Other·November 19, 2018

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. Representing the Department of Public Health: Surveyor ID: 33690, RN, HFEN Surveyor ID: 33668, RN, HFEN Surveyor ID: 31331, RN, HFEN Total Resident Population: 76 Total Resident Sample: 18 Highest Severity and Scope: L

F550 SS=E Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 11/21/2018 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity 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. 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: UKKV11 Facility ID: CA930000575 If continuation sheet 1 of 64 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 10/21/2018 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 §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure personal privacy and/or dignity was maintained for three of 18 sampled residents (Residents 20, 57, and 38). 1. During the initial tour of the facility, Residents 20 and 57 were observed with indwelling catheters (a tubing inserted through the urethra and into the bladder to drain urine) bags that were not covered in dignity bags to ensure their privacy. 2. Resident 38 was observed with an indwelling FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 2 of 64 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 10/21/2018 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 catheter bag not placed in a privacy bag to provide personal privacy for the resident. These deficient practices had the potential to violate Resident 20, 57, 38's personal privacy. Findings: 1a. A review of Resident 20's Admission Face Sheet (an admission record) indicated the resident was admitted to the facility on 9/29/18 with diagnosis that included chronic respiratory failure (a long-term condition that happens when the lungs can not get enough oxygen into the blood). A review of Resident 20's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 8/4/18, indicated the resident sometimes made self-understood or understood others and was moderately impaired in cognitive skills. Resident 20 required total dependence (full staff performance every time) from staff for all activities of daily living ([ADLs] such as transferring, dressing, eating, toileting, personal hygiene, and bathing). A review of Resident 20's physician order, dated 9/29/18, indicated the resident was ordered an indwelling catheter. During the initial tour of the facility, on 10/18/18 at 8 p.m., Resident 20 was observed with the indwelling catheter hanging on the bedframe, which was viewable from the doorway. The resident's indwelling catheter was not covered in a privacy bag. During an observation and interview, on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 3 of 64 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 10/21/2018 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 10/18/18 at 8:02 p.m., a Licensed Vocational Nurse (LVN 1) stated Resident 20's indwelling catheter should be covered in a privacy bag. 1b. A review of Resident 57's Admission Face Sheet (an admission record) indicated the resident was admitted to the facility on 6/16/18 with diagnosis that included chronic respiratory failure. A review of Resident 57's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 9/26/18, indicated the resident had persistent vegetative state/no discernible consciousness. Resident 57 required total dependence from staff for all ADLs. A review of Resident 57's monthly physician order for October 2018 indicated the resident was ordered for an indwelling catheter. During an initial tour, on 10/18/18 at 7:46 p.m., Resident 57's indwelling catheter was not placed in a privacy bag. A Licensed Vocational Nurse 2 (LVN 2) stated that Resident 57's indwelling catheter should be in dignity bag for privacy. During an interview, on 10/21/18 at 12:07 p.m., the Director of Infection Control stated the facility did not have a policy for providing the resident's privacy when there was an indwelling catheter bag and they would be revising policy and procedures to ensure it was meeting regulations. 2. A review of Resident 38's Admission Face Sheet (an admission record) indicated the resident was admitted to the facility on 10/7/18 with diagnosis that included chronic respiratory failure. A review of Resident 38's admission physician FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 4 of 64 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 10/21/2018 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 order indicated the resident had an order for a suprapubic (a hollow flexible tube that is used to drain urine from the bladder, inserted into the bladder through a cut in the tummy, a few inches below tummy button) catheter. During an initial tour and interview on 10/18/18 at 8:23 p.m., Resident 38's indwelling catheter was not placed in a privacy bag. Licensed Vocational Nurse (LVN 5) stated Resident 38's catheter should be in dignity bag for privacy.

F558 SS=D Reasonable Accommodations Needs/Preferences CFR(s): 483.10(e)(3)

F558 11/21/2018 §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (Resident 44) had a working call light. This deficient practice had the potential to delay care and services to Resident 44. Findings: A review of Resident 44's Admission Face FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 5 of 64 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 10/21/2018 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 Sheet indicated the resident was admitted to the facility on 5/30/17 with admitting diagnoses of chronic respiratory failure (lungs not working) and hypoxia (no oxygen in the body). A review of a Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 9/9/18, indicated Resident 44 had clear speech and was usually able to express ideas and wants. According to the MDS, Resident 44 required total assistance with dressing and personal hygiene. During an observation and interview, on 10/18/18 at 7:40 p.m., with Registered Nurse (RN 4) pushed Resident 44's call light button at the bedside and it did not work. RN 4 stated she would tell maintenance to fix it. According to the facility's policy and procedure titled, "Call light- Answering," dated 11/2016 indicated all residents will have a call light in place at all times. The policy further indicated malfunctioning call light will be reported to the chain of command and a work order generated.

F582 SS=E Medicaid/Medicare Coverage/Liability Notice CFR(s): 483.10(g)(17)(18)(i)-(v)

F582 11/21/2018 §483.10(g)(17) The facility must-(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 6 of 64 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 10/21/2018 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 facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section. §483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility. (v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 7 of 64 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 10/21/2018 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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to give the Skilled Nursing Facility Advance Beneficiary Notice ([SNF ABN] the form helps the resident make an informed choice about whether or not they want to receive these items or services, knowing that they might have to pay for them themselves), a Centers for Medicare & Medicaid Services form regarding the Medicare Part A (hospital insurance) services of the change as soon as was reasonably possible for two of 3 sampled residents (Residents 15 and 72). This deficient practice had the potential for Resident 15, and 72 to not have enough time to make alternate arrangements if needed. Findings: During an interview and record review, on 10/21/18 at 12:19 p.m., the Registered Nurse Clinical Coordinator (RNCC) stated she was not sure of the time frame to provide the resident and/or responsible party the SNF ABN notice form. a. A review of the SNF Beneficiary Protection Notification Review for Resident 15, indicated the resident received notice on 8/31/18, which was also the last day of coverage. b. Resident 72 was given SNF Beneficiary Protection Notification Review notice on 5/17/18, which was the last day of coverage. The RNCC stated that was not enough notice for the resident or their responsible party to arrange for an alternate. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 8 of 64 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 10/21/2018 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 facility's faxed paper work titled, "Beneficiary Policy," dated 10/22/18, indicated the facility should have provided notice to the resident and/or representative three days prior to expiration of benefits.

F584 SS=D Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) 11/21/2018 §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 9 of 64 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 10/21/2018 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 lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain a comfortable temperatures in the resident room and ensure the bed rail pad was not torn for two of 18 sampled residents (Resident 16 and 61). This deficient practice had the potential to negatively affect the quality of life for Resident 16, and 61, when there was no homelike environment provided. Findings: 1. A review of Resident 16's Admission Face Sheet indicated the resident was admitted to the facility on 8/5/16 with admitting diagnoses of chronic respiratory failure (lungs not working). A review of a Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 8/25/18, indicated the resident was in a vegetative state (no brain function). During an observation, on 10/20/18 at 9:30 a.m., with Licensed Vocational Nurse (LVN 8) Resident 16's air condition in the room, was on. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 10 of 64 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 10/21/2018 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 LVN 8 stated the room felt cold to her. On 10/20/18 at 9:45 a.m., during an interview with the Vice President of Operations (VPO) stated it was 58 degrees Fahrenheit (F) in Resident 16's room, when taken with their thermometer. The VPO was unsure what the comfortable resident's room temperature should be, but thought around 68 - 72 degrees F. The VPO stated he would check the policy. According to the facility policy titled, "Air Temperature, Humidity, and Pressure Policy," dated 10/2017 indicated the resident's rooms should be a temperature of 70-75 degrees Fahrenheit. 2. A review of Resident 61's Admission Face Sheet indicated the resident was admitted to the facility on 6/14/18 with admitting diagnoses of chronic respiratory failure (lungs not working). During an observation and concurrent interview on 10/21/18 at 9:52 a.m., Registered Nurse (RN 2) reposition Resident 61 and verified the resident moves side to side while in bed. RN 2 further verified the bed rail pad to the left side was torn. A review of the facility's policy titled "Activities of Daily Living" dated 2/22/17 indicated the facility should provide a functional environment.

