOR and OT 1 stated the PT and OT JMS were not completed annually since 2022 and were very late. The DOR stated therapists completed the JMS upon admission, readmission, annually to track and compare a resident's joint ROM and to compare the ROM from last year to see if there was a decline. The DOR stated if there was a decline in ROM, it was important to catch the decline so that therapy staff could intervene. The DOR stated if therapy staff did not complete the JMS annually or upon admission/readmission, then residents could have worsening contractures and joint instability, and staff would not know.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0688 During an interview on 3/20/2025 at 11:09 a.m., the DON stated joint mobility screens are to check if residents had contractures and helped to prevent further contractures. The DON stated it was important to Level of Harm - Minimal harm or screen the residents when it was scheduled because if staff did not screen residents on time, then staff could potential for actual harm not assess the resident and would not know if a resident declined in ROM and provide interventions as needed. Residents Affected - Some

During a review of the facility's undated P&P titled, Screening, the P&P indicated the Joint Mobility Screening form annual screens coincide with the MDS assessment schedule and are completed by PT and OT.

3). During a review of Resident 8's Admission Record (AR), the AR indicated Resident 8 was admitted to the facility on [DATE REDACTED] with diagnoses including but not limited to muscle weakness, contracture left ankle, and Alzheimer's disease.

During a review of Resident 8's care plan (CP) revised 12/22/2020, the CP indicated Resident 8 had the potential for alteration in joint mobility as evidenced by limitations noted on BLE and BUE. The CP goal indicated Resident 8 will minimize the risk for further loss of ROM daily. The CP interventions indicated initial, quarterly, annual assessment of joint mobility or as needed.

During a review of Resident 8's MDS dated [DATE REDACTED] the MDS indicated Resident 8 had severe cognitive impairments. The MDS indicated Resident 8 had functional limitations in ROM on both sides of the lower extremity and had no impairments in ROM on either side of the upper extremity. The MDS indicated Resident 8 required set up assistance with eating and dependent assistance with dressing, toileting, oral hygiene, and sit to lying.

During a review of Resident 8's OT Joint Mobility Screen (JMS), the OT JMS indicated completion dates of 3/7/2022 and 2/5/2025.

During a review of Resident 8's PT JMS, the PT JMS indicated completion dates of 3/4/2022 and 2/6/2025.

During an interview and record review on 3/19/2025 at 12:52 p.m., the DOR stated therapists completed the JMS upon admission, readmission, annually to track and compare a resident's joint range of motions and to compare the ROM from last year to see if there was a decline. The DOR stated if there was a decline in ROM, it was important to catch the decline so that therapy staff could intervene. The DOR stated if therapy staff did not complete the JMS annually or upon admission/readmission, then residents could have worsening contractures and joint instability, and staff would not know.

During an interview and record review on 3/20/2025 at 10:06 a.m., the DOR reviewed Resident 8's OT and PT JMS and stated PT and OT JMS were not completed annually in 2024. DOR stated Resident 8 had contractures and was at risk for further contractures.

During an interview on 3/20/2025 at 11:09 a.m., the DON stated joint mobility screens was to check if residents had contractures and helped to prevent further contractures. The DON stated it was important to screen the residents when it was scheduled because if staff did not screen residents on time, then staff could not assess the resident and would not know if a resident declined in ROM and provide interventions as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0688 During a review of the facility's undated P&P titled, Screening, the P&P indicated the Joint Mobility Screening form annual screens coincide with the MDS assessment schedule and are completed by PT and OT. Level of Harm - Minimal harm or potential for actual harm 4). During a review of Resident 24's Admission Record (AR), the AR indicated Resident 24 was admitted to

the facility on [DATE REDACTED] with diagnoses of chronic respiratory failure (any condition that affects breathing Residents Affected - Some function and result in lungs not functioning properly) with hypoxia (low oxygen level in tissues), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.

During a review of Resident 24's MDS, the MDS indicated Resident 24 had severe cognitive impairments.

The MDS indicated Resident 24 had functional limitations in ROM on both sides of the upper extremity and both sides of the lower extremity. The MDS indicated Resident 24 required dependent assistance with oral hygiene, toileting, bathing, dressing, rolling left and right. The MDS indicated the activities of lying to sitting

on side of bed, chair to bed transfers were not attempted.

