Other·June 6, 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 and investigation of two facility reported incident (FRIs): FRI numbers: CA00583545 and CA00580092 The following reflects the findings of the Department of Public Health during a recertification survey. Representing the Department of Public Health: Evaluator ID No: 36502, RN, HFEN Evaluator ID No: 33670, RN, HFEN Evaluator ID No: 36205, RN, HFEN Evaluator ID No: 36943, OT, HFE Evaluator ID No: 38942, RN, HFEN FRI number: CA00583545 refer to F tags 609 and 610. FRI number: CA00580092 refer to F tag 609 Total Resident Population: 89 Total Resident Sample: 36 Highest Scope and Severity: E

F557 SS=D Respect, Dignity/Right to have Prsnl Property CFR(s): 483.10(e)(2)

F557 05/26/2018 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: 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: PLZZ11 Facility ID: CA940000011 If continuation sheet 1 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity for 2 of 36 sampled residents (Resident 40 and Resident 84). For Resident 40 and 84, during breakfast observation, staff were observed standing while feeding the residents. This deficient practice had the potential to result in lowered self-esteem of the resident. Findings: a. A review of the clinical record indicated Resident 40 was admitted to the facility on 5/19/17 with diagnoses that included unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) without behavioral disturbance and malignant neoplasm (group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body) of the abdomen. A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 5/26/17 indicated Resident 40's cognition was severely impaired. Resident 40 required extensive assistance (resident involved in activity, staff provide weight bearing support) with bed mobility, transfer, dressing, toilet use and personal hygiene. Resident 40 required supervision with eating. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 2 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 On 4/25/18 from 7:30 a.m., during breakfast observation, Certified Nursing Assistant 22 (CNA 22) was observed standing while feeding Resident 40. Resident 40 was sitting in bed while being fed breakfast by CNA 22. On 4/25/18 at 7:55 a.m., an interview was conducted with the Director of Nursing (DON) who stated staff feeding the residents should be at eye level with the resident to maintain dignity. On 4/25/18 at 8:00 a.m., an interview was conducted with CNA 22 who confirmed she was standing while feeding resident 40. CNA 22 stated she should have sat down while feeding the resident. A review of the facility's undated policy and procedure titled" Feeding the Resident" indicated the purpose of the feeding procedure is to ensure food intake at meal times and to assist the resident with feeding. Position chair next to the resident; do not stand while feeding resident. b. A review of the clinical record indicated Resident 84 was admitted to the facility on 6/28/17 with diagnoses that included weakness and generalized muscle weakness. A review of the MDS, dated 7/5/17 indicated Resident 84's cognition was moderately impaired. Resident 84 required extensive assistance (resident involved in activity, staff provide weight bearing support) with bed mobility, transfer, dressing, toilet use and personal hygiene. Resident 84 required supervision with eating. On 4/25/18 from 7:30 a.m., during breakfast observation, Registered Nurse 1 (RN 1) was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 3 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 observed standing while feeding Resident 84. RN 1 was standing while the feeding resident with breakfast. Resident 84 was sitting in bed while being fed breakfast by RN 1. On 4/25/18 at 7:55 a.m., an interview was conducted with the DON who stated staff feeding the resident should be at eye level with the resident to maintain dignity. On 4/25/18 at 8:00 a.m., an interview was conducted with RN 1 who confirmed she was standing while feeding resident 40. RN 1 stated the staff feeding the resident need to sit down for eye level with resident to maintain dignity and residents will not feel rushed while being fed. A review of the facility's undated policy and procedure titled" Feeding the Resident" indicated the purpose of the feeding procedure is to ensure food intake at meal times and to assist the resident with feeding. Position chair next to the resident; do not stand while feeding resident.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 05/26/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 4 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to: a. Report an allegation of abuse regarding Resident 34 to the State Survey Agency (Department) and other officials immediately or not later than 24 hours for one of two abuse allegations in accordance with the State law and the facility's policy and procedures. b. Facility failed to provide the Department the final investigation report within five days per facility policy for two facility reported incidents (Residents 34 and 58) investigated during survey. This deficient practice had the potential to place residents in the facility's safety at risk. Findings: 1. A facility reported incident regarding staff to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 5 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 abuse was investigated during the facility's recertification survey. A record review of Resident 34's admission indicated resident was admitted to facility on 8/22/17. Admitting diagnoses include heart failure, major depressive disorder, Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), and essential hypertension (high blood pressure). A review of the Minimum Data Set [a standardized assessment and care plan tool (MDS)], a quarterly assessment dated 2/14/18, indicated that Resident 34 had a brief interview mental status score of 2 which signifies that resident is severely impaired cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). A review of activities of daily living (ADL) assistance indicated Resident 34 requires extensive assistance with transfer, dressing, toilet use, and personal hygiene. A review of the facility reported incident indicated on 4/18/18 at 7:30 a.m., it was reported that a staff-to-resident abuse allegation was reported between Resident 34 and Certified Nurse Assistant 23 (CNA 23). The allegation further indicated that a second CNA (CNA 17) reported Resident 34 was observed slapping herself on the face and saying what appeared to be the words "CNA." The allegation was reported to the Administrator and an investigation was started with the suspension of CNA 23. During an interview with the Administrator on 4/24/18 at 1:53 p.m., the Administrator acknowledged an alleged incident with Resident 34 and CNA 23 was being FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 6 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 investigated internally. The Administrator further stated the incident was reported to her on 4/18/18 during the day shift and reported to the appropriate agencies the following day. Administrator further stated the alleged staff member was suspended for three days pending investigation. Administrator also stated CNA 23 was reassigned and not work with Resident 34. A review of the facsimile (fax) confirmation sheet used to report the abuse allegation to the Department indicated it was faxed on 4/19/18 at 2:44 p.m.. During a concurrent interview with the Administrator on 4/26/18 at 8:45 a.m., she acknowledged that their policy is to report abuse to the appropriate agencies within 24 hours of the incident. Administrator also acknowledged the report was sent after 24 hours of the incident which was on 4/18/18 at 7:30 a.m.. A review of the facility's undated policy and procedure titled "Policy and Procedure on Patient Abuse and Prevention" indicated facility shall ensure reporting of all alleged and substantiated violations to the state agency and all other agencies as required, and take all necessary corrective action based on the results of the investigation. Policy further indicated facility shall report the incident by calling the Department of Health Services (DHS) within 24 hours of the knowledge of such incident; followed by a letter explaining the circumstances surrounding the incident. This letter shall be maintained in a separate file and made available to the Department upon request. On 4/26/18 at 8:45 a.m., the Administrator was asked about a final investigation report performed by the facility and submitted to licensing and certification within five days of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 7 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 incident. Administrator stated there was no final investigation report done. After a concurrent review of the facility's undated policy and procedure entitled, "Policy and Procedure on Patient Abuse and Prevention," it indicated "Facility administrator shall report findings of investigation to the department within five working days of the incident. Administrator acknowledged policy and procedure and stated she would submit a findings report immediately. b. A review of the Admission Record (face sheet) indicated that Resident 58 was admitted on 1/12/18 with diagnoses that included unspecified dementia (decline in mental ability severe enough to interfere with daily life), history of falling and muscle weakness. A review of Resident 58's MDS, dated 1/19/18, indicated that Resident 58 was moderately impaired in cognitive skills (ability to think and reason) for daily decision making. A review of the Admission Record (face sheet) indicated that Resident 87 was admitted on 6/29/16 with diagnoses that included hypertension, osteoporosis (softening of the bones) and difficulty walking. A review of Resident 87's MDS, dated 4/6/18, indicated that Resident 87 has intact cognitive skills for daily decision making. During an interview on 4/25/18 at 9:45 a.m., the Administrator stated that the facility did not report the results of the investigation to the Department within five (5) days of the incident for one resident-to-resident altercations, involving Resident 58 and 87, which occurred on 3/25/18. The Administrator was not aware that she needed to submit the final investigation report to the Department within five (5) days of the incident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 8 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 undated policy titled "Policy and Procedure on Patient Abuse and Prevention," indicated that the facility Administrator shall report findings of investigation to the Department within five (5) working days of the incident.