F623 SS=E Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8) FORM CMS-2567(02-99) Previous Versions Obsolete

F623 Event ID: UKKV11 11/21/2018 Facility ID: CA930000575 If continuation sheet 11 of 64 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 10/21/2018 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 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 12 of 64 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 10/21/2018 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 §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 13 of 64 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 10/21/2018 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 closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the correct address on the Notice of Proposed Transfer/Discharge was provided to two of 3 closed sampled residents (Residents 74 and 76). This deficient practice had the potential to deprive the residents the right to be informed of their rights regarding transfer and discharge which included the right of residents' to file an appeal to the appropriate agency within 10 days of being notified of a proposed transfer and discharge. Findings: 1. A review of Resident 74's Admission Face Sheet (record of admission) indicated the resident was admitted to the facility on 8/22/18 with a diagnosis of chronic respiratory failure (a long-term condition that happens when the lungs can not get enough oxygen into the blood). A review of Resident 74's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 9/4/18, indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 14 of 64 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 10/21/2018 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 usually made self-understood or understood others and had modified independence (some difficulty in new situations only) in cognitive skills. A review of Resident 74's "Notice of Transfer/Discharge," form dated 9/11/18, indicated the resident and/or representative had the right to appeal the transfer to the Office of the Administrative Hearing and Appeals on "J" Street in Sacramento, California. According to the "All Facilities Letter 10-20.1," dated 8/20/10, a letter from the Licensing and Certification (L&C) Program to health facilities was disseminated to all long term care health facilities which indicated, "All long term care health facilities will need to modify their current notification letters and to delete the reference to L&C District Office as point of contact for appeals and instead, reference: Office of Administrative Hearings and Appeals on Freeway Street in Sacramento, California." 2. A review of Resident 76's Admission Face Sheet indicated the resident was admitted to the facility on 8/13/18 with a diagnosis of chronic respiratory failure. A review of Resident 76's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 8/26/18, indicated the resident had clear speech and was able to make needs known. A review of Resident 76's "Notice of Transfer/Discharge," form dated 8/29/18, indicated the resident and/or representative had the right to appeal the transfer to the Office of the Administrative Hearing and Appeals on "J" Street in Sacramento, California. During an interview and record review of the Notice Transfer and Discharge form, on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 15 of 64 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 10/21/2018 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 10/21/18 at 12 p.m., with the Vice President of Quality (VPQ) stated she was unsure about the address on the form and the nurse was in charge of giving the notice. The VPQ stated when the resident did not have the correct address, they would not be able to appeal the transfer or discharge.

F636 SS=D Comprehensive Assessments & Timing CFR(s): 483.20(b)(1)(2)(i)(iii)

F636 11/21/2018 §483.20 Resident Assessment The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. §483.20(b) Comprehensive Assessments §483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychological well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnosis and health conditions. (xi) Dental and nutritional status. (xii) Skin Conditions. (xiii) Activity pursuit. (xiv) Medications. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 16 of 64 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 10/21/2018 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 (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. §483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.) (iii)Not less than once every 12 months. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to have an individualized care plan for one of the 18 sampled residents (Resident 27) that addressed the gastrostomy ([GT] a surgical opening through the abdomen into the stomach used for feeding and medications) tube feeding. The failure had the potential for Resident 27 to receive inadequate care and services FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 17 of 64 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 10/21/2018 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 individualized to their needs. Findings: A review of Resident 27's Admission Face Sheet indicated the resident was admitted to the facility on 5/30/17 with admitting diagnosis of chronic respiratory failure (lungs not working). A review of a Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 8/10/18, indicated Resident 27 had no speech and rarely/never understood. During a review of Resident 27's Physician Order dated 6/1/18 indicated to administer tube feeding, Jevity 1.5 (nutrition formula) at 45 milliliters an hour for 22 hrs. During an interview and record review of Resident 27's care plan titled, Feeding Tubes, dated 8/10/18 indicated to administer tube feeding at proper rate and volume as ordered. The Registered Nurse Clinical Coordinator (RNCC) acknowledged the resident's care plan for GT was general and not individualized. A review of the facility's policy and procedure titled "Plan of Care Documentation, Interdisciplinary," dated 2018, indicated interdisciplinary plan of care is individualized to the patient and is based upon actual or potential problems, anticipated length of stay, assessed needs, policies, patient care standards, cultural issues, available resources and will be consistent with other therapies and/or disciplines. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 18 of 64 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 10/21/2018 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

F641 Accuracy of Assessments CFR(s): 483.20(g)

F641 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/21/2018 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of 18 sampled residents (Resident 11) Minimum Data Set ([MDS] a standardized assessment and care screening tool) was coded correctly when there was no tracheostomy (tube inserted through a hole in the neck). The deficient practice placed Resident 11 at risk of not receiving needed care. Findings: A review of Resident 11's Admission Face Sheet indicated the resident was initially admitted to the facility on 8/8/18 with diagnoses including chronic respiratory failure and hypoxia (no oxygen in the body). A review of a MDS assessment, dated 8/18/18, indicated Resident 11 had no speech and was rarely/never understood. According to the MDS, Section G, the functional status indicated Resident 11 needed total assistance with dressing and eating. A review of Section O, Special Treatments, Procedures and Programs, indicated Resident 11 had a tracheostomy (tube inserted through a hole in the neck). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 19 of 64 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 10/21/2018 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 During an interview, on 10/21/18 at 10:15 a.m., with the minimum data set nurse coordinator (MDS 1) stated Resident 11 was only receiving oxygen and did not have a tracheostomy. The MDS 1 stated she will correct the MDS assessment because it was incorrectly coded. A review of the Center for Medicare and Medicaid Resident Assessment Instrument (helps facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) manual dated 10/2017 indicated in section O to code cleansing of the tracheostomy and/or cannula in this item. This item may be coded if the resident performs his/her own tracheostomy care.

