Western Convalescent Hospital

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

facility's undated P&P titled Abuse & Mistreatment of Residents were reviewed. RN 7 stated she wrote Resident 7's SBAR and Radiology Report indicating a right thumb bone fracture while residing in the facility. RN 7 stated that the P&P indicated an unusual occurrence like Resident 7's right thumb bone fracture could be a result of alleged abuse and must be reported to the California Department of Public Health (CDPH) immediately by the facility's nursing staff because there was a possibility of abuse. RN 7 stated the right thumb fracture could have occurred as a result of abuse because it was not witnessed by staff, not explained by the resident, and was a severe injury. During an interview on 9/22/2025 at 2:57 p.m. with MD 7, MD 7 stated Resident 7's fracture could be a result of accidents, mishandling, and abuse. MD 7 stated staff should consider mishandling and abuse any time a resident develops a bone fracture in the facility. During a review of the facility's undated P&P titled Abuse & Mistreatment of Residents, the P&P indicated the facility shall ensure all alleged violations of abuse were reported to the state agency. The P&P indicated any mandated reporter (an individual who holds a professional position that is required by law to report suspected or known instances of abuse to state agencies and local law enforcement) should report suspected instances of abuse to the CDPH by telephone immediately, as soon as practically possible, and within two hours of the knowledge of the incident. The P&P indicated a written report sent to the CDPH within two working days.

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

09/18/2025

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

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

rehabilitation department prior to resuming splint services. The DOR stated the rehabilitation department should have evaluated Resident 8 prior to ordering services to ensure the orders were appropriate for Resident 8. The DOR stated the RNA meeting notes dated 6/5/2025 indicated Resident 8 could not tolerate his bilateral hand splints with no new recommendations. The DOR stated Resident 8's inability to tolerate his splints is considered a change in condition. The DOR stated Resident 8 was not assessed upon readmission to the facility and after each notification of change in mobility and changes in condition. The DOR stated the policy was not followed when Resident 8 was not screened after readmission and when he was unable to tolerate his splints. The DOR stated Resident 8 could become more contracted and his mobility could worsen if he was not reassessed by the rehabilitation department. During a review of the facility's Physical Therapist Job Description, dated 11/23/2022, the job description indicated the Physical Therapist will evaluate residents promptly and record evaluations per facility policies. During a review of the facility's P&P titled Screening, dated 2023, the P&P indicated a PT and OT may complete a Joint Mobility Screening form for all readmissions and changes of condition. The P&P indicated a change of condition screen may be completed after a suspected change of condition is presented to the rehabilitation department to determine the need for skilled therapy intervention.

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

09/18/2025

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 0694

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review, for 1of 5 sample residents, Resident 2, the facility failed to:1).

Ensure the intravenous (IV- administration of the medications via a catheter inserted into a vein) medication was administered completely, consistent with professional standards of practice and physician's order.2).

Ensure the IV site was securely placed and did not dislodge (pulled out).This failure had the potential for

the infection will not be resolved due to an incomplete dose of antibiotic medication administered.This failure had the potential to cause infection on the IV site and the potential for a missed antibiotic dose.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including urinary tract infection (UTI-an infection of the urinary tract, which includes the kidneys, ureters, bladder, and urethra), dysphagia following cerebral infarction (difficulty swallowing that occurs after a stroke), and type 2 diabetes mellitus (abnormal blood sugar levels). During a review of Resident 2's Minimum Data Set (MDS-an assessment and care planning tool) dated 5/22/2025, the MDS indicated Resident 2 had no speech, was rarely/never understood and rarely/never understands. The MDS indicated Resident 2 was dependent on staff for toileting hygiene, personal hygiene, and shower/bathe of self. During a review of Resident 2's physician order dated 9/2/2025, the physician's order indicated to give Ertapenem Sodium (an antibiotic medication)1 gram IV every 24 hours for UTI until 9/10/2025. During a review of Resident 2's untitled care plan, dated 9/2/2025, the care plan indicated Resident 2 required IV therapy of Ertapenem 1 gram every 24 hours for UTI. The care plan goal indicated Resident 2's IV access will be maintained and be free of complications for successful completion of therapy until the next assessment. The care plan goals indicated the Registered Nurse (RN) to infuse the fluids and/or medications as ordered, observe the IV site frequently for signs and symptoms of complications such as redness, swelling, pain, drainage and leakage.