F610 SS=D Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4)

F610 05/26/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on record review and interview, the facility failed to protect residents during an abuse investigation when they failed to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 9 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 suspend a staff member immediately after notification of a staff to resident abuse allegation. This failure has the potential to place residents at risk for further abuse by the alleged staff member or other residents. Findings: A record review of Resident 34's admission indicated resident was admitted to facility on 8/22/17. Admitting diagnoses include heart failure, major depressive disorder, Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), and essential hypertension (high blood pressure). A review of the Minimum Data Set [a standardized assessment and care plan tool (MDS)], a quarterly assessment dated 2/14/18, indicated that Resident 34 has a brief interview mental status score of 2 which signifies that resident is severely impaired cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). A review of activities of daily living (ADL) assistance indicated Resident 34 requires extensive assistance with transfer, dressing, toilet use, and personal hygiene. A review of the facility reported incident indicated on 4/18/18 at 7:30 a.m., it was reported that a staff-to-resident abuse allegation was reported between Resident 34 and Certified Nurse Assistant 23 (CNA 23). The allegation further indicated that a second CNA (CNA 17) reported Resident 34 was observed slapping herself on the face and saying what appeared to be the words "CNA." The allegation was reported to the Administrator and an investigation was started with the suspension of CNA 23. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 10 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 record review of a "Time Card Report," printed on 4/25/18 for CNA 23, indicated the following: 4/18/18, Wednesday Work - 6:55 a.m. to 11:02 a.m. Lunch - 11:02 a.m. to 11:39 a.m. Work - 11:39 a.m. to 2:40 p.m. Total: 7.75 hours worked During an interview with the Director of Staff Development (DSD) on 4/25/18 at 2:40 p.m., the DSD acknowledged the alleged staff-toresident incident that occurred on 4/18/18 between Resident 34 and CNA 23. The DSD stated, the policy was to suspend the alleged staff immediately for the safety of the Resident 34 and other residents in the facility. CNA 23 was allowed to work the rest of her shift and was suspended after the day was over. The DSD stated CNA 23 should have been suspended immediately and should not have worked with any residents. During an interview with the Administrator on 4/25/18 at 2:55 p.m., The Administrator acknowledged that CNA 23 was allowed to work the rest of her shift after abuse allegation occurred. The Administrator also stated CNA 23 was reassigned and did not work with Resident 34 for the rest of her shift. The Administrator acknowledged that CNA 23 should have been suspended immediately for the safety of all the residents in the facility. A review of the facility's undated policy and procedure titled "Policy and Procedure on Patient Abuse and Prevention," it indicated that if the suspected perpetrator is a staff member, immediately place the staff member upon administrative leave for three (3) days or more depending upon the resolution and/or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 11 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 conclusion of the alleged violations.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 05/26/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 12 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to develop a comprehensive person-centered care plan for two of 36 sampled residents ( Resident 8 and 41). 1. Resident 8 had no plan of care that addressed interventions for anemia (a condition in which the blood does not carry enough oxygen to the rest of your body). 2. Resident 41's care plan for risk for skin breakdown did not reflect the use of Geri sleeves (protects residents' arms and legs against damage caused by friction and shearing) to both arms as ordered. As a result of these deficient practices the residents failed to receive the necessary care and intervention to achieve the highest potential well being. Findings: 1. A review of an Admission Record indicated Resident 8 was admitted to the facility on 10/18/11 and was readmitted on 9/21/16 with diagnoses that atherosclerotic heart disease (narrowing and hardening of the arteries in the heart), dementia ( memory loss) and angina pectoris ( chest pain due to lack of blood with oxygen to the heart). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 13 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 quarterly Minimum Data Set (MDS), a resident assessment and care area planning tool dated 1/18/18, indicated Resident 8 had severe impairment in memory and cognition ( ability to think and reason) and required extensive assistance (resident involved in activity, the staff provide weight bearing support) with one person assistance on bed mobility, eating and transfers. On 4/24/18 at 10:18 a.m., a review of Resident 8's laboratory results dated 4/5/18 and concurrent interview with Registered Nurse 3 (RN 3) indicated, Resident 8 had a low blood count suggestive of anemia. (a condition in which the blood does not carry enough oxygen to the rest of the body due to blood loss or not having the mineral iron found in the diet). RN 3 stated, Resident 8 had no care plan or interventions to assess or monitor resident for signs and symptoms of anemia. RN 3 also stated the following interventions should had been done such, as check the stool for blood, monitor for laboratory test for anemia, or refer to the dietician for the dietary supplements such as food high in iron to correct anemia. According to the facility's undated policy and procedure titled "Reporting of Lab and X-ray results" indicated, the facility shall develop a plan of care to address identified problem and/or revise the plan of care to reflect current status of the resident. 2. A review of the clinical record indicated Resident 41 was admitted to the facility on 1/11/13 with diagnoses that included adult failure to thrive (condition characterized by loss of appetite, weight loss, and inactivity) and Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 14 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 thinking skills, and eventually the ability to carry out the simplest tasks). A review of the MDS, dated 5/22/17 indicated Resident 41's cognitive skills for daily decision making was severely impaired. Resident 41 required total dependence (full staff performance) with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. A review of Resident 41's physician's order dated 4/19/18 indicated apply Geri sleeves to both arms as tolerated to maintain skin integrity. On 4/23/18 at 3:15 p.m., during initial tour of the facility, Resident 41 was observed awake in bed with Geri sleeves on both arms. On 4/24/18 at 1:20 p.m. Resident 41 was observed sleeping in bed with Geri sleeves on both arms. A review of Resident 41's care plan dated 1/12/13, updated 1/7/18 indicated the resident was at risk for skin breakdown due to fragile and dry skin with aging process and behavior of scratching on self. Resident 41's care plan did not reflect the use of Geri sleeves to both arms as ordered. The resident's plan of care was not updated to reflect the active order to apply Geri sleeves to both arms as tolerated to maintain skin integrity. 4/24/18 at 1:30 p.m., an interview was conducted with Licensed Vocational Nurse 1 (LVN 1) who confirmed Resident 41 was wearing Geri sleeves on both arms. LVN 1 stated the resident's care plan did not reflect the order to apply Geri sleeves to both arms as tolerated to maintain skin integrity. LVN 1 stated the care plan should have been updated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 15 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to serve as a guide to reflect the current intervention for the resident. 4/24/18 at 1:45 p.m., an interview was conducted with the Director of Nursing (DON) who stated Resident 41 needed Geri sleeves for both arms to skin protection due to history of constant scratching that resulted to skin tear. The DON indicated the resident's care plan is important to serve as a guide for all staff on how to provide care to the resident. DON confirmed the use of Geri sleeves as ordered was not written in the resident's plan of care. DON also stated the care plan should be updated to reflect the current physician's order. A review of the facility's undated policy and procedure titled "Care Plan" indicated services that are to be furnished for the resident to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being are to be included in the plan of care. Documentation in the resident's clinical record should include the following information: (e) Interventions carried out.

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

F658 05/26/2018 §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: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 16 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on interview and record review, the facility failed to follow professional standards of practice for 1 of 36 sampled residents (Resident 20). For Resident 20, who received Tylenol Tablet 325 milligrams (mg) 2 tablets by mouth for mild pain on 2/27/18, the licensed staff incorrectly documented in the pain assessment flowsheet that the medication was administered on 2/28/18. This deficient practice had the potential to result in ineffective pain management for the resident related to medication administration documentation error. Findings: A review of the resident information sheet indicated Resident 20 was admitted to the facility on 11/4/13 and was readmitted on 6/16/16 with diagnoses that included epilepsy (brain disorder in which a person has repeated seizures [convulsions] over time), major depressive disorder (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities) and blindness left eye. A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 11/3/17 indicated Resident 20 was cognitively intact. Resident 20 required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. Resident 20 required supervision with eating. A review of the physician's order for Resident 20 dated 6/16/16 indicated to administer Tylenol Tablet 325 milligrams (mg) give 2 tablets by mouth every 6 hours as needed for mild pain (not to exceed 3 grams/day). A review of Resident 20's Medication Administration Record (MAR) indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 17 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 20 received Tylenol Tablet 325 mg 2 tablets by mouth on 2/27/18. A review of Resident 20's Pain Assessment Flowsheet indicated the licensed staff documented Tylenol Tablet 325 mg 2 tablets by mouth was administered to the resident on 2/28/18 for left leg pain on 2/10 pain scale. On 4/24/18 at 1:55 p.m., an interview was conducted with the Director of Nursing (DON) who stated it was important to document pain and pain medication administration accurately. The DON indicated the licensed staff must document in the resident's clinical record accurately when the medication was given and the effectiveness of the medication. The DON confirmed based on the MAR, Resident 20 received Tylenol on 2/27/18 and was incorrectly documented as given on 2/28/18. DON stated pain is one of the components of vital signs and should be documented accurately. A review of the facility's undated policy and procedure titled' Medication and Treatment Administration" indicated licensed nurse administering the medication / treatment shall record the date, time, dose of the drug or treatment administered to the resident in the clinical record (e. g. MAR, Treatment Record).