F658 SS=E Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 11/21/2018 §483.21(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 follow professional standards by checking the blood pressure (BP), immediately prior to administration of BP medications for two of 4 sampled residents (Residents 39 and 50), during medication pass observations. This deficient practice had the potential for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 20 of 64 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 10/21/2018 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 39, and 50 to receive unnecessary medications and risk extreme lowering of BP, causing dizziness, and falls with injuries. Findings: 1. A review of Resident 50's Admission Face Sheet (record of admission) indicated the resident was admitted to the facility on 6/25/18 with a diagnosis of chronic respiratory failure (a long-term condition that happens when the lungs can not get enough oxygen into the blood). A review of Resident 50's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 9/21/18, indicated the resident rarely/never made self-understood or understood others and had severe impairment in cognitive skills. During a medication pass observation, on 10/20/18 at 9:15 a.m., a Licensed Vocational Nurse (LVN 3) stated was not going to check Resident 50's BP because it was taken earlier. LVN 3 stated the BP was 134/82 millimeter per mercury (mm/Hg) and heart rate (HR) was 85 beats per minute. LVN 3 prepared the following medications to be administered via a gastrostomy tube ([G-tube] a tube inserted through the abdomen that delivers nutrition directly to the stomach) for Resident 50: 1. Augmentin (a medication used to treat bacterial infection) 500-125 milligram (mg) one tablet 2. Juven (unique blend of amino acids, collagen protein, and micronutrients to support wound healing and tissue building) one pack, mix with 8-10 ounces (oz.) of water or juice 3. Multivitamin (MVI) nutritional supplement, one tablet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 21 of 64 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 10/21/2018 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 4. Oyster shell 500 mg plus Vitamin D3 (a nutritional supplement) 200 units one tablet 5. Losartan potassium (a medication used to treat high BP) 50 mg one tablet, hold for systolic BP ([SBP] first number measures the pressure in blood vessels when the your heart beats) less than 100 mmHg 6. Culturelle (a supplement to aid in digestion) one tablet 7. Vitamin D3 (a nutritional supplement) 400 unit one tablet 8. Aspirin (a medication used to prevent heart attacks) 81 mg one tablet 9. Banatrol plus (a natural remedy specifically formulated to provide nutrients for the dietary management of diarrhea without medication) for diarrhea and loose stool. 10. Zinc sulfate (a nutritional supplement) 220 mg one tablet During an interview immediately after medications were administered to Resident 50, on 10/20/18 at 10:03 a.m., LVN 3 stated the BP was done around 8 or 8:30 a.m. LVN 3 stated Resident 50's BP results obtained by the certified nursing assistant was still good one hour prior to the medication administration time. LVN 3 stated the best practice should have been checking the BP before giving the resident medications. A review of Resident 50's monthly physician order for October 2018, indicated the resident was ordered for the following medications: 1. Augmentin 500 mg-125 mg via G-tube every 12 hours (hrs.) for 10 days for eye redness. 2. Juven one packet via G-tube every 12 hrs. for wound healing. 3. MVI one tablet via G-tube daily as a supplement. 4. Oyster shell 500 mg + Vitamin D 500 mg via G-tube daily as supplement. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 22 of 64 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 10/21/2018 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 5. Losartan potassium 50 mg via G-tube daily for hypertension (a condition present when blood flows through the blood vessels with a force greater than normal), hold if SBP less than 100. 6. Culturelle one capsule via G-tube daily as supplement. 7. Vitamin D3 400 units via G-tube daily as supplement. 8. Aspirin 81 mg via G-tube prophylaxis for CVA (cardiovascular accident, stroke). 9. Banatrol plus packet via G-tube every 12 hrs. as a supplement. 10. Zinc sulfate 220 mg via G-tube twice a day as a supplement. A review of the facility's "Competency Validation Tool: Medication Administration," dated 9/2017, indicated to check vital signs as needed (for example BP if giving BP medications). 2. A review of Resident 39's Admission Face Sheet indicated the resident was admitted to the facility on 10/12/18 with a diagnosis of chronic respiratory failure (a long-term condition that happens when your lungs cannot get enough oxygen into your blood). A review of Resident 39's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 10/16/18, indicated the resident rarely/never made self-understood or understood others and had severe impairment in cognitive skills. During a medication pass observation, on 10/20/18 at 8:25 a.m., with Licensed Vocational Nurse (LVN 7) stated he took Resident 39's blood pressure (BP) at 7:30 a.m., that morning and he was going to hold the BP medication Labetalol (used to treat high blood) because BP was too low. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 23 of 64 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 10/21/2018 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 During a review of Resident 39's Physician Order dated 10/12/18 indicated to administer Labetlol 400 milligrams (mg) every 12 hours for hypertension (high blood pressure), hold if the systolic BP (top number in the BP reading) was less than 110 millimeter per mercury (mmHg) or heart rate was less than 60 beats per minute. During an interview, on 10/21/18 at 12:05 p.m., with the Vice President of Quality (VPQ) stated the BP should have been checked right before Resident 39's BP medication was administered to make sure it was accurate.

F677 SS=D ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2)

F677 11/21/2018 §483.24(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 18 sampled residents (Resident 54), who required total assistance with showers and/or baths, was assisted to ensure the resident did not have ungroomed oily hair, and was without body odor. Resident 54 had ungroomed oily hair, and strong body odor. This deficient practice had the potential for Resident 54 to be at risk for further decline of health from lack of personal hygiene and body odor. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 24 of 64 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 10/21/2018 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 Findings: A review of Resident 54's Admission Face Sheet (an admission record) indicated the resident was admitted to the facility on 10/21/17 with diagnosis that included chronic respiratory failure (a long-term condition that happens when the lungs can not get enough oxygen into the blood). A review of Resident 54's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 9/24/18, indicated the resident was in persistent vegetative state/no discernible consciousness. Resident 54 required total dependence (full staff performance every time) from staff for all activities of daily living ([ADLs] such as dressing, eating, toileting, personal hygiene, and bathing). During the initial tour of the facility, on 10/18/18 at 7:30 p.m., Resident 54 was observed with ungroomed oily hair, and strong body odor. During an observation and interview, on 10/18/18 at 9:21 p.m., a Licensed Vocational Nurse (LVN 2) stated Resident 54 had a strong "fishy" odor. LVN 2 stated sometimes even after being showered, Resident 54 would still have an odor. During an interview and record review, on 10/20/18 at 8:24 a.m., a Registered Nurse (RN 1) stated Resident 54 was scheduled for a shower on the same day. During a follow up observation, on 10/21/18 at 9:45 a.m., Resident 54's hair was well-groomed and the resident had no body odor. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 25 of 64 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 10/21/2018 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 During an interview and record review, on 10/21/18 at 9:51 a.m., RN 1 stated Resident 54 was last showered on 10/11/8 and was supposed to be showered on 10/17/18. RN 1 also stated the documentation on the ADL daily assessment did not indicate the resident received a bed bath either. RN 1 stated if the resident did not receive a shower, the resident should have been given a bed bath. RN 1 stated if the resident received a shower or bed bath, there should not be any foul body odor coming from the resident. RN 1 stated that family prefers the resident to be showered once a week because they believe the resident could get sick. RN 1 stated there was no care plan indicating the residents and/or family preferences in regards to showers. During requests for facility's policy and procedure addressing ADL care, none was made available for review.

F684 SS=D Quality of Care CFR(s): 483.25

F684 11/21/2018 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow the physician order by having the sequential compression device FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 26 of 64 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 10/21/2018 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 ([SCD] shaped like "sleeves" that wrap around the legs and inflate with air one at a time that helps to circulate blood in the legs of immobile patients) on for one of 18 sampled residents (Resident 44). The deficient practice had the potential for a blood clot in Resident 44's legs. Findings: A review of Resident 44's Admission Face Sheet indicated the resident was admitted to the facility on 5/30/17 with admitting diagnoses of chronic respiratory failure (lungs not working) and hypoxia (no oxygen in the body). A review of a Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 9/9/18, indicated the resident had clear speech and was usually able to express ideas and wants. According to the MDS, Resident 44 required total assistance with dressing and personal hygiene. During an observation and interview, on 10/18/18 at 7:39 p.m., with Registered Nurse (RN 4) Resident 44's SCDs were turned off. The RN 4 stated the resident's SCDs should be on to prevent blood clots. A review of the physician order for Resident 44 dated 5/30/17 indicated to apply SCD boots for deep vein thrombosis (blood clots). A review of an undated facility's policy and procedure titled, "Sequential Compression Device," indicated to be "developed."