During a concurrent observation and interview on 9/8/2025 at 11:15 a.m. with the Assistant Director of Nursing (ADON), at Resident 2's bedside, the IV antibiotic medication, Ertapenem 1 gram bag of 100 cubic centimeters (cc- a unit of measurement) was not infusing. The IV Ertapenem antibiotic bag indicated it was hung on 9/8/2025 at 5:30 a.m. and had 40 cc's left to infuse. The ADON stated the medication (IV Ertapenem antibiotic) should have been completely infused by 6:30 a.m. The ADON stated failure to monitor the IV Ertapenem was completely infused and ensure the complete dose was administered will not treat the infection. During a second concurrent observation and interview on 9/9/2025 at 11:05 a.m., with

the RN 1, Resident 2's saline lock (a thin, flexible tube placed into a vein) needle tip was observed dislodged out of Resident 2's vein and was lying on the skin of the right back side of hand. RN 1 stated Resident 2 received the IV antibiotic (Ertapenem) last night and there was no report of any problem. RN 1 stated a patent (open and unobstructed) saline lock should be in the vein to administer IV medications.During a review of the facility's policy and procedure (P&P) titled, Continuous Infusion of Medications and Solutions, dated 3/2023, the P&P indicated the RN and IV Certified Licensed Vocational Nurse must perform IV infusions according to state law and facility policy. The P&P indicated the nurse should monitor the venous access site frequently for signs and symptoms of complications, and report if appropriate.

Residents Affected - Few

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

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

09/18/2025

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 0695

Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review, the facility failed to ensure one of 5 sampled residents (Resident 2) was administered the correct amount of oxygen (a gas considered as medication essential for life to supplement the body's oxygen supply in conditions), ordered by the physician.This failure had the potential to cause oxygen toxicity (lung damage from breathing in excessive supplemental oxygen [also called oxygen poisoning] causing the resident to cough and trouble breathing and in severe cases, can cause death) to the affected resident.Findings:During a review of Resident 2's admission Record, the admission

Record indicated Resident 2 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including urinary tract infection (UTI-an infection of the urinary tract, which includes the kidneys, ureters, bladder, and urethra), dysphagia following cerebral infarction (difficulty swallowing that occurs after

a stroke), and type 2 diabetes mellitus (abnormal blood sugar levels). During a review of Resident 2's untitled care plan, dated 2/28/2025, the care plan indicated Resident 2 was receiving oxygen (O2) therapy due to chronic obstructive pulmonary disease (COPD- a group of lung diseases that cause long-term breathing problems) and Respiratory Failure. The care plan goal indicated Resident 2 will be free from adverse effects related to the use of oxygen daily until the next assessment. The care plan interventions indicated to provide oxygen as ordered, monitor O2 saturation (amount of oxygen level in the resident's system [normal range is 90-100%) and check the rate of oxygen flow every shift. During a review of Resident 2's Minimum Data Set (MDS-an assessment and care planning tool) dated 5/22/2025, the MDS indicated Resident 2 had no speech, was rarely/never understood and rarely/never understands. The MDS indicated Resident 2 was dependent on staff for toileting hygiene, personal hygiene, and shower/bathe of self. During a review of Resident 2's Order Summary Report dated 9/2/2025 through 9/30/2025, the Order Summary Report indicated a physician order dated 9/9/2025, to administer oxygen at 2 Liters per minute ([L]/min) via nasal cannula (NC- supplemental oxygen delivered to a patient through a flexible tube with two prongs that are placed into the nostrils), as needed. The Order Summary Report indicated to titrate (adjust) oxygen up to 3 L/min if oxygen saturation was less than 92% every shift. During an observation on 9/8/2025 at 11:15 a.m. and 12:40 p.m., Resident 2 was observed lying in bed, with oxygen at 3L/min via NC. During

a concurrent observation and interview on 9/9/2025 at 11:05 a.m., with Registered Nurse 1 (RN 1), Resident 2 was observed lying in bed, with O2 at 3L/NC. RN 1 stated when Resident 2 returned from the general acute care hospital, the physician order was for Resident to receive O2 at 2L/min via NC. RN 1 stated Resident 2 could be over oxygenated (excessive amount of oxygen which can lead to oxygen toxicity). During a review of the facility's policy and procedure (P&P) titled, Reconciliation of Medications on Admission, dated 7/2017, the P&P indicated the purpose of Reconciliation of Medications on admission was to ensure medication safety by accurately accounting for the resident's medications dosages upon admission or readmission to the facility to reduce medication errors and enhance resident safety by ensuring medications the resident need be continued without interruption, in the correct dose during the admission/transfer process.

Residents Affected - Few

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

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

09/18/2025

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

treatment or services Resident 8 did not tolerate. The DOR stated the DOR was responsible for overseeing RNA services, splint care, and accuracy of documentation.During a concurrent interview and record review

on 9/10/2025 at 4:15 p.m. with the Director of Nursing (DON), the facility's P&P titled Charting and Documentation was reviewed. The DON stated the P&P indicated documentation should be objective and should have accurate documentation of the treatment and services provided to the resident. During a concurrent interview and record review on 9/18/2025 at 2:00 p.m. with the DOR, the facility's Job Description - RNA, dated 8/23/2011, was reviewed. The DOR stated RNAs were responsible for documenting daily for residents in the RNA program, and document the significant changes, as per policy and procedure (P&P). During a review of the facility's P&P titled, Charting and Documentation, dated 2001,

the P&P indicated treatments and services performed and a resident's tolerance to the treatment must be documented objectively, completely, and accurately in the resident's medical record.

Event ID:

Facility ID:

If continuation sheet