Health inspection·February 2, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating to ensure an allegation of abuse was reported to the California Department of Public Health (CDPH) within two hours, for one of seven sampled residents (Resident 2). This deficient practice resulted to the delay in the abuse investigation by the CDPH and placed Resident 2 at risk for continuous abuse at the facility. Findings: During a review of Resident 2 ' s admission Record (face sheet), dated 1/22/2024, the face sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral infarction (interrupted blood flow to the brain), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood properly), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 2 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 1/6/2024, the MDS indicated Resident 2 usually understood and was usually understood by others. The MDS indicated Resident 2 required moderate (staff lifts or holds trunk or limbs and provides less than half the effort) to maximal (staff lifts or holds trunk or limbs and provides more than half the effort) assistance for activities of daily living (ADLs) such as toileting, dressing and personal hygiene. During a review of Resident 2 ' s progress note, dated 1/6/2024, the progress note indicated Resident 2 ' s daughter contacted the facility and informed Registered Nurse (RN) 3 of the resident ' s allegation that a male resident had hit her on the chest the previous night. The progress note indicated RN 3 spoke with Resident 3 and the resident stated, she was attacked by a male nurse and the police department was called. During an interview with the Director of Nursing (DON) on 1/23/2024 on 3:55 p.m., the DON stated she and the Administrator (ADM) were not in the building when the alleged abuse occurred, however RN 3 had notified her and the administrator regarding the alleged abuse on 1/6/2024. During a concurrent record review and interview on 1/23/2024 at 4:44 p.m. with the ADM, the facility ' s abuse policy was reviewed. The ADM stated, the facility ' s policy indicated an allegation of abuse should be reported within two hours. The ADM stated Resident 2 ' s alleged abuse occurred on Page 1 of 5 056218 056218 02/02/2024 Bell Convalescent Hospital 4900 E. Florence Ave Bell, CA 90201

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Saturday, 1/6/2024 and it was reported to the CDPH on Monday, 1/8/2024. The ADM stated Resident 2 ' s allegation of abuse was not reported to the CDPH because the facility was unable to substantiate the abuse occurred. The ADM stated the facility should have reported Resident 3 ' s allegation of abuse to within two hours. During a review of the facility ' s P&P titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated 4/2021, the P&P indicated all reports of resident abuse were reported to local, state, and federal agencies and thoroughly investigated by facility management. The P&P indicated the administrator or the individual making the allegation immediately reports his or her suspicion of resident abuse to the state licensing and certification agency. The P&P indicated the timeframe for reporting an allegation of abuse was within two hours. 056218 Page 2 of 5 056218 02/02/2024 Bell Convalescent Hospital 4900 E. Florence Ave Bell, CA 90201

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide visual monitoring and prevent accident hazards, as indicated in the resident ' s care plan, for one of seven sampled residents (Resident 1), who had a high risk for fall. This deficient practice resulted in Resident 1 falling, sustaining facial trauma and a right arm fracture (broken bone) which required hospitalization in a general acute care hospital (GACH) for evaluation and treatment. Findings: During a review of Resident 1 ' s admission record (face sheet), dated 1/22/2024, the face sheet indicated Resident 1, was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included parkinsonism (a brain condition that causes slow movement, stiffness, and tremors), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and osteoarthritis (a wearing down of the protective tissue at the ends of bones, causing pain and stiffness). During a review of Resident 1 ' s History and Physical (H&P) dated 1/14/2024, 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 standardized assessment and care screening tool), dated 11/1/2023, the MDS indicated Resident 1 sometimes understood others and was usually understood. The MDS indicated Resident 1 required moderate assistance from staff for activities of daily living (ADL) such as eating, oral hygiene, and personal hygiene. The MDS indicated Resident 1 required maximum assistance from staff for lower body dressing. The MDS indicated Resident 1 was dependent on staff for toileting, and showering. The MDS indicated Resident 1 was dependent on staff for transferring from a chair to a bed, and to the toilet. The MDS indicated Resident 1 required staff ' s assistance in wheeling her wheelchair for 50 feet with two turns and wheeling 150 feet. During a review of Resident 1 ' s fall risk assessment dated [DATE], the fall risk assessment indicated Resident 1 was a high risk for falls. During a review of Resident 1 ' s fall risk evaluation, dated 11/6/2023, the fall risk evaluation indicated Resident 1 was at high risk for falls. During a review of Resident 1 ' s care plan titled, At risk for fall/injury, dated 11/2023, the intervention indicated staff will assist Resident 1 with transfer and ambulation as needed (PRN), and visual monitoring every hour. During a review of Resident 1 ' s care plan titled, The resident has impaired cognitive function, impaired thought process related to dementia, dated 12/10/2023, the care plan intervention indicated staff will supervise Resident 1 as needed. During a review of Resident 1 ' s visual check monitoring sheet dated 8/2022, the monitoring sheet did not indicate Resident 1 was monitored every hour in 2024, as indicated in Resident 1 ' s care 056218 Page 3 of 5 056218 02/02/2024 Bell Convalescent Hospital 4900 E. Florence Ave Bell, CA 90201