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 11/21/2018 Facility ID: CA930000575 If continuation sheet 27 of 64 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 10/21/2018 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 SS=E CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide necessary care and services to three of 18 sampled residents (Residents 38, 51 and 61) to avoid worsening of pressure injury (areas of damaged skin caused by staying in one position for too long which reduces blood flow to the area and cause the skin to die and develop a sore) by failing the following: 1. Resident 38, the pressure relieving device of the neck roll was not provide for the occipital (back of the head) pressure injury. 2. Resident 61, the staff failed to reposition the resident every 2 hours per the facility's policy and procedure. 3. Resident 51, the licensed nurse failed to change both gloves, failed to perform hand hygiene (procedures include the use of alcoholbased hand rubs (containing 60%–95% FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 28 of 64 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 10/21/2018 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 alcohol) when hands are not visibly soiled, and or hand washing with soap and water) inbetween different pressure ulcer sites, used the same tongue depressor for applying ointment to two different sites, and when cleaning the wound, did not clean from clean to dirty site. The deficient practices could potentially hinder the healing of Resident 38, 61, 51's pressure ulcers, and cause infections. Findings: 1. A review of Resident 38's Admission Face Sheet (an admission record) indicated the resident was admitted to the facility on 10/7/18 with diagnosis that included chronic respiratory failure. A review of the admission physician order dated 10/7/18 indicated Resident 38 had a right occipital wound. A review of Resident 38's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 10/17/18, indicated the resident rarely/never made self-understood and sometimes understood others and was severely impaired in cognitive skills. Resident 38 required total dependence (full staff performance every time) from staff for all activities of daily living ([ADLs] such as dressing, eating, toileting, personal hygiene, and bathing) and had a pressure reducing device while in bed. During an observation on 10/21/18 at 8:39 a.m. with Licensed Vocational Nurse (LVN 4) verified Resident 38 was in supine (lying down) position, back of the head had a dressing, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 29 of 64 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 10/21/2018 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 laying directly on a pillow. LVN 4 further stated the thicker dressing was to decrease pressure on the head. During a subsequent observation and concurrent record review on 10/21/18 at 10:11 a.m. with LVN 6 stated Resident 38 had a donut device for his head but blood was pulling and facility changed the device to a neck roll to elevate the head away from the pillow. During the observation LVN 6 verified Resident 38 did not have the neck roll in place and the occipital part of the head was directly lying on the pillow. LVN 6 was notified of LVN 4's response of the dressing and verified other Licensed Nurses (LN) are not aware of the pressure injury treatment due to treatment nurse was the only LN in charge of pressure injury treatment and stated he would let other nurses know of the interventions for continuum of care. LVN 6 verified the pressure injury care plan failed to indicate the head roll as an intervention to prevent the worsening of the pressure injury. 2. A review of Resident 61's Admission Face Sheet indicated the resident was admitted to the facility on 6/14/18 with admitting diagnoses of chronic respiratory failure (lungs not working). A review of the high risk for skin breakdown care plan dated 9/14/18, indicated to reposition resident every two hours to promote circulation. During a continuos observation of Resident 61's repositioning on 1/20/18 at 12:53 p.m. to 3 p.m., Resident 61 was lying on the left side. During an interview on 10/20/18 at 2:57 p.m. with Registered Nurse (RN 2) when asked about the facility's procedure for resident's at risk for pressure injury he stated the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 30 of 64 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 10/21/2018 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 provided repositioning every 2 hours. During an observation on 10/20/18 at 2:58 p.m., Certified Nursing Assistant (CNA 2) assigned to Resident 61 for the 7-3 p.m. shift, went into the room closed the curtain and came out two minutes after. When asked what care was provided to Resident 61, CNA 2 stated she emptied the indwelling catheter (drains urine from bladder into a bag outside the body). During a subsequent interview on 10/20/18 3:05 p.m., at the end CNA 2's shift, when asked about the repositioning schedule, CNA 2 stated Resident 61 had a sacro pressure injury and today she reposition him on his back at 7 am, at 9 am on his right side, at 11 am on his back side, and her last repositioning was at 1 or 2 p.m. When asked when did she and the treatment nurse placed the resident on his left side, CNA 2 stated, the next repositioning was scheduled either at 3 or 4 p.m. During an observation on 10/20/18 at 3:17 p.m., CNA 2 and LVN 6 repositioned Resident 61 in the supine position. During an interview on 10/20/18 at 3:21 p.m., LVN 6 verified Resident 61 had a sacrococcyx Stage 3 (the sore gets worse and extends into the tissue beneath the skin, forming a small crater, the fat may show in the sore, but not muscle, tendon, or bones) pressure ulcer. LVN 6 stated CNA 2 asked him to assist to reposition the resident. When asked, LVN 6 stated the last time he went into Resident 61's room was before 12:30 a.m. LVN 6 verified Resident 61 was scheduled per facility's policy and procedure to be repositioned every 2 hours for circulation of blood and was scheduled to be turned by 2:30 p.m. 3. During a treatment observation with a Licensed Vocational Nurse (LVN 9) for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 31 of 64 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 10/21/2018 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 51, the facility failed to provide appropriate treatment to ensure the resident's pressure ulcers did not worsen. The following was observed: a. LVN 9 failed to change both gloves during treatment, b. LVN 9 failed to perform hand hygiene between changing dressings to four different sites (left trochanter, left ischial, sacrococcyx, and right ischial), c. LVN 9 used the same tongue depressor to apply Carrasyn (a gel ointment used to provide moister to the wound bed for healing of pressure ulcers) ointment to two different sites d. LVN 9 cleaned the wound to the sacrococcyx area and the right ischial by cleaning back and forth and not from cleanest to dirtiest. A review of Resident 51's Admission Face Sheet (an admission record) indicated the resident was admitted to the facility on 12/30/16 with diagnosis that included chronic respiratory failure (a long-term condition that happens when your lungs cannot get enough oxygen into your blood). A review of Resident 51's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 9/23/18, indicated the resident rarely/never made self-understood and sometimes understood others and was severely impaired in cognitive skills. Resident 51 required total dependence (full staff performance every time) from staff for all activities of daily living ([ADLs] such as dressing, eating, toileting, personal hygiene, and bathing). A review of Resident 51's physician order, dated 10/19/18, indicated the resident was ordered for the following treatments: a. Left trochanter pressure injury, irrigate with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 32 of 64 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 10/21/2018 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 normal saline (NS), pat dry, loosely pack with soaked gauze with carrasyn gel (medication), cover with tielle dressing daily and as needed (PRN) if soiled. b. Left ischial pressure injury, irrigate with NS, pat dry, loosely pack with soaked gauze with carrasyn gel, cover with tielle dressing daily and PRN if soiled. c. Sacrococcyx pressure injury, cleanse with NS, pat dry, apply calcium alginate, cover with tielle dressing daily and PRN if soiled. d. Right ischial pressure injury, cleanse with NS, pat dry, apply calcium alginate, cover with tielle dressing daily and PRN if soiled. During a treatment observation, on 10/21/18 at 10:52 a.m., LVN 9 gathered supplies for dressing changes for Resident 51's four pressure ulcer sites: left trochanter, left ischial, sacral, and right ischial. LVN 9 stated calcium alginate (medication) would be used for the sacral and right ischial area and carrasyn ointment would be used for the left trochanter and left ischial sites. LVN 9 cleaned left trochanter, left ischial, then sacrococcyx. LVN 9 removed the old dressing with one set of gloves, then removed glove to left hand, and donned (put on) a new pair to clean the wound. LNV 9 did not perform hand hygiene between dressing changes to each site. After removing the old dressing, LVN 9 cleaned the sites with normal saline (NS) by rubbing the NS back and forth on the wound, multiple times. LVN 9 also dried the wounds by making several passes over the wound back and forth. LVN 9 also used the same tongue depressor to apply carrasyn ointment to the left trochanter and left ischial sites. After completing the treatment to all four sites, LVN 9 stated she was supposed to change both gloves to prevent cross contamination. LVN 9 also stated she was not sure if she was supposed to perform hand hygiene between the different wound sites. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 33 of 64 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 10/21/2018 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 LVN 9 stated she was not supposed to use the same tongue depressor to apply to two different dressing sites. LVN 9 also stated she was supposed to clean the wound from inner to outer and pat dry from inner to outer to prevent cross contamination. During an interview, on 10/21/18 at 11:52 a.m., the Vice President of Quality (VPO) stated when changing dressings between different wound sites, the nurses should perform hand hygiene (for example use hand sanitizer or wash hands) and both gloves should be changed. The VPO stated the same tongue depressor should not be used on two different wound sites because there was a risk for cross contamination. The VPO stated nursing staff should clean the wounds from inner to outer which was from clean to dirty areas, to prevent infection. The VPO stated the resident's wound could potentially get worse. A review of the facility's policy and procedure titled, "Wound Care: Assessment and Documentation of Skin Integrity Impairment," dated 9/26/18, indicated the wound care treatment goal was to maintain moist wound environment as appropriate, absorb excess exudates, protect surrounding skin to keep it intact, and prevent wound contamination. All dressing changes should be done using sterile supplies and clean technique unless ordered otherwise. A review of the facility's policy and procedure titled, "Infection Prevention," dated 8/24/16, indicated all personnel should wash hands after removing gloves.