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

F684 05/26/2018 § 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 18 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 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: 3. A record review of Resident 34's admission record indicated the resident was admitted to the facility on 8/22/17. Admitting diagnoses included heart failure, major depressive disorder, Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), and essential hypertension (high blood pressure). A review of the MDS, quarterly assessment dated 2/14/18, indicated that Resident 34 has a brief interview mental status score of 2 which signifies that resident is severely impaired cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). A review of activities of daily living (ADL) assistance indicated Resident 34 requires extensive assistance with transfer, dressing, toilet use, and personal hygiene. During a record review of the licensed nurses progress notes, dated 4/10/18 at 4:00 p.m., it indicated "Noted generalized rash over whole body. Multiple mild erythematic (redness of the skin or mucous membranes) with irregular border. With no open wound over whole body. Resident no fever, no shortness of breath, no edema (a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body). Resident is not in acute distress, on and off itchiness noted. Noted mild pain with symptoms. Notified physician, received new order carried out including setting FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 19 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 up appointment with dermatologist (skin doctor) office. Informed resident representative of condition and plan of care." During an interview with Registered Nurse 2 (RN 2) who was also the treatment nurse, on 4/25/18 at 9 a.m., RN 2 acknowledged that the initial assessment documented on the licensed nurses progress notes was not complete. RN 2 also acknowledged that it should have been more detailed in order to measure effectiveness of the treatment. During a record review of the policy and procedure entitled "Policy and Procedure on Daily Body Check and Daily Body Check Report," undated, it indicated "Charge nurse shall conduct basic assessment and data collection based on the presented Daily Body Check and shall promptly notify the resident's physician of his/her findings." According to Thompson (2008), "Your physical assessment should include a complete inspection and palpation of the skin, assessing the entire skin surface for color, odor, texture, and hygiene. Be sure to document any lesions present, noting anatomic location and distribution over the body, size, shape, color, type, pattern, and any associated drainage." Thompson, P., Langemo, D., Hanson, D., Anderson, J., & Hunter, S., (2008) Assessing Skin Rashes. Nursing, Vol. 38(4), 59. http://ovidsp.ovid.com/ovidweb.cgi? T=JS&CSC=Y&NEWS=N&PAGE=fulltext&AN= 00152193-20080400000038&LSLINK=80&D=ovft FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 20 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview and record review the facility failed to provide necessary care and services to three of 36 sampled residents (Resident 8, 34 and 57) by failing to: 1. Resident 57, who had diabetes ( a disease in which your blood sugar levels are too high) was not reassessed or evaluated for elevated blood sugar level greater than 300 milligrams per deciliter for 3 months. In addition, Resident 57 was not educated about the importance of adhering to a diabetic diet. According Medlineplus.gov, a fasting (blood sugar tested before meals) blood glucose test, a level between 70 and 100 mg/dL (milligrams per deciliter) and a random blood glucose test level is below 125 mg/dL is considered normal. (https://medlineplus.gov/ency/article/003482 .htm) As a result of this deficient practice, Resident 57 had the potential to develop complication related to diabetes such as, blindness, ketoacidosis (a life-threatening condition due to breaking down of fat that causes blood to be acidic), diabetic coma (a coma results due to high blood sugar), and narrowing and hardening of the arteries that could damage the organs kidneys, heart and brain. 2. Resident 8 was not assessed, evaluated and provided necessary interventions for anemia (a condition in which the blood does not carry enough oxygen to the rest of your body) and provided necessary interventions to treat anemia. This deficient practice had the potential to result in severe anemia and a compromised to the resident's well being. 3. Resident 34 was not accurately assessed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 21 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 upon initial detection of the rash. This deficient practices had the potential and had resulted in the residents not to receive the necessary care timely to prevent a decline in the over all well-being. Findings: 1. A review of an Admission Record indicated Resident 57 was admitted to the facility on 2/7/18 with diagnoses that included cerebrovascular disease ( a disease resulted from lack of blood flow to the brain) with hemiphlegia ( paralysis or loss of movement) on the left side of the body) and diabetes mellitus ( a condition of high blood sugar). A review of the Minimum Data Set ([MDS] a resident assessment and care area planning tool], dated 2/14/18, Resident 57 had moderate impairment in memory and cognition ( ability to think and reason) that required extensive assistance with one person (resident involved in activity, the staff provide weight bearing support) on bed mobility, transfers and supervision (an oversight, encouragement and cueing) with set up only help on eating. On 4/25/18 at 8 a.m. during the facility tour Resident 57 observed lying in bed watching television. In an interview, Resident 57 stated, he was happy with the care provided by the facility. On 4/25/18 at 3:24 p.m. during a record review of the Medication Administration Record (MAR) and concurrent interview with Licensed Vocational Nurse 1 (LVN 1) indicated, Resident 57's blood sugar level where consistently high because the resident liked to eat snacks. LVN 1 also stated, she did not inform Resident 57 about importance of adhering to a diabetic diet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 22 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 (low concentrated sugar). On 4/25/18 at 4:00 p.m., during a review of the medical record and concurrent interview with Registered Nurse Supervisor 3 (RN 3) stated, Resident 57's the blood sugar level had been elevated for three months from February 2018 to March 2018, that was not reported to the doctor to ensure the insulin was adjusted. The RN 1 also stated, Resident 57 should had been informed about the importance of adhering to a diabetic diet due to a risk of developing atheroschlerosis (narrowing and hardening of the arteries in the heart), that could lead to strokes and heart attack and ketoacidosis. On 4/25/18 at 4:00 p.m., during a concurrent medical record review conducted with the Registered Nurse Supervisor 3 (RN 3) the following records indicated: a. A review of a physician's order, dated 2/8/18, for Resident 57's current medication regimen to treat diabetes included: -To check finger stick four times a day at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9 p.m. and administer Lispro (long acting insulin or medication used to lower the blood sugar level) according to the blood sugar result using a insulin sliding scale (insulin regimens approximate daily insulin requirements). -Glargine long acting insulin or medication used to lower the blood sugar level) inject 15 units given subcutaneously (under the skin) one time a day at 6:30 a.m. b. A review of the Medication Administration Record from February 2018 to April 2018 indicated, Resident 57's blood sugar level checked via finger stick (a process of checking blood sugar level with a needle prick) revealed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 23 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 consistent high blood sugar levels for three months as listed below: - For the month of February 8 to 28, 2018 at 11 a.m. the blood sugar level ranged from 192 to 370 mg/dL For the month of February 8 to 28, 2018 at 4:30 p.m. the blood sugar level ranged from 224 to 442 mg/dL For the month of February 8 to 28, 2018 at 9:30 p.m. the blood sugar level ranged from 171 to 455 mg/dL - For the month of March 1 to 31, 2018 at 11 a.m. the blood sugar level ranged from 316 to 438 mg/dL For the month of March 1 to 31, 2018 at 4:30 p.m. the blood sugar level ranged from 143 to 444 mg/dL For the month of March 1 to 31, 2018 at 9:30 p.m. the blood sugar level ranged from 174 to 402 mg/dL - For the month of April 1 to 26, 2018 at 11 a.m. the blood sugar level ranged from 226 to 491 mg/dL For the month of April 1 to 26, 2018 at 4:30 p.m. the blood sugar level ranged from 224 to 435 mg/dL For the month of April 1 to 26, 2018 at 9:30 p.m. the blood sugar level ranged from 199 to 399 mg/dL c. On 4/25/18 at 4:05 p.m., a review of Resident 57's laboratory result, dated 1/27/18, timed at 9:07 a.m. indicated Hemoglobin AIC level of 8.8% on 1/27/18, which was checked prior to Resident 57's admission to the facility on 2/8/18. In a concurrent interview with RN 3 she stated, the HGB A1C should had been rechecked after the resident admitted to the facility due to high blood sugar levels. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 24 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 According to the National Institute of Diabetes and Digestive and Kidney Diseases Hemoglobin AIC is a blood test that measures average blood sugar level over the past 3 months with the normal range level of 4.26.3%. (https://medlineplus.gov/a1c.html) On 4/26/18 10:45 AM in an interview, the Activity Director stated, Resident 57 always asked for cookies even when he was informed that he could not have anymore because of diabetes, but she sometimes gives the resident one or two more. On 4/26/18 at 1:53 p.m. in an interview, the Director of Nursing (DON) stated, the primary physician should had been informed when Resident 57's blood sugar level was high, so that the medication can be adjusted, check the laboratory results, assess the dietary habits, and revise the care plan because of the risk of complications such as infection, diabetic coma, glaucoma ( high fluid pressure in the eyes that could lead to blindness), stoke ( lack of blood flow to the brain) and heart attack (lack of blood flow to the heart). 2. A review of an Admission Record indicated Resident 8 was admitted to the facility on 10/18/11 and was readmitted on 9/21/16 with diagnoses that atherosclerotic heart disease (narrowing and hardening of the arteries in the heart), dementia ( memory loss) and angina pectoris ( chest pain due to lack of blood with oxygen to the heart). According to the quarterly MDS, dated 1/18/18, Resident 8 had severe impairment in memory and cognition (ability to think and reason) and required extensive assistance (resident involved in activity, the staff provide weight bearing support) with one person assistance on bed mobility, eating and transfers. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 25 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 On 4/24/18 at 10:18 a.m., a record review of Resident 8's laboratory results dated 4/5/18 conducted with Registered Nurse 3 (RN 3) indicated, Resident 8 had a low blood count suggestive of anemia, the laboratory results indicated below: Hemoglobin level of 11.6 (reference range 13.7 -17.5 grams per deciliter) (Hemoglobin (Hgb) is iron rich protein in the blood that carries oxygen from the lungs to the body.) Red Blood Cell count 3.96 (normal range 4.636.08 million units per liter) (Red Blood Count (RBC) carry hemoglobin to tissues throughout the body blood cells.) Hematocrit level 35.9 (reference range 40.151.0 %) (Hematocrit (Hct) is a measurement of the amount of red blood cells in the blood.) According to the National Institute of Health (NIH), anemia is a medical condition in which the red blood cell count or hemoglobin is less than normal with symptoms that included feeling tired, hair loss, shortness of breath and rapid heartbeat. (https://www.nhlbi.nih.gov/healthtopics/anemia) On 4/24/18 at 10:18 a.m., in a concurrent interview RN 3 stated, Resident 8 had no care plan or interventions to assess or monitor resident for signs and symptoms of anemia. RN 3 also stated the following interventions should had been done such, as check the stool for blood, monitor for laboratory test for anemia, or refer to the dietician for the dietary supplements such as food high in iron to correct anemia. According to the facility's undated policy and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 26 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 procedure titled "Reporting of Lab and X-ray results" indicated, the facility shall develop a plan of care to address identified problem and/or revise the plan of care to reflect the current status of the resident.

