Other·November 29, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during a Recertification survey conducted October 16, 2017. Representing the Department of Public Health: Surveyor ID: 36356, RN, HFEN Surveyor ID: 36385, RN, HFEN Total population: 75 Sample size: 16 Randomly Selected Residents: 7 Highest Severity and Scope: G LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 1 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F173 ALLOW OMBUDSMAN TO EXAMINE RESIDENT RECORDS CFR(s): 483.10(h)(3)(iii)

F173 12/13/2017

F221 12/13/2017 SS=B PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (h)(3)(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to post ombudsman (an official appointed to investigate and endeavor to resolve complaints made by, or on behalf of, individual residents in long-term care facilities) contact information in employees breakroom. The deficient practice had the potential of communication delay with residents' spokesperson. Findings: On 10-12-2017, at 8:10 p.m., During a witnessed observation and interview Licensed Vocational Nurse (LVN 2) confirmed ombudsman's contact information was not posted in the employee breakroom. LVN 2 stated was not aware ombudsman contact information was to be posted in the employees' breakroom.

F221 SS=D RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS CFR(s): 483.10(e)(1), 483.12(a)(2) §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 2 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). 42 CFR §483.12, 483.12(a)(2) The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s symptoms. (a) The facility must(1) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record reviews, the facility failed to ensure one of 16 sampled residents (Resident 1) was assessed and a less restrictive measure was attempted, had a physician order and consent from the resident's responsible party prior to the use of self-release seat belt (a strap used across the hips or waist). This deficient practice resulted in an unnecessary used of restraint, which could lead to injury. Findings: On October 12, 2017 at 1:15 p.m., Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 3 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was observed in the activity day room sitting on his wheelchair with a self-release seat belt across his waist. In the presence of the Activity Designee (AD), Resident 1 was asked to release the self-release belt by pressing on to the belt buckle to disengage the straps. Resident 1 was observed to attempt multiple times to press down on the red colored buckle with his left index finger, however could not hold down the buckle to disengage the straps. Resident 1 was observed to be unable to use his right hand to keep the belt steady and provide the tension (pull) to pull the straps apart. During a concurrent interview with the AD, she stated she could not remember how long Resident 1 had been on the self-release belt. During a follow up observation of Resident 1 on October 15, 2017 at 4:20 p.m., the resident was sitting on his wheelchair in the activity day room with a self-release seat belt across his waist. A review of Resident 1's admission records indicated the resident was admitted to the facility on November 11, 2015 and re-admitted on September 5, 2017 with diagnoses that included chronic respiratory failure (a condition when the lungs cannot get enough oxygen to the blood), tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow direct access to a breathing tube), gastrostomy (an artificial external opening into the stomach for nutritional support), cerebral palsy (a disorder that affects balance, movement, and muscle tone), epilepsy (a central nervous system disorder in which nerve cell activity in the brain becomes disrupted, causing seizures or periods of unusual behavior, sensations and sometimes loss of consciousness) and unspecified intellectual disabilities. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 4 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The Minimum Data Set (MDS, a standardized assessment and care screening tool), dated September 15, 2017, indicated Resident 1 had severe cognitive (ability to think, reason, understand, learn, and remember) impairment. The MDS indicated Resident 1 was totally dependent on staff for transfers (how a resident moves between surfaces including to and from the bed, chair, and wheelchair), dressing, eating, hygiene and bathing and there were no physical restraints. During an interview with the Clinical Coordinator (CC) on October 15, 2017 at 11:50 a.m., she stated that the self-release seat belt for Resident 1 was used for positioning, to keep his back upright. The CC stated that the resident loved to be up on the wheelchair all the time. The CC stated that if the self-release seat belt interfered with movement, it can be a form of restraint. The CC stated she was not sure, and she would check the resident's medical record if a least restrictive means of positioning was attempted prior to the selfrelease seat belt. A review of Resident 1's clinical records indicated no attempts in using other positioning devices or less restrictive measures to assist the resident up on his wheelchair. A review of Resident 1's physician order summary report form, dated October 2017 indicated there was no physician order for the use of a self-release seat belt to support posture while sitting on a wheelchair. During an interview with the CC on October 15, 2017 at 5:30 p.m., regarding a physician's order for self-release belt, CC stated there was no order prior to October 14, 2017. Resident 1 was observed with self-release seat belt FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 5 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE around his waist on October 12, 2017. In addition, CC was unable to provide documentation that Resident 1's responsible party was informed and consented for the use of self-release seat belt.

