Western Convalescent Hospital

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

During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/3/2025, the MDS indicated Resident 1 had severely impaired cognitive skills (problems with ability to think, use judgement and reason) skills for daily decision making.

The MDS indicated Resident 1 was totally dependent (helper does all of the effort) on staff with oral hygiene, toileting hygiene, and upper and lower body dressing.

During a review of the Physician's Order Summary Report dated 8/16/2025, the Order Summary Report indicated the physician placed a telephone order on 8/15/2025 for Resident 1 to be transferred to the GACH.

During a concurrent interview and record review on 8/26/2025 at 12:37 p.m. with the Clinical Manager (CM), Resident 1's medical records were reviewed.

The CM stated Resident 1's medical records were incomplete and not accurate.

The CM stated there was no documentation by facility staff indicating Resident 1 was transferred to the GACH on 8/15 or 8/16/2025.

The CM stated the licensed nurse should have documented Resident 1's clinical condition, vital signs (basic measurements of your body's core functions, including temperature, pulse rate, respiratory rate (breathing), and blood pressure) and other pertinent information at the time of transfer.

The CM stated accurate and complete clinical documentation provided better evaluation of the resident for continuity of care.

During a review of the facility's undated policy and procedure (P&P) titled, Medical Records, the P&P indicated the facility shall maintain complete, accurate, readily accessible and systematically organized medical records for each resident admitted to the facility.

During a review of the facility's undated P&P titled, Charting and Documentation, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/27/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Western Convalescent Hospital

2190 W Adams Blvd Los Angeles, CA 90018

SUMMARY STATEMENT OF DEFICIENCIES

During a review of Resident 2's History and Physical (H&P), dated 6/14/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.

During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 6/19/2025, the MDS indicated Resident 2 had severely impaired cognitive skills (problems with ability to think, use judgement, and reason) for daily decision making.

The MDS indicated Resident 2 was totally dependent (helper does all of the effort) on staff with oral hygiene, toileting hygiene, and upper and lower body dressing.

The MDS indicated Resident 2 was at risk for developing a pressure ulcer and had three stage 4 pressure ulcers and two unstageable pressure ulcers (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (dead tissue that is usually yellow, tan, gray, or green in color, usually moist and stringy in texture, that may be found in wounds) or eschar (dead tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like, usually firmly attached to the base, sides and/or edges of the wound and over time falls off) that were present upon admission.

During a concurrent interview and record review on 8/27/2025 at 2:30 p.m., with the Clinical Manager (CM), Resident 2's care plans were reviewed.

The CM stated the facility developed a baseline care plan for Resident 2 upon admission, but no comprehensive care plan was developed (over two months later).

The CM stated Resident 2 had no comprehensive care plan addressing her multiple PU's which was important because it served as a guide for monitoring and treatment of pressure ulcers.

The CM stated without a comprehensive care plan, there would be no specific guidance for Resident 2's wound care.

During an interview on 8/27/2025 at 3 p.m., the Director of Nursing (DON) stated the baseline care plan was good for 14 days.

The DON stated the comprehensive care plan should be developed by the interdisciplinary team (IDT, members from different disciplines who come together to discuss resident care) 14 days after admission, quarterly and as needed.

The DON stated it was important to develop a comprehensive care plan for PU for Resident 2 to evaluate the effectiveness of wound care treatment and to provide other interventions.

During a review of the facility's undated policy and procedure (P&P) titled, Guide to Comprehensive Care Plans, the P&P indicated to ensure a comprehensive care plan was created for skin alterations, pressure ulcers, vascular ulcers, and diabetic ulcers.

The P&P also indicated to ensure that care plan goals were realistic, measurable, and included a time frame for re-evaluation.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/27/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Western Convalescent Hospital

2190 W Adams Blvd Los Angeles, CA 90018

SUMMARY STATEMENT OF DEFICIENCIES

Federal health inspectors cited WESTERN CONVALESCENT HOSPITAL in LOS ANGELES, CA for a deficiency under regulatory tag F-F0686 during a complaint investigation conducted on 2025-08-27.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 4 deficiencies cited during this inspection of WESTERN CONVALESCENT HOSPITAL.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-11.