F689 SS=E Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 05/26/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide safe equipment and supervision by failing to: a. Ensure three of four sampled shower chairs had functional breaks. b. Ensure Resident 14 had adequate supervision while sitting in a wheelchair in the facility parking lot. c. Measure the temperature and ensure calibration (measurement or adjustment for a particular function) of the rehabilitation room's hydrocollator (unit filled with water to provide consistent heat for hot packs). These failures had the potential to lead to injury, including falls and burns. Findings: a. During an observation on 4/25/18 at 9:58 a.m., Certified Nursing Assistant 18 (CNA 18) and CNA 19 transferred Resident 17 from the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 27 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 shower chair to the bed. Prior to the transfer, Resident 17 stated, "Make sure you put the brakes on." During the two-person transfer, the shower chair continued to move. During an observation and concurrent interview on 4/25/18 at 9:58 a.m., CNA 18 stepped on a lever attached to each of the shower chair's four wheels to activate the brakes. The shower chair's wheels continued to move with the brakes activated. CNA 18 stated that the shower chair was not supposed to move when the brakes were down. During an observation on 4/25/18 at 10:03 a.m., CNA 7 and CNA 15 assisted Resident 33 from the bed to the shower chair. The shower chair continued to move while transferring Resident 33 into the shower chair. During an observation on 4/26/18 at 8:10 a.m. with the Director of Staff Development (DSD), there were four (4) shower chairs present in the men's shower room. One shower chair did not have brakes attached to both front wheels. The DSD pushed down to activate the brakes attached to each shower chair's wheels. Three of the four shower chairs continued to move despite having the brakes applied. The DSD stated that ineffective brakes on the shower chairs placed the residents at risk for fall. DSD stated that the CNAs were supposed to report any problems with the shower chairs to the DSD or the maintenance staff. The DSD stated that the maintenance staff was supposed to check the shower chairs. A review of the facility's maintenance request log located at Nursing Station A, dated from 11/16/17 to 4/8/18, did not indicate the shower chair brakes had been reported. During an interview on 4/26/18 at 8:22 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 28 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 Maintenance Supervisor (MS) stated that the shower chairs were checked at least once per week. The MS stated that the maintenance staff serviced the shower chairs for cleaning, which included disinfecting, power washing, removing hair from wheels, and applying oil to wheels. The MS stated that the CNAs should bring the shower chair to the maintenance staff if the shower chair brakes were not functional. A review of the maintenance log, dated 3/12/18 to 4/25/18, did not indicate service to the facility's shower chair brakes. b. During an observation on 4/24/18 at 1:14 p.m., Resident 14 was sitting in a wheelchair in the facility's parking lot. There was no facility staff or family members present with the resident. Resident 14's wheelchair was positioned behind a metal U-shaped structure cemented and attached to the parking lot's asphalt. Resident 14 was pulling and pushing on the U-shaped structure while sitting in the wheelchair. During an interview on 4/24/18 at 1:14 p.m., Laundry Staff 1 stated that Resident 14's family member usually assisted and supervised Resident 14. During an interview on 4/24/18 at 1:21 p.m., the Director of Nursing (DON) stated that Resident 14's family member left the resident unattended to use the restroom. A review of the admission record indicated Resident 14 was admitted to the facility on 7/21/16. Resident 14's diagnoses included left femur fracture (fracture of the upper leg bone) close to the hip, dementia (decline in mental ability severe enough to interfere with daily life), and muscle weakness. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 29 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 Resident 14's fall risk assessment, dated 3/24/18, indicated Resident 14 achieved a score of 11. A score above 10 indicated a high risk for fall. A care plan for falls, initially dated on 7/22/16, indicated Resident 14 was at risk for falls related to general weakness, unsteady gait, use of an assisted device, poor/fair safety awareness, history of falls, and dementia. The plan included to instruct Resident 14 not to make sudden position changes. During a follow-up interview on 4/24/18 at 2:15 p.m., DON stated that the facility had a care plan meeting with Resident 14's family member on 4/24/18 regarding not leaving Resident 14 unsupervised in the parking lot. c. During an observation on 4/23/18 at 3:13 p.m., a small hydrocollator was present in the rehabilitation room. There was no sticker attached to the hydrocollator indicating the date of its last calibration. A warning sign attached to the top of the hydrocollator indicated that the water temperature should not exceed 165 degrees Fahrenheit (F). However, the water temperature inside the hydrocollator measured 171 degrees F. In a concurrent interview, Rehabilitation Staff 1 (Rehab Staff 1) stated there was a cleaning log for the hydrocollator but was unable to locate the temperature log. During an interview on 4/23/18 at 3:13 p.m., Rehab Staff 2 stated that if the hydrocollator's temperature exceeded the manufacturer's recommendations, then there was a possibility the hot packs can cause superficial burns. During an interview on 4/24/18 at 7:37 a.m., the Director of Rehabilitation (DOR) stated that the Rehabilitation Staff did not periodically check the temperatures for the hydrocollator. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 30 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 DOR stated that the facility received the hydrocollator in January 2017 but have not had it calibrated to ensure proper functioning. A review of the hydrocollator's manufacturer user manual indicated the recommended operating temperature was 160 to 165 degrees F. During a follow-up interview on 4/24/18 at 8:07 a.m., DOR acknowledged that the hydrocollator's temperature exceeded the manufacturer's recommendations. DOR acknowledged that the high temperature could possibly cause burns, especially for residents with impaired sensation.