F226 SS=D DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3)

F226 12/13/2017 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 6 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on interview and record review, the facility failed to ensure one employee was able to name different types of and identify abuse. The deficient practice had the potential of failure to report abuse. Findings: During an interview on October 14, 2017, at 7:07 a.m. interpreted by Licensed Vocational Nurse 6 (LVN 6), Housekeeper (HK 1) was not able to name different types of abuse. HK 1 stated "I don't know the different types of abuse." HK 1 also stated he would not be able to identify abuse. HK 1 further stated he attended abuse training. A review of the facility's policy and procedure titled "Abuse Prevention, Identification, Investigation, and Protection," dated March 23, 2017, indicated abuse was willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The document also indicated abuse included verbal, sexual, physical, mental, involuntary seclusion, neglect, and misappropriation of resident property.

F241 SS=E DIGNITY AND RESPECT OF INDIVIDUALITY F241 CFR(s): 483.10(a)(1) 12/13/2017 (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident’s individuality. The facility must protect and promote the rights of the resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide full privacy during care for two sampled residents (Resident 8 and 14) and one of seven FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 7 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE randomly selected residents (RSR 18). The deficient practice had the potential of lowering the residents' self-esteem. Findings: a. On October 15, 2017 at 8:00 a.m., Resident 8, before and after shower care was observed. Certified Nurse Assistant 3 (CNA 3) did not fully close the bedside privacy curtains which permitted easy visual observation of the resident from the patio. The window blinds to the patio were observed opened. The resident was exposed from the waist down. During an interview on October 15, 2017, at 9:00 a.m., CNA 3 stated it was important to provide privacy and dignity during resident care. Resident 8 was admitted to the facility on February 19, 2017, with diagnoses not limited to head trauma and anoxic (lack of oxygen) encephalopathy (disease, damage, or malfunction of the brain). The Minimum Data Set (MDS, a comprehensive assessment tool, and carescreening tool), dated July 20, 2017, indicated Resident 8 was in vegetative (without apparent brain activity or responsiveness). The MDS indicated the resident was dependent on staff for transfer, locomotion, dressing, eating, eating, toilet use, and personal hygiene. b. During medication pass observation and interview on October 14, 2017, at 9:10 a.m., Licensed Vocational Nurse 3 (LVN 3) was observed checking gastric tube (GT, stomach) feeding for residual and administer medications through the GT with bedside privacy curtains not fully closed. LVN 3 stated it was important FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 8 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to provide resident with privacy and respect at all times. Resident 14 was admitted to the facility on September 6, 2017, with diagnoses not limited to brain injury and anoxic encephalopathy. The MDS dated July 14, 2017, indicated Resident 14 was in vegetative state. The MDS indicated the resident was dependent on staff for transfer, locomotion, dressing, eating, eating, toilet use, and personal hygiene. c. During an observation on October 14, 2017, at 6:15 a.m., CNA 1 was observed providing morning care and the resident's bedside privacy curtains not fully drawn closed. During an interview on October 14, 2017, at 7:00 a.m., CNA 1 stated RSR 18's bedside privacy curtains should have been drawn during resident's care. RSR 18 was admitted to the facility on September 29, 2017, with diagnoses not limited to chronic respiratory failure and ventilator dependence. The MDS document dated October 9, 2017, indicated RSR 18 had severe cognitive impairment. The MDS indicated the resident was dependent on staff for transfer, locomotion, dressing, eating, eating, toilet use, and personal hygiene. A review of the facility's admission packet indicated residents had the right to dignity, privacy, and humane care.