F690 SS=D Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3) FORM CMS-2567(02-99) Previous Versions Obsolete

F690 Event ID: UKKV11 11/21/2018 Facility ID: CA930000575 If continuation sheet 34 of 64 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 10/21/2018 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 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (Resident 57), who had an indwelling catheter (a tubing inserted through FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 35 of 64 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 10/21/2018 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 urethra and into the bladder to drain urine), was adequately assessed and provided with treatment. Resident 57 was observed with sediments (particles) in the indwelling catheter tubing. There was no documentation indicating Resident 57 was assessed for sediments in the urine and physician was not notified for further instructions about potential treatment. This deficient practice had the potential to delay Resident 57 receiving treatment and increasing the risk for having severe infection such as sepsis (a life-threatening infection). Findings: A review of Resident 57's Admission Face Sheet (an admission record) indicated the resident was admitted to the facility on 6/16/18 with diagnosis that included chronic respiratory failure. A review of Resident 57's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/26/18, indicated the resident had persistent vegetative state/no discernible consciousness. Resident 57 required total dependence from staff for all activities of daily living ([ADLs] such as dressing, eating, personal hygiene, and toileting). A review of Resident 57's monthly physician order for October 2018 indicated the resident was ordered for an indwelling catheter. A review of Resident 57's care plan titled, "Care Plan: Altered Urine Elimination," dated 6/29/18, indicated the resident was at risk for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 36 of 64 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 10/21/2018 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 urinary tract infection (UTI). Assess the resident' urine elimination and monitor for signs and symptoms (s/s) of UTI and complications such as checking sediments or hematuria or foul smelling urine. Report to physician any abnormal s/s and lab results. During the initial tour of the facility, on 10/18/18 at 7:46 p.m., Licensed Vocational Nurse (LVN 2) stated Resident 57 had an indwelling catheter with dark yellow urine and sediments in the tubing. LVN 2 stated the resident should not have sediments in the urine because it might mean the resident had an infection. During an interview, on 10/21/18 at 10:26 a.m., Registered Nurse (RN 1) stated Resident 57 did not have any documentation indicating the resident had cloudy or sediments in the urine since 10/18/18 to present. During an observation and interview, on 10/21/18 at 10:28 a.m., RN 1 stated Resident 57's catheter tubing had sediments in the urine. RN 1 stated if nursing staff noticed the resident had sediments, the physician should have been notified. RN 1 stated usually the physician would order for laboratory tests to see if the resident had a urinary tract infection and would start antibiotics to treat the UTI if needed. RN 1 stated LVN 2 should have notified the resident's physician when it was observed during the initial tour of the survey, about the sediments. RN 1 stated because the resident's physician was not notified timely, the resident was at risk for becoming septic and she would call the physician now. During an interview, on 10/21/18 at 12:10 p.m., the Director of Infection Control (DIC) stated if staff noticed something abnormal in the urine, the resident's physician should have been notified because there was a potential for delay FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 37 of 64 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 10/21/2018 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 in receiving treatment and/or the resident could become septic. A review of the facility's policy and procedure titled, "Physician Notification," dated 12/2/17, indicated to ensure timely and effective communication between appropriate caregivers. The nurse assigned to the resident or supervising the care of the resident was responsible for notification of and communication to the medical staff regarding significant changes or deterioration in the resident's condition and for assuring that there was a physician response. A review of the facility's policy and procedure titled, "CAUTIs (Catheter-Associated UTI): Prevention," dated /27/18, indicated to check tubing at the beginning of each shift and during each resident assessment.

F693 SS=E Tube Feeding Mgmt/Restore Eating Skills CFR(s): 483.25(g)(4)(5)

F693 11/21/2018 §483.25(g)(4)-(5) Enteral Nutrition (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§483.25(g)(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 §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 38 of 64 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 10/21/2018 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 and to prevent complications of enteral feeding including but not limited to aspiration 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 have the head of bed ([HOB] higher than 30 degrees angle) elevated while the gastrostomy ([GT] a surgical opening through the abdomen into the stomach used for feeding and medications) feeing was running for four of 32 residents on tour and failed to check residuals (the volume of fluid remaining in the stomach) prior to medication administration via GT for one of 4 sampled selected residents for medication administration (Resident 39). Findings: 1. During the initial tour of the facility, on 10/18/18 from 7:30 p.m. - 8:30 p.m., with Registered Nurse (RN 4) there was four resident's with GT feedings running but their HOB was below 30 degree angle. RN 4 stated the HOB should be higher than 30 degrees angle to prevent aspiration (when food, liquids, saliva, or vomit is breathed into the airways). A record review of the facility's policy and procedure titled, "Enteral Feeding Tubes," dated 7/2016 indicated elevate patient's HOB 30-45 degrees at all times. 2. A review of Resident 39's Admission Face Sheet indicated the resident was admitted to the facility on 10/12/18 with a diagnosis of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 39 of 64 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 10/21/2018 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 chronic respiratory failure (a long-term condition that happens when the lungs can not get enough oxygen into the blood). A review of Resident 39's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 10/16/18, indicated the resident rarely/never made self-understood or understood others and had severe impairment in cognitive skills. During an observation of the medication pass, on 10/20/18 at 8:30 a.m., with Licensed Vocational Nurse (LVN 7), checked the placement of the GT, then he added 30 cubic centimeter (cc) of water into the syringe that was connected to the GT and was about to flush the water in the tubing when the surveyor asked if there was residual in the GT. LVN 7 stated he forgot to check the residual. LVN 7 flushed the 30 cc of water from the syringe, replaced it with air, and then checked the stomach residual. LVN 7 stated the residual should be checked prior to flushing with water. LVN 7 stated if there was more than 100 cc's of residual left in the resident's stomach, the nurses are supposed to hold the feedings. During a review of the Physician Order for Resident 39 dated 10/12/18 indicated to check residual every 8 hours and to hold if there was more than 100 milliliters (ml) for one hour then resume feeding and record amount. A review of the facility's policy and procedure titled, "Enteral Feeding Tubes," dated 7/2016 indicated for gastric residuals the patients receiving continuous nasogastric tube feedings shall have residuals checked and documented at a minimum of every four hours.