During a review of Resident 24's CP revised 7/3/2023, the CP indicated Resident 24 was at risk for further decline in ADLs and development of contractures. The CP goal indicated Resident 24 will maintain joint mobility status. The CP interventions indicated to provide the RNA program as ordered to minimize decline in joint mobility status and/or maintain mobility.

During a review of Resident 24's Order Summary Report dated 3/19/2025, the OSR indicated the following:

-RNA to perform active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) of all joints in both UE to maintain current level of function five times a week or as tolerated, ordered 10/6/2023.

-RNA to perform PROM of both LE once a week, five times a week or as tolerated, ordered 1/23/2024.

a. During an observation and interview on 3/19/2025 at 8:47 a.m. while in Resident 24's room, RNA 1 performed RNA treatment with Resident 24. RNA 1 performed ROM on Resident 24's right elbow, shoulder, wrist, and fingers followed by ROM on Resident 24's left hip, knee, and ankles. After the ROM exercises on

the LLE, RNA 1 put on ankle splints on Resident 24's left ankle/foot. RNA 1 then completed ROM exercises

on Resident 24's right hip, knee, and ankle and put on ankle splints on the right ankle/foot. RNA 1 completed ROM exercises on Resident 24's left elbow, shoulder, wrist, and fingers. RNA 1 stated there were no orders to put on both ankle splints, but this was documented on the weekly summary. RNA 1 stated we put on the ankle splints for four to six hours because the order stated to put on the splints for four hours or as tolerated.

During a review of Resident 24's Restorative Nursing Weekly Summary - Splint Care (RNA WS) dated 2/28/2025, the RNA WS indicated Resident 24 wore both leg ankle splints for four to six hours five times a week.

During a review of Resident 24's RNA WS Splint Care dated 3/7/2025, the RNA WS indicated Resident 24 wore both leg ankle splints for four to six hours five times a week.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0688 During a review of Resident 24's RNA WS Splint Care dated 3/14/2025, the RNA WS indicated Resident 24 wore both leg ankle splints for four to six hours five times a week. Level of Harm - Minimal harm or potential for actual harm During an interview and record review on 3/19/2025 at 12:52 p.m., the DOR reviewed Resident 24's RNA orders and confirmed Resident 24 did not have an RNA order to put on both ankle splints and stated there Residents Affected - Some were no RNA tasks for RNAs to put on ankle splints. The DOR stated RNAs should not be putting on any ankle splints for Resident 24 because there was no RNA order to put on ankle splints. The DOR stated if RNAs put on a splint without an order, Resident 24 was at risk for skin breakdown and pain because the splint may not be adjusted and appropriate for the resident.

During an interview on 3/20/2025 at 11:09 a.m., the DON stated RNA staff should follow the physician's order for RNA as it was written.

During a review of the facility's P&P RNA Job Description (JD), the JD indicated RNAs assists residents with ROM exercises, ambulation/transfer exercises per the physician's orders.

b. During a review of Resident 24's OT JMS, the OT JMS indicated a completion date of 10/6/2023.

During an interview and record review on 3/19/2025 at 12:52 p.m., the DOR and OT 1 reviewed Resident 24's OT JMS and stated there were no OT JMS completed since 10/6/2023. OT 1 stated OT missed the annual OT JMS in 10/2024. The DOR stated therapists completed the JMS upon admission, readmission, annually to track and compare a resident's joint ROM and to compare the ROM from last year to see if there was a decline. The DOR stated if there was a decline in ROM, it was important to catch the decline so that therapy staff could intervene. The DOR stated if therapy staff did not complete the JMS annually or upon admission/readmission, then residents could have worsening contractures and joint instability, and staff would not know.

During an interview on 3/20/2025 at 11:09 a.m., the DON stated joint mobility screens are to check if residents had contractures and helped to prevent further contractures. The DON stated it was important to screen the residents when it was scheduled because if staff did not screen residents on time, then staff could not assess the resident and would not know if a resident declined in ROM and provide interventions as needed.

During a review of the facility's undated P&P titled, Screening, the P&P indicated the Joint Mobility Screening form annual screen coincides with the MDS assessment schedule and is completed by PT and OT.