F281 SS=E SERVICES PROVIDED MEET PROFESSIONAL STANDARDS CFR(s): 483.21(b)(3)(i) FORM CMS-2567(02-99) Previous Versions Obsolete

F281 Event ID: JI0S11 12/13/2017 Facility ID: CA930000575 If continuation sheet 9 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure two of 16 sampled residents was provided with care that meet professional standards of quality, including: Ensure Resident 8 who required cool aerosol therapy, 28 percent (%) of oxygen via tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing) was provided with continuous oxygen during shower and a non-licensed nurse would not disconnect and connect oxygen equipment. The deficient practice had the potential for Resident 8's oxygen in the body to be depleted. Ensure Resident 14 received correct dosage of ascorbic acid medication via gastric (stomach). The deficient practice may result to ineffective medication therapy. Findings: a. According to the admission record, Resident 8 was admitted to the facility on February 19, 2017, with diagnoses not limited to head trauma and anoxic (lack of oxygen) encephalopathy (Disease, damage, or malfunction of the brain). The Minimum Data Set (MDS, a comprehensive assessment tool, and carescreening tool) document dated 07-20-2017, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 10 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated Resident 8 was in vegetative (without apparent brain activity or responsiveness). The MDS indicated the resident was dependent on staff for transfer, locomotion, dressing, eating, eating, toilet use, and personal hygiene. During an observation on October 15, 2017 at 8:00 a.m., Licensed Vocational Nurse 7 (LVN 7) was observed disconnect Resident 8 from GT feeding. Certified Nurse Assistant (CNA 3) was observed disconnect Resident 8 from cool aerosol therapy attached to FIO2 (oxygen) at 28 percent (%) via the resident's tracheostomy. Then CNA 3 was observed wheeled the resident to the shower room without oxygen. After shower CNA 3 was observed return the resident back to bed and reconnect the resident back to cool aerosol therapy via tracheostomy. During an interview on October 15, 2017, at 9:00 a.m., CNA 3 stated she was not supposed to disconnect or reconnect Resident 8 from cool aerosol therapy. CNA 3 stated the licensed nurses were supposed to disconnect and reconnect residents on any form of oxygen therapy. During an interview on October 15, 2017, at 11:30 a.m., LVN 7 confirmed CNAs have been disconnecting and reconnecting residents on cool aerosol therapy. LVN 7 stated Resident 8 was on oxygen via cool aerosol therapy. LVN 7 also stated the resident was supposed to have continuous oxygen therapy. A review of Resident 8's Physician's Orders dated October 10, 2016, indicated Resident 8 to have FIO2 28%. A review of the facility's policy and procedure titled "Aerosol Therapy Bland, Heated, and Cool." indicated to adjust flowmeter to meet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 11 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE patient's (resident) demand but not less than 10 liters per minute (liters/min). A review of the facility policy and procedure titled "Oxygen therapy." dated December 2017, indicated oxygen was a drug and should be administered with same precautions as any other medication. b. According to the admission record, Resident 14 was admitted to the facility on September 6, 2017, with diagnoses not limited to brain injury and anoxic encephalopathy. The MDS dated July 14, 2017, indicated Resident 14 was in vegetative state. The MDS indicated the resident was dependent on staff for transfer, locomotion, dressing, eating, eating, toilet use, and personal hygiene. During medication pass observation on October 14, 2017, at 9:10 a.m., LVN 3 prepared one tablet of ascorbic acid (Vitamin C) 500 milligrams (mgs) tablet to a powder form. LVN 3 dissolve and administer ascorbic acid 500 mg, one multivitamin tablet, lactulose (stool softener) 30 grams (gms), keppra (control seizures) 750 mg, and docusate sodium (stool softener) 100 mg. LVN 3 was observed add water in the clear plastic cup with remaining partially ascorbic acid and then spilled on a white disposable tray. LVN 3 stated she had completed medication pass. During an interview on October 14, 2017, at 9:20 a.m., LVN 3, confirmed that the ascorbic acid had spilled on the white disposable tray. LVN 3 was not able to state how many mgs of ascorbic acid the resident had received during medication pass.