F690 SS=D Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3)

F690 05/26/2018 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 31 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 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 provide necessary assistance to maintain continence (control) to one of 36 sampled residents (Resident 74) who was continent of bowel and was assessed as a "good candidate" for bowel and bowel training. This deficient practice had the potential for Resident 74 to decline in toileting abilities. Findings: A review of an Admission Record indicated Resident 74 was admitted to the facility on 12/18/15 with diagnoses that included atheroschlerosis of aorta (narrowing and hardening of the blood vessel in the heart) and gastric ulcer ( a sore in the lining of your stomach). A review of the Minimum Data Set (MDS), a resident assessment and care area screening tool dated 3/22/18, Resident 74 had moderate impairment in memory and cognition ( ability to think and reason) and required limited assistance (resident highly involved in activity, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 32 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 staff provide guided maneuvering of limbs or non weight bearing assistance) with one person assistance with transfers, personal hygiene and toileting. The MDS also indicated Resident 74 was continent (ability to control) bowel and frequently incontinent (no ability to control) of bladder. On 4/25/18 at 10:50 a.m., according to "Bowel and Bladder Assessment" dated 3/22/18, Resident 74 had a score of 15 (a score of 1015 indicated resident was a good candidate for bowel and bladder retraining). In a concurrent interview, the MDS nurse stated, she assessed Resident 74 as a good candidate for bowel and bladder retraining but did not placed Resident 74 in bowel and bladder (B and B) retraining because Resident 74 was in the toileting retraining last January 2018 but was not continued because Resident 74 refused. However, the MDS nurse stated, there was no IDT, care plan or any documentation of Resident 74 refusal to participate in the B and B retraining program. On 4/25/18 at 2 p.m. during an observation, Resident 74 observed standing in front of the wheelchair by the sink with the wheelchair. On 4/26/18 at 8:39 a.m. during an interview, Resident 74 observed lying in bed with left arm paralysis. In an interview, Resident 74 stated he uses the wheelchair to go to the bathroom and no one assists him to go to the toilet when needed. A review of the facility's policy and procedure titled " Bowel and Bladder Assessment" if the resident is continent upon admission, risk factors of incontinency, such as frequency of urination, limited mobility shall be considered with appropriate care planning to prevent any decline in bowel and bladder functioning. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 33 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F692 Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/26/2018 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to evaluate one of 36 sampled residents (Resident 692) for adequate nutrition. For Resident 692, the facility failed to perform weekly weights upon admission and failed to perform a dietary re-evaluation. These deficient practices resulted in a weight loss of 8.2 pounds (6.46%) from 2/10/18 to 3/19/18 and had the potential to lead to continued FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 34 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 avoidable weight loss. Findings: A review of the admission record indicated Resident 692 was admitted to the facility on 2/9/18. Resident 692's diagnoses included pneumonia, heart failure, muscle weakness, and diabetes (disease in which the body's ability to produce or respond to the hormone insulin is impaired). A review of Resident 692's Minimum Data Set (MDS - a comprehensive assessment used as a care planning tool), dated 2/16/18, indicated Resident 692 was severely impaired for daily decision-making. Resident 692 required extensive assistance with one-person physical assistance for eating, bed mobility, transfers, dressing, and bathing. The MDS indicated Resident 692's weight was 127 pounds. A review of the physician's order, dated 2/9/18, indicated Resident 692 required a mechanical soft diet with ground texture, no concentrated sweetener, no added salt, and nectar thick liquids. A review of Resident 692's care plan, dated 2/10/18, for At Risk for Unintended Weight Loss indicated the approach plan included but was not limited to monitoring weights and intakes, monitoring diet tolerance, and offer substitutes for food not eaten. A review of the Initial Nutritional Assessment, dated 2/12/18, indicated Resident 692 weighed 126.8 pounds and required 1,521 to 1,920 calories daily. The plan and recommendation included to provide the prescribed diet, monitor weight and labs, and to incorporate food preference when possible. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 35 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 undated policy and procedure entitled "Monthly and Weekly Weights" indicated that the resident "upon admission or re-admission to the facility, shall be weighed on a weekly basis for four (4) consecutive weeks." A review of the Resident 692's weight record indicated the following weights: 126.8 pounds on 2/10/18, 118.6 pounds on 3/19/18, 116.6 pounds on 3/26/18, 114.5 pounds on 4/2/18, 113.4 pounds on 4/9/18, 112.2 pounds on 4/16/18, and 113.6 pounds on 4/23/18. There were no weekly weights recorded after Resident 692's admission on 2/9/18. Resident 692 lost 8.2 pounds (6.46%) from 2/10/18 to 3/19/18. A review of the meal intake from 2/9/18 to 3/18/18 indicated Resident 692's meal intake varied from 20% to 100% with one refusal on 3/15/18. During an interview on 4/25/18 at 8:16 a.m., the Dietary Supervisor (DS) stated that the facility did not have a dietary spreadsheet with the portion sizes and food items for each type of diet. The DS stated that the nutritional value, including amount of calories per meal, was uncertain for the facility's menus. A review of the Weight Variance Committee Assessment, dated 3/20/18, indicated Resident 692 had a significant loss of 8.2 pounds from 2/10/18 to 3/19/18. The Weight Variance Committee did not include a Registered Dietitian (RD). A review of the facility's undated policy and procedure entitled "Weights" indicated that when a significant weight change was noted, then a RD consultation was recommended prior to altering a resident's nutritional plan of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 36 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 care. A review of the Interdisciplinary Team (IDT) Conference, dated 3/20/18, indicated that the facility's new environment might be a contributing factor to Resident 692's weight loss. IDT recommended weekly weights for four (4) weeks, two (2) calorie house nourishment 60 cc by mouth twice daily, and add one (1) bowl of boiled rice and one (1) bowl of fortified cereal to meals. A review of the Nutritional Progress Note, dated 3/21/18, included the RD's assessment that Resident 692 had a significant weight loss but was still within ideal body weight. RD indicated a plan to follow-up with weekly weights and food intake. RD's goal was to maintain weight within ideal body weight range and prevent significant weight loss. During an interview on 4/25/18 at 11:16 a.m., the RD stated that she was consulted when resident had significant weight changes, which RD defined as 5% weight loss in one month. RD stated that she consulted with the facility for four (4) hours every two weeks, totaling eight (8) hours per month. During a follow-up interview on 4/25/18 at 12:08 p.m., the RD was unable to provide the facility's dietary spreadsheet to indicate each meal's caloric intake. RD acknowledged that the caloric intake for each meal was unknown due to the absence of a dietary spreadsheet. During an interview on 4/26/18 at 11:09 a.m., the RD stated that a resident with significant weight loss should be followed up within two weeks. RD stated that she assessed Resident 692 on 3/21/18. RD's last consultation with the facility was on 4/16/18. RD reviewed Resident 692's clinical record and acknowledged that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 37 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 692 continued to lose weight between 3/21/18 to 4/16/18. RD stated that she failed to provide Resident 692 with a re-evaluation on 4/16/18. RD stated that she did not have an established system to re-evaluate residents with weight loss. RD stated that she depended on the Dietary Supervisor to inform RD of residents with weight loss. During an interview on 4/26/18 at 2:16 p.m., the Director of Nursing (DON) stated that the RD did not have an established schedule for consultation visits. DON stated that the IDT implemented nutritional interventions without consulting the RD since the facility was unaware when the RD would come to the facility.