F 0689 plan intervention. Level of Harm - Actual harm During a review of Resident 1 ' s Situation, Background, Assessment, and Recommendation (SBAR) Fall report, dated 1/7/2024, the SBAR indicated on 1/7/2024, Resident 1 was in the hallway outside her room, waiting to be transferred to bed. The SBAR indicated Resident 1 was found on the floor, face down, in front of the wheelchair. The SBAR indicated Resident 1 had a pain level of 6/10 (moderate pain) and swelling to her left elbow and forehead. The SBAR indicated Resident 1 ' s Physician ordered the resident to be transferred to an emergency room (ER) for further evaluation. Residents Affected - Few During an interview with Registered Nurse (RN 1) on 1/22/2024 at 3:30 p.m., RN 1 stated on 1/7/2024, while at the nurses ' station, a Certified Nurse Assistant (CNA) notified him, Resident 1 fell. RN 1 stated it was an unwitnessed fall which occurred after a CNA (name unknown) left Resident 1 on his wheelchair, outside the resident ' s room, unattended. RN 1 stated the CNA should not have left Resident 1 in the hallway and unattended. RN 1 stated the CNA should have notified another staff to monitor Resident 1 for safety. During an interview with Licensed Vocational Nurse (LVN 1) on 1/23/2024 at 2:45 p.m., LVN 1 stated on 1/7/2024, she observed Resident 1 outside her room on her wheelchair when she fell. LVN 1 stated she was not sure who brought Resident 1 back outside her room since the residents had just finished eating lunch. LVN 1 stated Resident 1 was at risk for falls and should not have been left unsupervised. During a concurrent interview and record review with the Director of Nursing (DON) on 1/23/2024 at 3:55 p.m., Resident 1 ' s fall risk assessment was reviewed. The DON stated Resident 1 was at risk for falls. The DON stated Resident 1 ' s interventions included visual checks and monitoring. The DON stated, Resident 1 fell after a CNA left the resident in the wheelchair, unsupervised in the hallway. The DON stated there was no staff monitoring or supervising Resident at the time of the fall. During a phone interview with CNA 1 on 2/1/2024 at 12:19 p.m., CNA 1 stated she saw Resident 1 on the floor face down, when she was walking down the hall. CNA 1 stated there were no other CNAs around when Resident 1 fell because it happened after lunch time. CNA 1 stated CNAs were busy taking residents back to their rooms. CNA 1 stated staff were not supposed to leave any residents in the hallway. During an interview with LVN 1 on 2/1/2024 at 3:42 p.m., LVN 1 stated Resident 1 was in the hallway in front of her room when Resident 1 fell. LVN 1 stated it was hard to see the resident in the hallway if the staff were inside the nurse ' s station. LVN 1 stated if staff could not see Resident 1 in the hallway, the resident was not supervised and could fall. LVN 1 stated Resident 1 ' s fall could have been prevented if the resident was supervised and monitored. During a concurrent interview and record review on 2/1/2024 at 4:11 p.m., with RN 2, Resident 1 ' s fall risk care plan was reviewed. RN 2 stated interventions for the fall risk care plan included visual (seeing) monitoring every hour. RN 2 stated visual monitoring meant making rounds every hour and seeing where the residents were. RN 2 stated the facility had just switched from paper to electronic charting and she was not sure where the visual monitoring for Resident 1 was documented. During a concurrent interview and record review on 2/1/2024 at 4:40 p.m., of Resident 1 ' s Visual Checks Monitoring Sheet dated 8/2022, with the medical records (MR), the MR stated the last visual check monitoring sheet for Resident 1 was from 8/2022 and was unable to find documentation visual 056218 Page 4 of 5 056218 02/02/2024 Bell Convalescent Hospital 4900 E. Florence Ave Bell, CA 90201

F 0689 monitoring being done every hour on the electronic records. Level of Harm - Actual harm During a phone interview with LVN 1 on 2/2/2024 at 9:35 a.m., LVN 1 stated she saw a CNA push Resident 1 in her wheelchair while she was gathering resident supplies. LVN 1 stated, then she saw Resident 1 sitting in the hallway outside her room but did not see any staff with Resident 1. LVN 1 stated when Resident 1 fell in the hallway, and no one saw Resident 1 fell, no one must have been keeping an eye on Resident 1. LVN 1 stated she did not tell any other staff to keep an eye on Resident 1. LVN 1 stated if anyone was at the nurses ' station, it would have been difficult to see Resident 1. Residents Affected - Few During a review of Resident 1 ' s physician ' s order dated 1/7/2024 at 1:32 p.m., the order indicated to transfer Resident 1 to the GACH ER. During a review of Resident 1 ' s GACH radiology (process of taking pictures to diagnose and treat diseases) report dated 1/7/2024, the report indicated multiple right rib fractures, most likely old, maxillofacial (jaw and face) with soft tissue swelling, left supracondylar (a round part at the end of a bone) fracture and dislocation (separation of bones). During a review of Resident 1 ' s GACH ' s, H &P, dated 1/8/2024, the H &P indicated Resident 1 fell from a wheelchair and sustained a left forehead, periorbital (surrounding the eye), left elbow bruising with deformity (abnormal shape). During a review of Resident 1 ' s GACH Discharge summary, dated [DATE], the discharge summary indicated Resident 1 ' s admitting diagnosis included a fall with facial trauma and bilateral orbital ecchymosis (bruises), left elbow fracture and multiple rib fractures (possibly old findings). The discharge summary indicated Resident 1 had a left shoulder brace in place and due to her age, the resident was not a candidate for surgery because the risks outweighed the benefits. During a review of the facility ' s policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 7/2017, the P&P indicated the facility ' s priority was to ensure resident safety, supervision, and assistance to prevent accidents. The P&P indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The P&P indicated implementing interventions to reduce accident risks and hazards shall include communicating specific interventions to relevant staff and assigning responsibility for carrying out interventions. 056218 Page 5 of 5