F312 SS=D ADL CARE PROVIDED FOR DEPENDENT RESIDENTS FORM CMS-2567(02-99) Previous Versions Obsolete

F312 Event ID: JI0S11 12/13/2017 Facility ID: CA930000575 If continuation sheet 12 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE CFR(s): 483.24(a)(2) (a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 8) who was totally dependent on staff for activities of daily was provided with complete shower. Resident 8's back, buttocks, and perineum (area between the anus and the scrotum or vulva) were not washed during shower. The deficient practice had potential for skin breakdown and body odor. Findings: According to admission record, Resident 8 was admitted to the facility on February 19, 2017, with diagnoses not limited to head trauma and anoxic (lack of oxygen) encephalopathy (Disease, damage, or malfunction of the brain). The Minimum Data Set (MDS, a comprehensive assessment and carescreening tool), dated July 20, 2017, indicated Resident 8 was in vegetative (without apparent brain activity or responsiveness). The MDS indicated the resident was dependent on staff for transfer, locomotion, dressing, eating, eating, toilet use, and personal hygiene. During an interview on October 14, 2017 at 12:40 p.m., Resident 8's responsible party stated during shower, the resident would be trapped on the facility's narrow shower bed for safety which could not allow Certified Nurse Assistants (CNAs) to turn and wash the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 13 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident's back, buttocks, and perineum. The resident's responsible party also stated the practice often caused the resident to smell bad. During shower preparation observation on October 15, 2017 at 8:00 a.m., Resident 8 was observed with bowel movement on a disposable incontinent pad. Certified Nurse Assistant 3(CNA 3) was observed wipe away bowel movement, transfer and strap the resident onto the shower gurney, then wheeled the resident to the shower room. CNA 3 was observed shave the resident's face, wash the resident's head, chest and private area, arms, and legs with soap and water. CNA 3 was also observed dry the resident and wheeled the resident back to bed. CNA 3 transferred the resident back to bed, dry the resident back, applied body lotion, dress, and cover the resident. CNA 3 stated shower was completed. During an interview on October 15, 2017, at 9:00 a.m., CNA 3 confirmed Resident 8's back, buttocks, and perineum were not washed during shower. CNA 3 stated the resident's back, buttocks, and perineum should have been washed with soap and water after the resident was returned back to bed.

F317 SS=G NO REDUCTION IN ROM UNLESS UNAVOIDABLE CFR(s): 483.25(c)(1)