F756 SS=D Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5)

F756 05/26/2018 §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 38 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on observation. interview and record review the facility the pharmacy consultant failed to identify irregularities during the monthly medication regimen review (MRR) for one of 36 sampled residents (Resident 57) with uncontrolled blood sugar levels for the last three months from February to April 2018. As a result of this deficient practice Resident 57 could develop a complication related to consistent elevated blood sugar such as blindness, ketoacidosis (a life-threatening condition due to breaking down of fat too fast that the liver processes the fat into a fuel called ketones, which causes the blood to become acidic), diabetic coma (a coma results due to high blood sugar), and narrowing and hardening of the arteries that could damage the organs kidneys, heart and brain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 39 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 an Admission Record indicated Resident 57 was admitted to the facility on 2/7/18 with diagnoses that included cerebrovascular disease ( a disease resulted from lack of blood flow to the brain) with chenille (paralysis or loss of movement) on the left side of the body) and diabetes mellitus ( a condition of high blood sugar). According to the admission Minimum Data Set (MDS), a resident assessment and care area planning tool, dated 2/14/18, Resident 57 had moderate impairment in memory and cognition (ability to think and reason) that required extensive assistance (resident involved in activity, the staff provide weight bearing support) with one person assistance on bed mobility, transfers and supervision (an oversight, encouragement and cueing) with set up only help on eating. According Medlineplus.gov, a fasting ( blood sugar tested before meals) blood glucose test, a level between 70 and 100 mg/dL (milligrams per deciliter) and a random blood glucose test level is below 125 mg/dL is considered normal. On 4/25/18 at 4 p.m., during a review of the medical record review conducted with the Registered Nurse Supervisor 3 (RN 3) the following records indicated: 1. A review of a physician's order, dated 2/8/18, for Resident 57's current medication regimen to treat diabetes included: a. To check finger stick four times a day at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9 p.m. and administer Lispro (long acting insulin or medication used to lower the blood sugar level) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 40 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 according to the blood sugar result using a insulin sliding scale (insulin regimens approximate daily insulin requirements). b. Glargine ( long acting insulin or medication used to lower the blood sugar level) inject 15 units given subcutaneously ( under the skin) one time a day at 6:30 a.m. 2. A review of the Medication Administration Record from February 2018 to April 2018 indicated, Resident 57's blood sugar level checked via fingerstick (a process of checking blood sugar level with a needle prick) revealed a consistent high blood sugar levels for three months as listed below: a. For the month of February 8 to 28, 2018 at 11 a.m. the blood sugar level ranged from 192 to 370 mg/dL For the month of February 8 to 28, 2018 at 4:30 p.m. the blood sugar level ranged from 224 to 442 mg/dL For the month of February 8 to 28, 2018 at 9:30 p.m. the blood sugar level ranged from 171 to 455 mg/dL b. For the month of March 1 to 31, 2018 at 11 a.m. the blood sugar level ranged from 316 to 438 mg/dL For the month of March 1 to 31,2018 at 4:30 p.m. the blood sugar level ranged from 143 to 444 mg/dL For the month of March 1 to 31,2018 at 9:30 p.m. the blood sugar level ranged from 174 to 402 mg/dL c. For the month of April 1 to 26, 2018 at 11 a.m. the blood sugar level ranged from 226 to 491 mg/dL For the month of April 1 to 26, 2018 at 4:30 p.m. the blood sugar level ranged from 224 to 435 mg/dL FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 41 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 For the month of April 1 to 26, 2018 at 9:30 p.m. the blood sugar level ranged from 199 to 399 mg/dL 3. On 4/25/18 at 4:05 p.m., a review of Resident 57's laboratory result, dated 1/27/18, timed at 9:07 a.m. indicated an elevated Hemoglobin AIC level of 8.8% taken on 1/27/18, which was was checked prior to Resident 57's admission to the facility on 2/8/18. In a concurrent interview with RN 3 she stated, the HGB A1C should had been rechecked after the resident was admitted due to the facility due to consistently high blood sugar level. According to the National Institute of Diabetes and Digestive and Kidney Diseases Hemoglobin AIC is a blood test that measures average blood sugar level over the past 3 months with the normal range level of 4.26.3%. (https://medlineplus.gov/a1c.html) 4. A review of the MMR indicated the pharmacy consultant had no documented evidence that Resident 57's medications to lower the blood sugar were reviewed for ineffectiveness to control Resident 57's blood sugar level. On 4/25/18 at 4:05 p.m., in concurrent interview with RN 3 indicated, Resident 57 medication regimen had not been changed since admission to the facility on 2/8/18, but should have been checked by the pharmacist and report to the physician any recommendation to change the medications for diabetes.

F757 SS=E Drug Regimen is Free from Unnecessary Drugs FORM CMS-2567(02-99) Previous Versions Obsolete