F695 Respiratory/Tracheostomy Care and Suctioning F695 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 11/21/2018 Facility ID: CA930000575 If continuation sheet 40 of 64 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 10/21/2018 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) SS=L CFR(s): 483.25(i) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observations, interviews and record reviews, the facility failed to have a ventilator alert system that would notify the respiratory therapist (RT) and the licensed nurses of the specific room and resident when the ventilator alarms are triggered, converts to blinking or silence for of 52 ventilator assisted residents (require mechanical aid for breathing to assist or replace spontaneous ventilatory efforts (any mode of mechanical ventilation where every breath is spontaneous such as patient triggered and patient cycled) to achieve medical stability or maintain life) of 76 residents in the facility; 27 of the 52 ventilator assisted residents were on isolation (the prevention of contagious diseases from being spread from a patient to other patients, health care workers, and visitors, or from outsiders to a particular patient). Resident 53, a ventilator dependent (machine that helps the person breath) resident, who was on isolation precautions, had ventilator alarm on silent, indicating a high pressure (means there is an blockage somewhere along the system of tubes that lead to the air sacs in the lungs) with no facility staff present. The facility staff had no knowledge of who silenced the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 41 of 64 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 10/21/2018 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 alarm and the length of time the alarm had been triggered. This resulted in a situation of the facility's non-compliance with a delay in a respiratory assessment and intervention as evidenced by: a. Resident 53's ventilator alarm was silenced, and there was no staff present. b. The facility staff were required to monitor the hallways for the location of alarm inside the rooms, which occupied two to three residents. c. There were two L-shaped sections of the facility layout, where one respiratory therapist (RT) had to monitor two separate hallways. d. Staff verbalized short staffing at night and if the nurse and RT assigned to the same assignment were busy, there were no staff to monitor the hallway for a quick response to the resident's alarms. e. During a family interview stated sometimes the staff failed to answer the alarms in a timely manner. These deficient practices had the likelihood to cause, serious injury, harm, impairment or death of ventilator assisted residents. The facility's Chief Nursing Officer, Clinical Nurse Coordinator and Clinical Educator were informed of the Immediate Jeopardy (IJ) on 10/18/18 at 10 p.m. The non-compliance related to the IJ was identified to have existed on 10/18/18 (the date Resident 53's alarm was silenced) continued through 10/19/18 when Resident 10's and 35's ventilator alarm settings for high pressure (limits highest pressure allowed by ventilator; causes of high pressure alarm may include coughing, accumulation of secretions, kinked tubing, pneumothorax [a collapsed lung], decreased lung compliance) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 42 of 64 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 10/21/2018 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 and positive end expiratory pressure ([PEEP] pressure maintained in lungs at end of letting the air out, used to improve oxygenation by opening collapsed alveoli, improving ventilation/perfusion, increasing oxygenation) was tuned off, making it hard for the staff to notice a resident was having difficulty breathing. The IJ was removed on 10/19/18 at 10:22 p.m., based on the acceptable Plans of Action (POA) developed and implemented by the facility. Findings: During initial tour of the facility on 10/18/18 at 8:04 p.m., the licensed vocational nurse (LVN 5) acknowledged Resident 53's ventilator high pressure indicator was blinking and there was no audible sound to alert the staff when the resident was having trouble breathing. The silenced reset button had an illuminating red light. Concurrently, during an interview, when asked if she had knowledge of Resident 53's ventilator high pressure alarm, LVN 5 stated she would call RT. On 10/18/18 at 8:04 p.m., during an interview RT 1 stated the blinking of a high pressure alarm indicated the alarm was triggered and no one heard it because it was on silent mode. When asked if he knew or if someone reported to him Resident 53's alarm was in progress, RT 1 stated he did not know who silenced the alarm and nobody notified him during change of shift. RT 1 further explained the facility's system for ventilator alarms was to physically stay in hallway to hear the alarms and then required RT or a nurse to walk through the hallway to find out where the alarm was coming from. RT 1 verified the facility had no system outside of the residents' rooms or any other FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 43 of 64 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 10/21/2018 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 place on the unit to provide visual notification which room the ventilator alarm was coming from. A review of Resident 53's admission Face Sheet indicated the resident was admitted to the facility on 6/14/18, with diagnosis that included chronic respiratory failure (a chronic condition resulting from inadequate exchange of oxygen or carbon dioxide, or both by the respiratory system). A review of Resident 53's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/24/18, indicated the resident required a ventilator for breathing and was totally dependent (full staff performance every time) on staff for all activities of daily living, such as dressing, eating, toileting, personal hygiene, and bathing. A review of Resident 53's monthly physician order for October 2018, indicated there was an order, dated 6/14/18, for the resident to be connected to a mechanical ventilator machine. During an observation of the facility's ventilators alarm response system on 10/18/18 at 8:08 p.m., RT 1 was in with a resident's room when the ventilator alarm of an isolation room was triggered, however, there was no other staff in the hallway. RT 1 was observed exiting the room at 8:11 p.m., donned (put on) on personal protective equipment ([PPE] refers to protective clothing, helmets, gloves, face shields, goggles, facemask and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) and entered the resident room with the triggered alarm. During an interview on 10/18/18 at 8:21 p.m., a randomly selected family member was asked if FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 44 of 64 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 10/21/2018 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 facility staff answers ventilator alarms quickly and in a timely manner, the family member stated staff did not answer alarms timely. During a subsequent hallway observation on 10/18/18 at 8:26 p.m., the ventilator alarm in a resident's room, triggered. However, there was no facility staff monitoring the hallways to ensure quick response to the ventilator alarm. During an interview on 10/18/18 at 8:58 p.m., the registered nurse (RN 3) stated there were five RTs scheduled for the night shift and one of five was the lead RT, who came from the hospital to made rounds every two hours. RN 3 stated the four RTs had to monitor different hallways and had 13 of 13 ventilator assisted residents each to monitor. During an interview on 10/18/18 at 9:04 p.m. with a RT stated the facility currently had two different types of ventilators in use. When asked about ventilator high pressure alarms, RT stated ventilator high pressure alarm triggered due to the pressure back from the machine when the resident was coughing. RT stated if the resident was not assessed when the ventilator's high pressure alarm was on, the worst possible scenario could be the resident's lungs could "blow up" or get decannulated (accidental removal of a tracheostomy tube a curved tube that is inserted into a tracheostomy stoma [the hole made in the neck and windpipe]). The RT continued to explain the ventilator alarms could silence themselves if the problem resolves by itself. When asked how staff verified ventilators alarms were functional, RT stated the ventilators did not have a test button thus, the staff either lowered the setting levels or capped the machine to verify the alarms were functional. When asked about staffing the RT stated the assignment for tonight (10/18/18) was 13 residents for each FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 45 of 64 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 10/21/2018 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 RT, when the usual ratio was 10 residents per one RT. The RT stated lately the facility had been short staffed and sometimes one RT had 14 to 16 residents. When asked about the worst possible scenario due to short staffing, the RT stated if a resident was decannulated due to turning and the RT was replacing the cannula and another ventilator alarm went off for another resident there would be no RT available for that resident. The RT further stated nurses had to call for another RT and there was one assignment where the RT had to monitor two L-shaped hallway. The RT further stated the RTs always had to stay on their run. A review of the undated most recent Facility Assessment (the facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies) indicated the average resident census of the facility was 73 to 75 residents with an average of "10 RT per day in a 24 hour period, more based on acuity." The Facility Assessment failed to include an evaluation of the care required by the resident population considering other pertinent facts that were present within that population (e.g., assistance with mobility, activities of daily living) to account for care time verses time staff had to monitor the hallways. A review of the RT Department Patient Master List for 10/18/18, indicated a total of 4.7 RTs for night shift. The staffing instructions indicated to round up staffing if 0.5 and above, meaning on 10/18/18 a total of 5 RTs were required. There were 4 RTs present on 10/18/18. The facility's Chief Nursing Officer, Clinical Nurse Coordinator and Clinical Educator were informed of the Immediate Jeopardy (IJ) on 10/18/18 at 10 p.m. due to the following FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 46 of 64 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 10/21/2018 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 concerns: a. Resident 53's ventilator alarm was silenced, and there was no staff present. b. The facility staff were required to monitor the hallways for the location of alarm inside the rooms, which occupied two to three residents. c. There were two sections of the facility layout, which was an L-shaped, where one respiratory therapist (RT) had to monitor two separate hallways. d. Staff verbalized short staffing at night and if the nurse and RT assigned to the same assignment were busy, there were no staff to monitor the hallway for a quick response to the resident's alarms. e. During a family interview stated sometimes the staff failed to answer the alarms in a timely manner. These deficient practices had the likelihood to cause, serious injury, harm, impairment or death to ventilator assisted residents. The noncompliance related to IJ was identified to have existed on 10/18/18 (the date Resident 53 alarm was silent) and continued through 10/19/18 when Resident 10's and 35's ventilator alarm settings for high pressure (limits highest pressure allowed by ventilator; causes of high pressure alarm may include coughing, accumulation of secretions, kinked tubing, pneumothorax, decreased lung compliance) and positive end expiratory pressure (PEEP/pressure maintained in lungs at end of expiration used to improve oxygenation by opening collapsed alveoli, improving ventilation/perfusion, increasing oxygenation) were off. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 47 of 64 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 10/21/2018 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 During a follow up observation and interview, of the IJ called on 10/18/18, on 10/19/18 at 5:29 p.m., the following observations were made with RT 1 from Room 1 to 38: two of 52 residents, Resident 10 and 35, who were on ventilators were observed with their ventilator settings turned off. The monitor indicated "high and low (H&L) PEEP Off". Concurrently, during an interview, RT 2 stated Resident 35's ventilator H&L PEEP setting should not be off. The RT 2 stated the ventilator would not turn off the setting by itself, someone had to turn it off. The RT 2 stated he had reset the ventilator. The RT 2 stated when the PEEP setting was off, the machine would not alert staff in the event the resident had a high PEEP. The RT 2 stated having a high PEEP was not good. Continuing with the follow up observations, Resident 10's ventilator machine also indicated H&L PEEP off. The RT 2 stated when the alarm was turned off, there was no alert to let staff know if there was a problem with the resident. The RT 2 was observed to don (put on) the PPE, which included gown and gloves to go inside the resident's room to check and reset the ventilator machine. a. A review of Resident 35's Admission Face Sheet (an admission record) indicated the resident was admitted to the facility on 11/21/16, with diagnosis that included chronic respiratory failure. A review of Resident 35's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/1/18, indicated the resident rarely/never made self-understood or understood others and had severely impaired cognitive skills for daily decision making. Resident 35 required a total dependence (full staff performance every time) from staff for all activities of daily living (ADLs), such as dressing, eating, toileting, personal hygiene, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 48 of 64 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 10/21/2018 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 and bathing. A review of Resident 35's monthly physician order for October 2018, indicated the resident had an order for mechanical ventilator settings on 8/13/18 for PEEP at 5. A review of Resident 10's Admission Face Sheet indicated the resident was admitted to the facility on 9/25/18, with diagnosis that included chronic respiratory failure. b. A review of Resident 10's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 8/18/18, indicated the resident had persistent vegetative state/no discernible consciousness. Resident 10 required a total dependence (full staff performance every time) from staff for all activities of daily living (ADLs), such as dressing, eating, toileting, personal hygiene, and bathing. A review of Resident 10's monthly physician order for October 2018, indicated the resident had an order for mechanical ventilator settings on 9/25/18 for PEEP at 5. During an interview on 10/19/18 at 6 p.m., with the Director of Respiratory Services (DR) provided the ventilator manual for Resident 53's ventilator. According to the manual if someone silenced the ventilator alarm the audible alarm would be silent for 60 seconds and then it would be audible again. When asked what the illuminated silence button meant, DR stated it the ventilator alarm was silenced. DR stated a high pressure alarm was most common when the resident was coughing, had a bronchospasm (a tightening of the muscles that line the airways the lungs) that required a breathing treatment (medication to help breathing easier), a kink in the tubing or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 49 of 64 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 10/21/2018 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 obstruction (secretions or water) in tubing. These conditions would trigger the high pressure alarm. The DR further stated if the alarm was silenced it would reset in 60 seconds. When asked what could happen to a resident with a high pressure alarm in 60 seconds, DR stated the resident might have had difficulty breathing that required clearance of airway due to an obstruction. A review of the Facility's Policy titled "Respiratory Therapy" dated 5/25/16, indicated ventilator should not be manipulated except in an emergency. The IJ was removed on 10/19/18 at 10:22 p.m. when the facility presented acceptable POA that were developed and implemented by the facility. The following included in the plan: 1. Assessment of Resident 53 for signs and symptoms of distress and check of ventilator with manufacturer's settings and recommendations. 2. Assessed the other 51 residents' ventilators and signs of distress. 3. Increased respiratory therapy staff by one per shift, to ensure continuous monitoring of the residents until call system was in place. 4. The duties of roving RT are: a. Verify all ventilator alarm settings are active and set per policy b. Implementation of the verification audit tool once a shift c. Assist in response to residents requiring ventilator intervention 5. Project for alert call system FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 50 of 64 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 10/21/2018 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 6. Policy revision staff shall not silence alarms unless at bedside with a resident 7. Facility Assessment utilization for determining staffing level of the facility.

