Western Convalescent Hospital
WESTERN CONVALESCENT HOSPITAL in LOS ANGELES, CA — inspection on March 21, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
555069
Form Approved OMB
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
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.
555069
Form Approved OMB
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