5). During a review of Resident 17's Admission Record, the Admission Record indicated, Resident 17 was initially admitted to the facility on [DATE REDACTED] and was most recently admitted on [DATE REDACTED]. Resident 17's diagnoses included chronic respiratory failure (a long-term condition when the airways that carry air to your lungs become narrow and damaged), chronic kidney disease (CKD-condition which the kidneys are damaged and cannot filter blood as well as they should), and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).

During a review of Resident 17's History and Physical (H&P), dated 1/11/2025, the H&P indicated Resident 17 did not have the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0688 During a review of Resident 17's MDS dated [DATE REDACTED], the MDS indicated Resident 17 was assessed to have no comprehension (the action or capability of understanding something) of conversations. The MDS Level of Harm - Minimal harm or indicated Resident 17 was dependent on staff for ADLs such as toileting, dressing, rolling left and right, potential for actual harm showering, and personal hygiene.

Residents Affected - Some During a review of Resident 17's Order Summary, an order was placed on 3/4/2025 for Resident 17 to participate in the RNA program for application of bilateral hand roll four hours or as tolerated seven days a week. An order was placed on 3/6/2025 for RNA program for application of right elbow extension splint four hours or as tolerated seven days a week.

During a review of Resident 17's RNA documentation for application of right elbow extension splint seven days a week, no services were documented as given on 3/8/2025 and 3/16/2025.

During a review of Resident 17's RNA documentation for application of bilateral hand rolls seven days a week, indicated no services were documented as given on 3/8/2025 and 3/16/2025.

During an interview on 3/19/2025 at 1:22 p.m. with RNA 1, RNA 1 stated physician orders must be followed. RNA 1 stated RNA treatments that are not done would affect the resident, contractures would worsen, get stiff, and when exercising cause pain.

During an interview on 3/21/2025 at 12 p.m. with Director of Nursing (DON), the DON stated if splints and braces were not put on it would result in the contracture getting worse or not resolved.

During a review of the facility's P&P revised 7/2017 titled, Resident Mobility and Range of Motion, the P&P indicated residents with limited ROM will receive treatment and services to increase and/or prevent further decrease in ROM.

During a review of the facility's P&P RNA Job Description (JD), the JD indicated RNAs assists with residents with ROM exercises, ambulation/transfer exercises per the physician's orders.

6). During a review of Resident 67's Admission Record, the Admission Record indicated Resident 67 was admitted to the facility on [DATE REDACTED] with diagnoses including (a sudden, uncontrolled electrical disturbance in

the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), hypertension (HTN-high blood pressure), and right hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body).

During a review of Resident 67's History and Physical (H&P), dated 7/14/2024, the H&P indicated Resident 67 did not have the capacity to understand and make decisions.

During a review of Resident 67's care plan, dated 8/7/2024, the care plan indicated Resident 67 was at risk for joint contracture and decline in muscle strength.

During a review of Resident 67's Minimum Data Set ([MDS] a resident assessment tool), dated 12/12/2024,

the MDS indicated Resident 67 was dependent on staff for toileting, showering, and dressing and was unable to walk.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0688 During a review of Resident 67's Order Summary Report, dated 3/20/2025, the report indicated on 2/27/2025

the physician entered an order for the RNA to apply a right pressure relieving ankle foot orthosis ([PRAFO]- a Level of Harm - Minimal harm or splint applied to keep the ankle/foot aligned and supported) for four hours, seven times a week. potential for actual harm

During a review of the RNA task form for application of the right PRAFO for four hours, dated 2/27/2025 Residents Affected - Some through 3/18/2025, the task indicated the PRAFO was applied on the following dates:

2/27/2025

3/2/2025

3/3/2025

3/4/2025

3/5/2025

3/6/2025

3/7/2025

3/9/2025

3/10/2025

3/11/2025

3/12/2025

3/14/2025

3/15/2025

3/17/2025

3/18/2025

During an interview on 3/21/2025 at 9:19 a.m. with Restorative Nurse's Aide (RNA) 1, RNA 1 stated she provides RNA services including range of motion, splinting, and walking residents. RNA 1 stated if you don't apply splints as ordered a resident can get a contracture. RNA 1 stated sometimes she is removed from RNA duties to work on the floor as a Certified Nurse's Aide ([CNA]- a healthcare professional who provides basic care to patients).