F757 Event ID: PLZZ11 05/26/2018 Facility ID: CA940000011 If continuation sheet 42 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE CFR(s): 483.45(d)(1)-(6) §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: Based on record review and interview the facility medicated three of 36 sampled residents (Residents 11, 34, & 48) with Elimite (medication to treat scabies) without fulfilling criteria for use and as a prophylactic (intended to prevent disease). This failure has resulted in the unnecessary use of medication to multiple residents. Findings: a. A review of Resident 11's admission record indicated the resident was admitted to facility on 4/20/17. Admitting diagnoses include essential hypertension (high blood pressure), unspecified dementia without behavioral FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 43 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 disturbance (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), muscle weakness, and spinal stenosis (is a narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine). A review of the Minimum Data Set [a standardized assessment and care plan tool (MDS)], a quarterly assessment dated 1/23/18, indicated that Resident 11 has a brief interview mental status score of 3 which signifies that resident is severely impaired cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). A review of activities of daily living (ADL) assistance indicated Resident 11 required extensive assistance with transfer, walk in room, walk in corridor, locomotion on/off unit, dressing, toilet use, and personal hygiene. A review of Resident 11's physician's orders indicated an order to "Apply Elimite cream from neck down to toes on 4/16/18 at 9 p.m., wash off on 4/17/18 at 9 a.m. for scabies prophylaxis." During a review of Resident 11's treatment record nurse's notes dated 4/17/18 at 2 p.m. indicated, "Assessment done after Elimite cream. application. No change in skin noted. No redness. No open skin, denies itchiness." During a record review of a document entitled, "Surveillance Data Collection Form," indicated for "Scabies," the form indicated the criteria for treatment: 1. A maculopapular and/or itching rash 2. At least 1 of the following scabies subFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 44 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 criteria: a. Physician diagnosis b. Laboratory confirmation (scraping or biopsy) c. Epidemiologic linkage to a case of scabies with laboratory confirmation. According to the surveillance form, "Both criteria 1 and 2 must be present." During an interview with Registered Nurse 2 (RN 2) on 4/25/18 at 9 a.m., RN 2 acknowledged that Elimite treatment was given to Resident 11 due to "Cohorting (potentially exposed to the disease)." RN 2 further stated, Resident 11 was given Elimite treatment because her roommate was being treated for suspected scabies. RN 2 acknowledged surveillance form was not completed, and Resident 11 did not fulfill criteria for treatment. b. A review of Resident 34's admission record indicated resident was admitted to facility on 8/22/17. Admitting diagnoses include heart failure, major depressive disorder, Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), and essential hypertension (high blood pressure). A review of the MDS, dated 2/14/18, indicated that Resident 34 has a brief interview mental status score of 2 which signifies that resident is severely impaired cognitively. A review of activities of daily living (ADL) assistance indicated Resident 34 requires extensive assistance with transfer, dressing, toilet use, and personal hygiene. A review of Resident 34's physician's orders indicated an order to "Apply Elimite cream. from neck down to toes on 4/16/18 at 9 p.m., wash off on 4/17/18 at 9 a.m. for scabies FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 45 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 prophylaxis." During a record review of Resident 34's care plan dated 4/16/18, it indicated for Resident 34 "Prone for reactive skin rashes due to Scabicide prophylactic treatment." It further indicated, "Apply Elimite cream. (prophylaxis) as ordered," as an intervention. A review of licensed nurse's progress notes dated 4/16/18 at 4 p.m. indicated, "Resident's skin condition, generalized body rash, has not improved with currently ordered treatment. Physician notified, received new order, scabicide prophylactic treatment." During a record review of a document entitled, "Surveillance Data Collection Form," indicated for "Scabies," the form indicated the criteria for treatment: 1. A maculopapular and/or itching rash 2. At least 1 of the following scabies subcriteria: a. Physician diagnosis b. Laboratory confirmation (scraping or biopsy) c. Epidemiologic linkage to a case of scabies with laboratory confirmation. According to the surveillance form, "Both criteria 1 and 2 must be present." During an interview with Registered Nurse 2 (RN 2) on 4/25/18 at 9 a.m., RN 2 acknowledged that Elimite treatment was given to Resident 34 as prophylactic treatment. RN 2 further stated Resident 34's rash and itchiness was not getting better so the physician was notified and the new order was given. RN 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 46 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 stated no scrape was done, and no scrape was ordered. RN 2 acknowledged the criteria was not met for scabies treatment, but medication was still administered. c. A review of Resident 48's admission record indicated the resident was admitted to facility on 7/4/17. Admitting diagnoses include Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), weakness, unspecified dementia without behavioral disturbance (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), heart failure, and muscle weakness. A review of the MDS, a quarterly assessment dated 2/12/18, indicated that Resident 48 has a brief interview mental status score of 3 which signifies that resident is severely impaired cognitively. A review of activities of daily living (ADL) assistance indicated Resident 48 requires extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. A review of Resident 48's physician's orders indicated an order to "Apply Elimite cream. from neck down to toes on 4/16/18 at 9 p.m., wash off on 4/17/18 at 9 a.m. for scabies prophylaxis." During a record review of Resident 48's treatment record nurse's notes dated 4/17/18 at 2 p.m. indicated, "Reassessed after Elimite cream. treatment as prophylaxis. No redness or any other acute distress noted." During a record review of a document entitled, "Surveillance Data Collection Form," indicated for "Scabies," the form indicated the criteria for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 47 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 treatment: 1. A maculopapular and/or itching rash 2. At least 1 of the following scabies subcriteria: a. Physician diagnosis b. Laboratory confirmation (scraping or biopsy) c. Epidemiologic linkage to a case of scabies with laboratory confirmation. According to the surveillance form, "Both criteria 1 and 2 must be present." During an interview with Registered Nurse 2 (RN 2) on 4/25/18 at 9:00 a.m., RN 2 acknowledged that Elimite treatment was given to Resident 48 due to "cohorting." RN 2 further stated, Resident 48 was given Elimite treatment because her roommate was being treated for suspected scabies. RN 2 acknowledged surveillance form was not completed, and Resident 48 did not fulfill criteria for treatment.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 05/26/2018 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 48 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on record review and interview the facility failed to complete the monthly psychotropic summary sheet for two of 36 sampled residents (Residents 20 & 47). These deficiencies have the potential to result in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 49 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 use of unnecessary medication, or nontherapeutic use of psychotropic medication. Findings: a. A review of Resident 47's admission record indicated the resident was admitted to the facility on 8/24/16. Admitting diagnoses include unspecified dementia without behavioral disturbance (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), essential hypertension (high blood pressure), and weakness. A review of the Minimum Data Set [a standardized assessment and care plan tool (MDS)], a quarterly assessment dated 3/1/18, indicated that Resident 47 has a brief interview mental status score of 3 which signifies that resident is severely impaired cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). A review of activities of daily living (ADL) assistance indicated Resident 47 requires limited assistance with transfer, walk in room, walk in corridor, toilet use, and personal hygiene. Resident 47 required extensive assistance with dressing and bathing. A review of the physician's orders and informed consent verification sheet for psychotropic drug indicated an order for Seroquel 25 milligrams (mg) 1 tab by mouth at bedtime for psychosis manifested by striking out to others. Order and consent was received on 8/17/17 at 11 a.m.. A record review of the psychotropic summary sheet indicated for Seroquel 25 mg by mouth at bedtime for psychosis. Further indicated behavior manifestation as "Striking out to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 50 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 others." The psychotropic summary sheet, initiated the month of August 2017 displays the monthly time period, behaviors per shift, total behaviors, adverse reactions and staff signature and date. For the month of March 2018, there was no documented evidence of monitoring. A review of the policy and procedure entitled "Psychotherapeutic Drug Management," undated, indicated, "The monthly psychotherapeutic summary will be completed." Policy further indicated, "The attending medical practitioner will review the current drug regimen monthly and determine if the resident should remain on the same dose or an adjustment should be made. b. A review of the admission record indicated Resident 20 was admitted to the facility on 11/4/13 and was readmitted on 6/16/16 with diagnoses that included epilepsy (brain disorder in which a person has repeated seizures [convulsions] over time), major depressive disorder (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities) and blindness left eye. A review of the MDS, dated 11/3/17 indicated Resident 20 was cognitively intact. Resident 20 required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. Resident 20 required supervision with eating. A review of the physician's orders for Resident 20 indicated the following: - Prozac 20 milligrams (mg) give one capsule by mouth one time a day for depression manifested by verbalization of sadness. Date ordered: 9/27/17 - Remeron 7.5 mg give one tablet by mouth at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 51 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 bedtime for depression manifested by verbalizing hopelessness over condition. Date ordered: 8/24/17. A review of the Resident 20's Psychotropic Summary sheet indicated the facility failed to summarize resident's behavior for the use of Prozac and Remeron. On 4/24/18 at 2:35 p.m., an interview was conducted with the Director of Nursing (DON) who confirmed Resident 20 was currently on Prozac for depression manifested by verbalization of sadness and Remeron for depression, manifested by verbalization of hopelessness over condition, as ordered. DON indicated to determine the effectiveness of the medication, the facility needs to monitor the targeted behavior for the use of Prozac and Remeron. DON stated it is a requirement to total the monthly behavior exhibited by the resident. DON stated this should be documented in the Psychotropic Summary Sheet. On 4/24/18 at 2:50 p.m., an interview was conducted with the Social Services Director (SSD) who confirmed the Psychotropic Summary Sheet was not completed for January 2018, February 2018 and March 2018 for behavior monitoring for the use of Prozac and Remeron. The SSD stated it was her responsibility to tally the hash marks of the behavior exhibited from the medication administration record (MAR) but she missed to summarize the behaviors. The SSD indicated it is important to summarize the behavior to see how many behavior in each shift was exhibited by the resident, to be able to identify if more or less behaviors were exhibited and if resident needed medication adjustment based on the total behavior exhibited each month. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 52 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 undated policy and procedure titled" Behavior Monitoring, Evaluation and Discontinuation Orders" indicated residents with specific behavior manifestations and for which psychotropic medication is indicated, shall be monitored for frequency of occurrence of behavior, duration of occurrence of behavior, changes or trends in the occurrences of behavior and presence and absence of behavior. On a monthly and as needed basis whenever there is a change in physician's orders, licensed nurse shall evaluate appropriateness of behavior monitoring to ensure it is the same indication as medical symptoms for use of psychotropic medications.