F317 12/13/2017 (c) Mobility. (1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident’s clinical condition demonstrates that a reduction in range of motion is unavoidable. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 14 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview, and record review, the facility failed to ensure a resident who enters the facility without limited range of motion (ROM - full movement to a joint) does not experience reduction in ROM unless it is unavoidable due to the medical condition for one Randomly Selected Resident (RSR 17), including: 1. Failure to refer RSR 17 to Physical Therapist (PT) for evaluation upon readmission to the facility on November 23, 2016, to ensure preventive ROM exercises were provided prevent functional decline in ROM. 2. Failure to evaluate RSR 17's need for Restorative Nursing Assistant (RNA - nursing assistant program that help residents maintain any progress made after therapy intervention to maintain their function) services for ROM when RSR 17 was identified with contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to left wrist and fingers on March 30, 2017 and a splint to the left hand was ordered. 2. Failure to provide RSR 17 with passive range of motion (PROM - amount of motion at a given joint when moved by another person) to left wrist, hand and fingers before splint was applied as ordered by the physician on August 24, 2017. 3. Failure to implement the Joint Mobility/ROM Care Plan dated June 1, 2017, for RSR 17's high risk for developing contractures due to physical limitations by not referring to rehabilitation staff for evaluation of any changes in the ROM status. As a result, RSR 17 developed contractures to the left wrist/hand/fingers and loss of the ability FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 15 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to flex the right fingers (unable to close the hand) requiring an special call light button and was no longer able to type on a keyboard. Findings: On October 14, 2017 at 6:20 p.m., during an interview, RSR 17 stated he had not been receiving physical therapy (PT) for his hands and fingers and could not extend his left fingers and could not close his right hand (unable to flex the fingers). RSR 17 was observed wearing a splint (a rigid device used to prevent motion of a joint) to his left hand. RSR 17 stated he received a new call light the day prior (October 13, 2017), because he could not press on the call light button to call for assistance. A review of the Admission Record indicated RSR 17 was admitted to the facility on August 19, 2016 and re-admitted on November 23, 2016, with diagnoses including chronic respiratory failure (the inability of the respiratory system to move air through the body), muscular dystrophy (a group of diseases that cause progressive weakness and loss of muscle mass), systemic lupus erythematosus (disease where the body's immune system mistakenly attacks healthy cells), and multiple sclerosis (a disease where the immune system attacks the protective sheath that covers nerve fibers and causes communication problems between your brain and the rest of the body). Upon re-admission, there was no documented order for RNA to provide RSR 17 with ROM exercises to the hands and wrists. A review of the Joint Mobility Assessment dated August 24, 2016, indicated left and right finger extensions were within functional limits (WFL). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 16 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the Minimum Data Set (MDS standardized assessment and care planning tool) dated November 29, 2016 and September 1, 2017 indicated RSR 17's cognitive (memory and thinking skills) impaired and required total care. The MDS indicated RSR 17 had functional limitation in the ROM to both sides of the upper and lower extremities (hands, arms, legs and feet). A review of the Physician's Order dated March 30, 2017 indicated Restorative Nursing Assistant (RNA) to apply left wrist and fingers flexion splints two to four hours five times a week. May release and re-apply every two hours for 15 minutes. Check skin integrity and circulation for contracture management. There was no documented order for RNA to provide RSR 17 with ROM exercises to right and left hands. A review of the Joint Mobility/ROM Care Plan with a review date of June 1, 2017, for RSR 17's high risk for developing contractures due to physical limitations, had a goals to minimize further decline in ROM and maintain the current joint mobility status. The interventions included assessing RSR 17's joint mobility status when giving care, referring to rehabilitation staff if any decline, and using a left wrist and hand finger flexion splint as ordered. A review of the Physician's Order dated August 24, 2017 indicated RNA to apply left wrist, hand and fingers splints three to six hours after passive ROM (PROM). Monitor for circulation and skin integrity before and after splint application. However, there was no documented the order was implemented for RNA to provide RSR 17 with ROM exercises. A review of the Interdisciplinary Team (IDT FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 17 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE several disciplines of the health care team including the resident and/or representative) Conference Notes dated September 6, 2017, indicated RSR 17's responsible party attended the meeting and requested PT evaluation. A review of the Joint Mobility Assessment dated September 14, 2017, indicated left finger extension to be moderate (50% to 75%) and right finger extension to be minimal (75% to 100%). There was no documented order for RNA to provide RSR 17 with ROM exercises. There was no documented evaluation by PT as requested by RSR 17's responsible party on September 6, 2017. On October 15, 2017 at 2:07 p.m., during an interview with RNAs 1 and 2, RNA 1 stated RNAs were not providing PROM exercises to RSR 17 because there was no order for it. RNA 2 confirmed there was no order for PROM. On October 16, 2017 at 4:45 p.m. during further record review with the MDS Nurse stated there was no order for PROM exercise since re-admission on November 23, 2016 or on March 30, 2017 when the resident was identified with left hand contractures. On October 15, 2017 at 5:10 p.m., during a telephone interview, Physical Therapist 1 (PT 1) stated RSR 17 was in and out of the hospital and a new order had to be placed upon reentry but this was not done. PT 1 explained WFL indicated the fingers were able to spread out and there were no obvious or visible contractures and moderate meant, "Half of what the full ROM should be." On October 16, 2017 at 5:45 p.m., during an interview, the Administrator stated when RSR 17 was re-admitted on November 16, 2016, PT FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 18 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was not notified of the need to evaluate RSR 17. On October 16, 2017 at 6 p.m., during a followup interview, RSR 17 stated he used to type on a keyboard before he was admitted to the facility, but now he could not which made him feel bad. A review of facility's policy and procedures titled "Inpatient Physical Therapy Evaluation" revised on April 2016 and approved on May 25, 2016 indicated physical therapy evaluation shall document the resident's ability to complete tasks that included range of motion and gross strength: assessment of active/passive range of motion all extremities, neck and trick, joint mobility, soft tissue limitations and indicate joints with limitations outside normal functional limits.