F759 SS=E Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 11/21/2018 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of 5 percent (%) or greater during the medication pass observation. The facility had a cumulative medication error rate of 25.9 % consisting of seven errors in a sample size of 27 opportunities for error. The medication error consisted of: 1. There was no flushing in between medications for Resident 39 via gastrostomy tube ([GT] a surgical opening through the abdomen into the stomach used for feeding and medications). 2. There was no flushing in between medications for Resident 50 via GT, 3. The Licensed Vocation Nurse (LVN) crushed all of Resident 18's medications, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 51 of 64 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 10/21/2018 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 administered them together. Findings: 1. A review of Resident 39's Admission Face Sheet indicated the resident was admitted to the facility on 10/12/18 with a diagnosis of chronic respiratory failure (a long-term condition that happens when the lungs can not get enough oxygen into the blood). A review of Resident 39's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 10/16/18, indicated the resident rarely/never made self-understood or understood others and had severe impairment in cognitive skills. During an observation of the medication pass, on 10/20/18 at 8:24 a.m., with Licensed Vocational Nurse 7 (LVN 7), administered the following medications: 1. Keppra 1500 milligrams (mg) (used for seizures [uncontrolled jerking movement]) 2. Protonix 40 mg (used for gastroesophageal reflux disease ([GERD] acid reflux) 3. Miramax 17 grams (gm) (used for constipation) 4. Phenobarbital 60 mg (used for seizures) 5 opportunity During the medication pass LVN 7 did not flush with water in between each medications administered. During an interview, on 10/21/18 at 12:05 p.m., with the Vice President of Quality (VPQ) she stated the nurse should have flushed with only water in between meds to prevent clogging. 2. A review of Resident 50's Admission Face Sheet (record of admission) indicated the resident was admitted to the facility on 6/25/18 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 52 of 64 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 10/21/2018 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 with a diagnosis of chronic respiratory failure (a long-term condition that happens when the lungs can not get enough oxygen into the blood). A review of Resident 50's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 9/21/18, indicated the resident rarely/never made self-understood or understood others and had severe impairment in cognitive skills for daily decision making. During a medication pass observation, on 10/20/18 at 9:15 a.m., LVN 3 prepared the following medications for Resident 50 for gastrostomy tube ([G-tube] a tube inserted through the abdomen that delivers nutrition directly to the stomach) administration: 1. Augmentin (a medication used to treat bacterial infection) 500 milligram (mg)-125 mg one tablet 2. Juven (unique blend of amino acids, collagen protein, and micronutrients to support wound healing and tissue building) one pack, mix with 8-10 ounces (oz.) of water or juice 3. MVI (a multivitamin nutritional supplement) one tablet 4. Oyster shell 500 mg + Vitamin D3 (a nutritional supplement) 200 units one tablet 5. Losartan potassium (a medication used to treat high BP) 50 mg one tablet, hold for systolic BP (SBP) less than 100 6. Culturelle (a supplement to aid in digestion) one tablet 7. Vitamin D3 (a nutritional supplement) 400 unit one tablet 8. Aspirin (a medication used to prevent heart attacks) 81 mg one tablet 9. Banatrol plus (a natural remedy specifically formulated to provide nutrients for the dietary management of diarrhea without medication) for diarrhea and loose stool. 10. Zinc sulfate (a nutritional supplement) 220 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 53 of 64 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 10/21/2018 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 mg one tablet LVN 3 checked placement and for residuals prior to administration of medications via the Gtube. LVN 3 performed a pre and post flush of medications administered. LVN 3 administered the medications individually via G-tube. LVN 3 did not flush between each medications administered. During an interview immediately after medications were administered to Resident 50, on 10/20/18 at 10:03 a.m., LVN 3 stated she was supposed to flush between each medication and did not. During an interview, on 10/20/18 at 10:09 a.m., a Registered Nurse 1 (RN 1) stated the CNA assigned to Resident 50, took the BP at the start of her shift around 7:30 a.m. During an interview, on 10/21/18 at 12 p.m., the Vice President of Quality (VPO) stated that best nursing practice would be to check blood pressure before administering medications if the medication had parameters when not to give the medication. The VPO stated the facility did not have a policy to indicate how long between obtaining the BP and administering the BP medication. The VPO stated that vital signs were checked at 7:30 a.m. A review of Resident 50's monthly physician's order for October 2018, indicated the resident was ordered for the following medications: 1. Augmentin 500 mg-125 mg via G-tube every 12 hours (hrs.) for 10 days for eye redness. 2. Juven one packet via G-tube every 12 hrs. for wound healing. 3. MVI one tablet via G-tube daily as a supplement. 4. Oyster shell 500 mg + Vitamin D 500 mg via G-tube daily as supplement. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 54 of 64 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 10/21/2018 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 5. Losartan potassium 50 mg via G-tube daily for hypertension (a condition present when blood flows through the blood vessels with a force greater than normal), hold if SBP less than 100. 6. Culturelle one capsule via G-tube daily as supplement. 7. Vitamin D3 400 units via G-tube daily as supplement. 8. Aspirin 81 mg via G-tube prophylaxis for CVA (cardiovascular accident, stroke). 9. Banatrol plus packet via G-tube every 12 hrs. as a supplement. 10. Zinc sulfate 220 mg via G-tube twice a day as a supplement. A review of the facility's "Competency Validation Tool: Medication Administration," dated 9/2017, indicated that medications given via G-tube should be flushed with at least 5-10 mL of water after each medication and ensure medication cups were free from medication residuals. 3. During a medication pass observation, on 10/20/18, at 8:22 a.m., Licensed Vocational Nurse (LVN 4) prepared the following medications for Resident 18: 1. Neurontin 300 milligrams (mg) 1 capsule 2. Pepcid 20 mg 1 tablet (tab) 3. Multivitamin (MVI) 1 tab 4. Vitamin C 500 mg 1 tab 5. Lactulose10 gram/ 15 milliliters LVN 4 crushed MVI, Vitamin C and Pepcid all together. As a result was unable to flush between medications. During an interview on 10/20/18 at 1:16 p.m. with LVN 4 verified her last skills was in 8/18 and was taught to crush medications individually and flush between medication. LVN 4 stated she failed to crush medications individually and flush between the medications. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 55 of 64 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 10/21/2018 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 During an interview on 10/20/18 at 1:43 p.m. with Registered Nurse 2 (RN 2), verified Resident 18 had a large liquid stool on 10/20/18 at 6:43 a.m. and the lactulose order indicated to hold medication for loose stool. A review of the facility's procedure titled, "Medication Administration," indicated medication for gastric tube should be flushed in between medications administration.

