Western Convalescent Hospital

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

nursing staff to make sure resident's POLST was completely filled out. The DON stated the POLST was a part of resident's AD and should be followed by the health care staff because this was the medical wishes of the resident or her representative when Resident 2's condition deteriorated and became irreversible (permanent). During a review of the facility's policy and procedure (P&P) titled, Quick Reference Guide on POLST in Nursing Homes, dated 5/2024, the P&P indicated, It should be a standard of practice, before signing the form, for the physician / NP / PA to speak to the resident or, if the resident lacks capacity, the resident's legally recognized decision-maker to confirm that the orders on the POLST are consistent with resident's medical condition and accurately reflect the resident's wishes.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure one of two sampled residents (Resident 1's) transfer to the general acute care hospital (GACH) was documented in resident's medical records. This deficient practice had the potential to place Resident 1 at risk of not receiving appropriate care and delay in communication among staff due to incomplete medical records.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe), and gastrostomy tube placement (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems). 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure a comprehensive care plan for pressure ulcer/injury (PU/PI] - localized damage to the skin and/or underlying tissue usually over a bony prominence) was developed for one of four sampled residents (Resident 2), who had multiple pressure ulcers. This deficient practice had the potential for Resident 2 not receiving the appropriate wound care interventions which could lead to infection or worsening of the wounds. Findings: During a review of Resident 2's admission Record, the admission Record indicated, Resident 2 was initially admitted to the facility on [DATE REDACTED] with diagnoses including PU Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), urinary tract infection (UTI - an infection in the bladder/urinary tract), and gastrostomy tube placement (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems). 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

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)

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.