F322 SS=D NG TREATMENT/SERVICES - RESTORE EATING SKILLS CFR(s): 483.25(g)(4)(5)

F322 12/13/2017 (g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident’s clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and (5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 19 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure two of 16 sampled residents (Residents 11 and 14) who received formula via gastrostomy tube (GTF, a tube surgically inserted through abdominal wall into the stomach for formula, medication and fluid administration) were provided care to prevent GTF complication including: Ensure licensed staff was called before rendering care to Resident 11 that required the GTF pump to be turned off and/or placed on hold. Ensure Resident 14's GT placement was checked before medications were administered. Findings: a. According to the admission record, Resident 14 was admitted to the facility on September 6, 2017, with diagnoses not limited to brain injury and anoxic encephalopathy. The MDS dated July 14, 2017, indicated Resident 14 was in vegetative state. The MDS indicated the resident was dependent on staff for transfer, locomotion, dressing, eating, eating, toilet use, and personal hygiene. During medication pass observation on October 14, 2017, at 9:10 a.m., LVN 3 was observed aspirate gastrostomy (GT, soft rubber inserted into the stomach for nutrition and medication) for feeding residuals LVN 3 did not check GT placement using a stethoscope (an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 20 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ear instrument used to hear sounds from the chest and other parts of the body). LVN 3 stated she had completed medication pass. During an interview on October 14, 2017, at 9:20 a.m., LVN 3 stated because the GT was already in Resident 14's abdomen, there was no need to check or verify its placement. LVN 3 also stated she listened for bubble sounds with her ears to verify GT placement. LVN 3 confirmed she did not have a stethoscope on her during the medication pass and should have used it to check and verify GT placement before administering medication to the resident. During an interview on October 16, 2017, at 4:45 p.m., Director of Nursing stated licensed nurses must always verify resident's GT placement by injecting 10 milliliters (mls) of air and listen with a stethoscope for gurgle sounds over the abdomen before food and or medication administration. A review of the facility's policy and procedure titled "Nasogastric Tubes Insertion, Feedings, and Discontinuation," dated July 27, 2017, indicated to auscultate of air entering the stomach before medication administration. b. During an incontinent care observation on October 15, 2017 at 8:20 a.m., Certified Nurse Assistant 5 (CNA 5) turned off Resident 11's gastrostomy tube (GTF, a tube surgically inserted through abdominal wall into the stomach for formula, medication and fluid administration), lowered the resident's head of bed to a flat position and check the resident's incontinent pad. At 8:25 a.m., an audible sound was heard from the G-tube feeding pump and CNA 5 stated "It's the G-tube, I had to interrupt it because I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 21 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE laid the resident flat." CNA 5 was concurrently observed to re-start the G-tube feeding pump, then raise Resident 11's head of bed to 30 degrees. During an interview with Licensed Vocational Nurse 8 (LVN 8) on October 15, 2017 at 9:06 a.m., he stated that the CNAs have to call the licensed nurses when they need to provide care to start or re-start the feeding pump. During an interview with Registered Nurse 2 (RN 2) on October 15, 17 at 9:08 a.m., she stated that the LVNs and RNs were allowed to turn the G-tube feeding on and off. The CNAs call the LVNs to turn the G-tube feeding off. During an interview with the Clinical Coordinator (CC) on October 15, 2017 at 11:50 a.m., she stated that the licensed staff turned the G-tube feedings off and on and CNAs have to call the licensed nurses prior to care. During an interview with CNA 5 on 10/15/17 at 1:30 p.m., she stated that before a resident's head of bed is put down, "We have to stop the G-tube, when we put them back up, and we turn it back on." CNA 5 further stated that "We can stop it (G-tube feeding) when we are doing something with the resident. That's the practice, I don't know what it is now." CNA 5 stated she could not remember when she was in-serviced for G-tubes.