During an interview on 3/21/2025 at 10:12 a.m. with the IPN, the IPN stated if RNA services (range of motion and splinting) are not provided as ordered, a resident can become stiff and contracted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0688 During a review of the Restorative Nursing Assistant job description, dated January 2022, the job description indicated the RNA will monitor placement of restorative devices/equipment to ensure proper utilization. The Level of Harm - Minimal harm or RNA will provide residents with routine restorative nursing care and services in accordance with the potential for actual harm resident's assessment, care plan, and as directed by supervisors.

Residents Affected - Some During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL's), Supporting, dated March 2023, the P&P indicated the facility will provide care and services to prevent and/or minimize functional decline.

During a review of the facility's policy and procedure (P&P) titled, Resident Mobility and Range of Motion, dated July 2017, the P&P indicated residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in range of motion.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47042

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure an extension cord was free from safety hazards for one out of one sampled resident (Resident 96).

This deficient practice had the potential to result in an unsafe environment with a fire hazard risk and a risk for fall and injury.

Findings:

During a review of Resident 96's Admission Record, the Admission Record indicated, Resident 96 was initially admitted to the facility on [DATE REDACTED] and was most recently readmitted on [DATE REDACTED]. Resident 96's diagnoses included pressure ulcer/injury Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the sacrum (large, triangle-shaped bone in the lower spine that forms part of the pelvis), chronic respiratory failure (a long-term condition when the airways that carry air to your lungs become narrow and damaged), and hypotension (low blood pressure).

During a review of Resident 96's Minimum Data Set (MDS - a resident assessment tool), dated 1/17/2025,

the MDS indicated Resident 96 was assessed to comprehend (the action or capability of understanding something) most conversations. The MDS indicated Resident 96 was dependent on staff for activities of daily living (ADLs) such as toileting, dressing, roll left and right, showering, and personal hygiene.

During a review of Resident 96's History and Physical (H&P), dated 3/15/2025, the H&P indicated Resident 96 did have the capacity to understand and make decisions.

During a concurrent observation and interview on 3/19/2025 at 9:55 a.m. with Licensed Vocational Nurse (LVN) 3 in Resident 96's room, personal chargers were plugged into an extension cord that ran on the ground along next to the resident's bed and was then plugged into another extension cord which the socket end of the extension cord was lying on the ground under resident's bed. LVN 3 stated the extension cords should not be like that. LVN 3 stated this was a fall and fire risk, which was a safety issue that would harm a resident.

During an interview on 3/19/2025 at 10:02 a.m. with Maintenance Aide (MA) 1, MA 1 stated that was the wrong type of extension cord to use. MA 1 stated the extension cord should not be plugged into another extension cord and not lying on the ground. MA 1 stated this was a hazard for falls and fire, a safety issue that would harm the resident.

During an interview on 3/21/2025 at 12 p.m. with Director of Nursing (DON), the DON stated that it was an unsafe situation to have an extension cord plugged into another extension cord and lying on the ground. The DON stated it was a fall and fire hazard, this was a safety issue.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0689 During a review of the facility's policy and procedure (P&P) titled, Electrical Safety for Residents, dated January 2011, the P&P indicated, the resident will be protected from injury associated with the use of Level of Harm - Minimal harm or electrical devices including electrocution, burns and fire. Extension cords shall not be used as a substitute for potential for actual harm adequate wiring in the facility. When extension cords are used the following precaution must be taken, secure extension cords and do not place overhead, under carpets, or where they can cause trips, calls, or Residents Affected - Few overheat. Connect extension cords to only one device. Ensure that the type of cord used is appropriate of the size and type of electrical load and ensure that cords have proper grounding.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 48 555069 Department of Health & Human Services Printed: 09/04/2025 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 555069 B. Wing 03/21/2025

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

Western Convalescent Hospital 2190 W Adams Blvd Los Angeles, CA 90018

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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm 41379

Residents Affected - Some Based on observation, interview, and record review, the facility failed to provide adequate and sufficient nursing staff to provide care for residents requiring Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) treatments.

This deficient practice had the potential for 81 residents with physician's orders for RNA to experience a decline in range of motion (ROM, full movement potential of a joint), mobility, and activities of daily living (ADL, basic activities such as eating, dressing, toileting) function. CROSS REFERENCE TO