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 11/21/2018 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to have the food FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 56 of 64 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 10/21/2018 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 labeled, dented cans separated and ice machine be free from pink/dark black substance inside the machine. This deficient practices had the potential for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: During initial tour of the kitchen on 10/20/18 at 11:11 a.m., with the General Manager (GM) the following was observed: 1. The ice machine had dark black and pink substances that was wiped off on a napkin on the coroners of the inside plastic bin, 2. Kimchi (side dish made from salted and fermented vegetables), opened in small containers with no opened date placed in the fridge, 3. Cucumbers in soy sauce in small plastic container with no label in fridge, 4. Five trays of sandwiches of turkey and ham with no label in fridge, 5. Two loaves of open bread with no open date, 6. Six 50 pound bin containers with no date when opened that contained sugar, regular rice, Jasmine rice, brown rice, Korean rice and flour, 7. Box of pancake mix, opened but not dated open dated 9. Two dented cans of fruit cocktail, 10. Multiple plastic opened bins in the produce walk in fridge, that was not dated. In a concurrent interview with the GM stated he will put the ice machine out of order till they clean it, the foods with no label, will check their policy and the dented cans should be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 57 of 64 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 10/21/2018 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 separated with the other products to be returned. The GM stated the ice machine was cleaned once a month. A review of the facility's policy and procedure titled, "Purchasing, Receiving and Storage," dated 10/2015 indicated products not meeting specifications will be rejected and returned to the vendor for credit. Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents, or swells will not be accepted, but kept in a separate, labeled are in the storeroom. Dry Bulk foods such as flour, sugar, and cereals are stored in metal or plastic containers with tight fitting lids and are labeled. A review of the facility's policy and procedure titled, "Production and Service," dated 10/2015 indicated leftovers will be refrigerated promptly and used within 72 hours. They should be covered, labeled and dated. A record review of the facility's policy and procedure titled, "Ice handling," dated 10/2015 indicated visible areas of the ice machine are clean weekly.

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 11/21/2018 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 58 of 64 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 10/21/2018 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 prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(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; §483.80(a)(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 contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 59 of 64 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 10/21/2018 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 §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(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 interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection, by failing to use personal protected equipment ([PPE] refers to protective clothing, helmets, gloves, face shields, goggles, facemask and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) and keeping medical devices off the floor for two of 18 sampled residents. This deficient practice had the potential to result in the development and transmission of disease and infection to the residents, staff and visitors. Findings: 1. A review of Resident 20's Admission Face Sheet (an admission record) indicated the resident was admitted to the facility on 9/29/18 with diagnosis that included chronic respiratory FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 60 of 64 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 10/21/2018 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 failure (a long-term condition that happens when the lungs can not get enough oxygen into the blood). A review of Resident 20's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 8/4/18, indicated the resident sometimes made self-understood or understood others and was moderately impaired in cognitive skills for daily decision making. Resident 20 required total dependence (full staff performance every time) from staff for all activities of daily living (such as transferring, dressing, eating, toileting, personal hygiene, and bathing). A review of Resident 20's physician order, dated 10/9/18, indicated the resident was ordered to be on contact isolation (used for infections, diseases, or germs that are spread by touching the patient or items in the room where the healthcare workers should wear a gown and gloves while in the patient's room) for Acinetobacter baumannii ([ACB] a bacteria that causes a variety of diseases, ranging from pneumonia to serious blood or wound infections, and the symptoms vary depending on the disease) sputum (a mixture of saliva and mucus coughed up from the respiratory tract) and may share room with other resident with the same organism requiring the same type of isolation. a. During an initial tour of the facility, a Licensed Vocational Nurse (LVN 1) did not put on PPE (gown and gloves) before entering a resident's room, which was identified as a contact isolation precaution room. b. During an initial tour of the facility, on 10/18/18 at 8 p.m., LVN 1 without wearing PPE, entered a resident's room identified as a contact isolation precaution room. LVN 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 61 of 64 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 10/21/2018 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 touched Resident 20's nutritional supplements that were on the resident's bedside table and left the room without washing her hands or performing hand hygiene (a general term that applies to routine hand washing, antiseptic hand wash, and or antiseptic hand rub). During an interview, on 10/18/18 at 8:02 p.m., LVN 1 stated she was supposed to wear PPE before entering the room and was supposed to wash her hands before leaving the room because it was an isolation room. A review of the facility's policy and procedure titled, "Infection Prevention: Contact Precautions," dated 3/22/17, indicated to perform hand hygiene (wash hands or use hand sanitizer before and after resident contact, before and after gloving, and upon leaving resident rooms). Wear a gown whenever anticipating that clothing would have direct contact with the resident or potentially contaminated environment surfaces or equipment in close proximity to the resident. Wear gloves when entering the room. 2. A review of Resident 174's Admission Face Sheet indicated the resident was admitted to the facility on 10/12/18, with the admitting diagnoses of chronic respiratory failure (not enough air in the lungs) and hypoxia (not enough oxygen in the body). A review of a Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 10/19/18, indicated the resident had unclear speech and was sometimes understood. According to the MDS, Resident 174 needed total assistance for dressing and toilet use. During an observation and interview, on 10/18/18 at 7:36 p.m., with Registered Nurse (RN 4) Resident 174's hand mitten and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 62 of 64 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 10/21/2018 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 indwelling catheter (tubing to help urinate) collection bag was on the floor out of the privacy bag. RN 4 stated the hand mittens should be on the resident's hands and the catheter collection bag should not be on the floor due to infection control issues. During an interview, on 10/21/18 at 12:12 p.m., with the Vice President of Quality (VPQ) stated the hand mittens and catheter collection bag should not be on the floor due to infection control issues. The VPQ was unable to find a policy indicating hand mittens should not be on the floor. A review of the facility's policy and procedure titled, "Catheter- Associated Urinary Tract Infections: Prevention", with a revised date of 4/2018 indicated to keep the collection bag below the level of the bladder at all times and off the floor.

F908 SS=E Essential Equipment, Safe Operating Condition F908 CFR(s): 483.90(d)(2) 11/21/2018 §483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to ensure the kitchen refrigerator did not have broken gaskets and can opener was not chipped. The deficient practice had the potential to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 63 of 64 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 10/21/2018 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 cause foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) if equipment in the kitchen was not maintained. Findings: During the observation of the kitchen, on 10/20/18 at 11:11 a.m., with the General Manager (GM) the following was observed: 1. Broken gasket on the cold preparation fridge and the floor stock fridge #18 and #19 2. Chipped can opener In a concurrent interview with the GM stated he will notify maintenance to get the issues fixed. A record review of the facility's policy and procedure titled, "Safety Program," dated 10/2015 indicated the grounds and equipment are maintained appropriately. Unsafe conditions and broken equipment are corrected as soon as possible. If necessary, a work order is created online and submitted to the Engineering Department. The department follows up on the status of the work orders. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKKV11 Facility ID: CA930000575 If continuation sheet 64 of 64