F441 SS=F INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.80(a)(1)(2)(4)(e)(f) 12/13/2017 (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 22 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2); (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 23 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement infection control policies and procedures by not performing hand hygiene for three of 16 sampled residents (Residents 6, 7, and 15) and two of seven randomly selected residents (RSR 18 and 23). This deficient practice created a high risk of spreading infections to all 76 residents in the facility, staff, and visitors. Findings: a. On October 12, 2017, at 6:25 p.m., during initial tour accompanied by Licensed Vocational Nurse 1 (LVN 1), Resident 6 was sharing the room with Resident 7. LVN 1 stated Resident 6's sputum (mixture of saliva and mucus coughed up from the respiratory tract) sample tested positive for ESBL [extended spectrum beta (ß) lactamase, enzyme produced by many species of bacteria which destroy one or more antibiotics] on September 27, 2017 and was placed on contact isolation precautions FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 24 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (measures to help stop spread of germs from one person to person). Certified Nursing Assistant 4 (CNA 4) was observed wearing gloves, and providing care to Resident 6. CNA 4 touched the privacy curtain with the same gloves she provided care to Resident 6. Resident 6 was admitted to the facility on April 24, 2017, with diagnoses including Extendedspectrum Beta-lactamases (ESBL, resistant bacteria), and had a tracheostomy (an opening on the neck to assist with breathing), and ventilator (machine that supports breathing) dependence. The Minimum Data Set (MDS - standardized assessment and care planning tool) dated July 4, 2017 indicated Resident 6 had severe cognitive (ability to think, remember, reason, understand, and learn) impairment and was dependent on staff for transfer, locomotion, dressing, eating, eating, toilet use, and personal hygiene. A review of the Physician's Order dated September 27, 2017, indicated contact isolation for Resident 6 due ESBL in sputum. Resident 6 could share room with other resident with same isolation. Resident 6's roommate, Resident 7, was admitted to the facility on September 6, 2017, with diagnoses including chronic respiratory failure, tracheostomy, and ventilator dependence. The MDS dated September 16, 2017, indicated Resident 7 had severe cognitive impairment and was dependent on staff for transfer, locomotion, dressing, eating, eating, toilet use, and personal hygiene. There was not documentation Resident 7 had ESBL infection. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 25 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE October 14, 2017, at 12 p.m., during an interview, the Clinical Coordinator (CC) and the Infection Preventionist (IP) both stated Resident 7 should not be sharing the room as Resident 7 did not have an infection. Both CC and IP stated staff must observe strict hand hygiene before and after resident care. CC stated the physician was not notified of Resident 7's potential exposure to ESBL bacteria. A review of the facility's policy and procedure titled, "Isolation Precautions Infection Prevention," dated March 22, 2017, indicated contact precautions in addition to standard precautions are used on patients with multidrug (several medications) resistant organisms of epidemiological (branch of medicine which deals with the incidence, distribution, and control of diseases) such as extendedspectrum beta lactamase (ESBL) producing organisms. The document also indicated hand hygiene must be performed by either a 15-20 second hand wash or by use of a alcohol hand sanitizer between all patients contacts, after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by these fluids. b. Resident 8 was admitted to the facility on February 19, 2017, with diagnoses including head trauma and anoxic (lack of oxygen) encephalopathy (damage of the brain functions). The MDS dated July 20, 2017, indicated Resident 8 was in vegetative (without apparent brain activity or responsiveness) state and was totally dependent on staff for care. During shower preparation observation on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 26 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE October 15, 2017 at 8 a.m., Resident 8 was observed with bowel movement. CNA 3, while wearing gloves, provided incontinent care to Resident 8. CNA 3, with the same gloves, disconnected Resident 8's cool aerosol oxygen device. CNA 3 wearing the same gloves, wheeled the resident to the shower room, touched the shower door knob, and showered Resident 8. CNA 3, still using the same gloves, wheeled Resident 8 back to the room, transferred Resident 8 back in bed, and wiped dry the resident and touched privacy curtains and the restroom door handle. On October 15, 2017, at 9 a.m., during an interview, CNA 3 stated she should have changed gloves after providing incontinence care and washed her hands before disconnecting and reconnected Resident 8 from and to the cool aerosol oxygen therapy. A review of the facility's policy and procedure titled, "Hand hygiene," dated August 24, 2017, indicated to perform hand washing with plain soap and a hand rub (if hands not soiled) before and after routine patient (resident) care activities and non-patient care activities. c. Resident 15 was admitted to the facility on May 30, 2017, with diagnoses including chronic respiratory failure, tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing) and ventilator dependence (mechanical life support because of inability to breathe effectively). The MDS dated September 9, 2017, indicated Resident 15 consistently and reasonably made independent decisions regarding tasks of daily life. On October 14, 2017, at 1:35 p.m., Resident 15 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 27 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE requested for his tracheostomy to be suctioned. Respiratory Therapist (RT 4) was observed with a cell phone on her hand, proceeded to get gloves, dropped one, picked it up from the floor, discarded it, put on gloves, and the suctioned Resident 15. RT 4 did not wash hands after using the cell phone, prior to put on the gloves. After finishing the procedure, at 1:40 p.m., during an interview, RT 4 stated she should have performed hand hygiene before resident care to prevent spread of infection. d. RSR 18 was admitted to the facility on September 29, 2017, with diagnoses not limited to chronic respiratory failure and ventilator dependence. The MDS dated October 9, 2017, indicated RSR 18 had severe cognitive impairment and required total care. During an observation on October 14, 2017, at 6:15 a.m., CNA 1 was wearing gloves, picked up a small blue plastic sheet on the floor and performed partial bed-bath on RSR 18. CNA 1, wearing the same gloves, picked up clean linen from a clean linen cart. During an observation on October 14, 2017, at 6:30 a.m., RT 3 was observed suctioning RSR 18 with gloves on, and proceeded to turn off RSR 18's suction machine wearing the same gloves. A review of RSR 18's Laboratory Detail dated October 10, 2017, indicated RSR 18's sputum was positive for ESBL infection. e. During wound care observation on October FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 28 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056311 (X3) DATE SURVEY COMPLETED 10/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HOLLYWOOD PRESBYTERIAN MEDICAL CENTER D/P SNF 4636 Fountain Ave Los Angeles, CA 90029 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 14, 2017, at 8:50 a.m., Licensed Vocational Nurse (LVN 4) was observed putting on partially (just over the arms) a coat apron with thumb hole sleeves and done gloves on both hands. LVN 4 removed right hand glove, pumped and quickly rub hand gel sanitizer with the right hand for less than five seconds. LVN 4 was further observed removing both gloves, quickly applying and rubbing hand gel sanitizer on both hands for less than 10 seconds, wear gloves and covered a sacral (low back) wound with a dressing. A review of the Admission Record, indicated RSR 23 was admitted to the facility on May 30, 2017, with diagnoses including chronic respiratory failure and right trochanter (hip bone) pressure sore (localized injury to the skin and/or underlying tissue over a bony prominence, as a result of pressure, or pressure in combination with shear). The MDS dated June 27, 2017, indicated RSR 23 had severe cognitive impairment and required total care. On October 14, 2017, at 11:15 a.m., during an interview, LVN 4 acknowledged it was important to remove both gloves and pull back the blue plastic apron thumb holes from both hands to thoroughly perform hand hygiene. On October 12, 2017, there were 18 residents of a total of 76 census were on contact isolation for ESBL, and Elizabethkingia meningoseptica. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0S11 Facility ID: CA930000575 If continuation sheet 29 of 29