F800 SS=E Provided Diet Meets Needs of Each Resident CFR(s): 483.60

F800 05/26/2018 §483.60 Food and nutrition services. The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to develop a dietary spreadsheet to indicate portion sizes and food items for each type of diet to be served and provide adequate estimated daily calories which may potentially affect all residents in the facility. This deficient practice had the potential for all residents to have unintended weight gain or loss. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 53 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 the facility's breakfast menu for 4/25/18 included hot cereal, scrambled eggs, ham, and French toast. There were two separate menus for lunch and dinner, which provided American and Korean options. The menu did not include portion sizes and food items required for each type of diet. During a breakfast preparation observation on 4/25/18 at 6:31 a.m., Cook 1 was scooping hot cereal from the pot and placing the cereal into plastic bowl containers. Cook 1 stated that she was scooping ¼ quart (8 ounces) of cereal into each cup. Cook 1 then started scooping cereal with a six (6)-ounce ladle. During further observation on 4/25/18 at 6:31 a.m., the steam table contained baked eggs, scrambled eggs, chopped ham, ground ham, ground bread, chopped bread, and single slices of French toast. A plate with a regular and mechanical soft diets received hot cereal in a separate bowl, two (2) ounces of ham, three (3) ounces of egg, and French toast. A puree diet received cereal in a separate bowl, three (3) ounces of baked egg, and four (4) ounces of bread. No ham was served to the residents receiving puree trays. During an interview on 4/25/18 at 7:40 a.m., the Dietary Supervisor (DS) stated residents with puree diets should receive pureed ham in addition to cereal, baked egg, and puree bread. In a concurrent interview, Cook 1 stated that only chopped and ground ham were prepared for breakfast. DS stated that residents should receive the same food items as the other diets. DS stated that residents with puree diet should receive ham to ensure they received enough protein. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 54 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 interview on 4/25/18 at 8:16 a.m., DS stated that the facility did not have a dietary spreadsheet with the portion sizes and food items required for each type of diet. DS stated that the nutritional value, including amount of calories per meal, was uncertain for the facility's American and Korean menus. DS stated that the Registered Dietitian (RD) did not provide the spreadsheet for the facility's menus. During an interview on 4/25/18 at 11:16 a.m., the RD stated that she consulted with the facility for four (4) hours every two weeks, totaling eight (8) hours per month. The RD stated that she approved the facility's menu months ago with the dietary spreadsheet information. The RD stated that the DS informed her two weeks ago that the dietary spreadsheet information could not be located. The RD stated that she did not have a copy of the dietary spreadsheet information for the facility's current menu. The RD did not know who was responsible to develop the dietary spreadsheet information at the facility. The RD stated that she provided the Administrator with a new menu, which included the dietary spreadsheet information. A review of the facility's undated job description for Dietitian indicated that the primary responsibility of the facility's dietitian included approving the "regular and therapeutic diets so that food and nutritional needs of the residents are met in accordance with the physician's orders and, to the extent medically possible, meet the dietary allowances of the Food and Nutrition Board of the National Academy of Sciences, National Research Council." During a follow-up interview on 4/25/18 at 12:08 p.m., the RD again stated that she could not provide the dietary spreadsheet information FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 55 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 for the facility's current menu. The RD stated that the new menu provided to the facility was a recycled menu from another facility and did not have a Korean option. The RD stated she developed the dietary spreadsheet information for the proposed new menu when she was a full-time employee with another facility, which paid her to develop the facility's dietary spreadsheet.

F802 SS=E Sufficient Dietary Support Personnel CFR(s): 483.60(a)(3)(b)

F802 05/26/2018 §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.60(a)(3) Support staff. The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. §483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in § 483.21(b)(2)(ii). This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to have competent staff members provide sugar packets and sugar substitutes on resident meal trays. This deficient practice had the potential for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 56 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 inaccurate distribution of sugar to residents with diabetic (have high blood sugar levels) diets. Findings: During a breakfast observation on 4/26/18 at 7:19 a.m., the Director of Staff Development (DSD) checked the resident trays on the meal carts. On 4/26/18 at 7:25 a.m., Certified Nursing Assistant 21 (CNA 21) proceeded to place sugar and zero calorie sweeter packets on the meal trays. During an interview on 4/26/18 at 7:25 a.m., the Dietary Supervisor (DS) stated that it was the facility's practice that the CNAs place the sugar packets and zero calorie sweeteners on the residents' trays. DS stated that the red sticker on the meal card indicated residents with diabetic diets. During an interview on 4/26/18 at 7:44 a.m., the DSD reviewed the in-service binder and stated that the facility did not provide CNAs with dietary in-service training. The DSD stated that the CNAs were verbally educated that red stickers on the meal card indicated residents with diabetic diets. The DSD stated that the dietary staff told the CNAs to place sugar and zero calorie sweeteners on the trays. During an interview on 4/26/18 at 8:48 a.m., Dietary Staff 1 stated that the previous Dietary Supervisor decided about a year ago that the CNAs would place sugar on the meal trays because the residents kept asking for more sugar from the kitchen. Dietary Staff 1 stated the CNAs placed the sugars on resident trays for breakfast, lunch, and dinner. During an interview on 4/26/18 at 9:10 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 57 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 CNA 21 stated that the previous Dietary Supervisor taught the CNA staff how to place the packets of sugar or zero calorie sweetener on resident trays. CNA 21 stated that the packets were placed on trays when passing out coffee, which was after the charge nurse checked the trays. A review of the undated job description for Certified Nurse Assistant did not include meal tray preparation. A review of the undated job description for Dietary Assistant, Diet Aide, Dishwater, Hostess indicated specific responsibilities included "preparing foods for trayline, working on trayline, nourishment preparation and servicing the dining room."

F803 SS=E Menus Meet Resident Nds/Prep in Adv/Followed CFR(s): 483.60(c)(1)-(7)

F803 05/26/2018 §483.60(c) Menus and nutritional adequacy. Menus must§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 58 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to: a. Provide adequate servings of protein to residents with puree diets, review the dietary menu periodically, and adhere to the facility's recipes. These deficient practices had the potential to decrease residents' appetites and increase protein deficiency, which can lead to weight loss and delayed wound healing. b. For Resident 51, failed to ensure that the resident met her nutritional needs and preferences. This deficient practice had the potential for a resident to experience significant weight loss. Findings: a. During a group interview on 4/24/18 at 10 a.m., two of six residents, who were alert and oriented, expressed concern regarding the flavor of the facility's food, especially breakfast. A review of the facility's breakfast menu for 4/25/18 included hot cereal, scrambled eggs, a.m., and French toast. During an observation on 4/25/18 at 6:31 a.m., the steam. table contained steamed eggs, scrambled eggs, chopped a.m., ground a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 59 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 ground bread, chopped bread, and single slices of French toast. A plate with a regular diet received hot cereal in a separate bowl, two (2) ounces of chopped a.m., three (3) ounces of scrambled egg, and one slice of French toast. A plate with mechanical soft chopped or ground diets received hot cereal in a separate bowl, two (2) ounces of either chopped or ground a.m., and three (3) ounces of scrambled or baked egg. A puree diet received cereal in a separate bowl, three (3) ounces of baked egg, and four (4) ounces of bread. No a.m. was served to the residents receiving puree trays. During an interview on 4/25/18 at 6:31 a.m., Cook 1 stated that the ground and chopped a.m. were sautéed on the grill. During an observation on 4/25/18 at 7:11 a.m., there was no more a.m. available for at least seven meal trays. Cook 1 went into the refrigerator, came out holding a ham, chopped the ham, and sautéed the ham in a pan over the stove. No other ingredients were added to the ham. During an interview on 4/25/18 at 7:11 a.m., Cook 1 acknowledged not making enough ham for breakfast. Cook 1 stated that she was told not to cook excessive amounts of food to prevent throwing it out. During an interview on 4/25/18 at 7:40 a.m., the Dietary Supervisor (DS) stated residents with puree diets should have pureed ham in addition to cereal, baked egg, and puree bread. In a concurrent interview, Cook 1 stated that only chopped and ground ham were prepared for breakfast. The DS stated that the residents should receive the same food items as the other diets. The DS stated that residents with puree diets should receive ham to ensure they receive enough protein. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 60 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 Food Manager recipe book dated 3/16/92 was done with the DS. The DS provided recipes for French toast and baked ham slices. A review of the French toast recipe indicated to "cut French toast diagonally - serve 3 to 4 triangles per portion." A review of the baked ham slices recipe indicated to bake ham in brown sugar, dry mustard, and water, pineapple, or spiced fruit juice. During an interview on 4/25/18 at 8:16 a.m., The DS acknowledged that the facility's recipe book was not revised since 3/16/92. The DS stated that the Administrator and owner were aware about the recipes and were in the process of changing the menu. The DS acknowledged that Cook 1 did not adhere to the facility's recipes. A review of the facility's breakfast menu for 4/26/18 included hot cereal, fried eggs, turkey sausage, and toast with jelly and butter. During a second breakfast preparation observation on 4/26/18 at 6:50 a.m., the mechanical soft and regular diet plates received two ounces of turkey sausage, three ounces of egg, and either one slice or four ounces of chopped bread. The puree diet plates received three ounces of egg and four ounces of puree bread. No turkey sausage was provided to residents with puree diets. In a concurrent interview, Cook 2 stated that the residents on puree diets only received eggs and bread on their plates. During an interview on 4/26/18 at 8:31 a.m., Resident 17 stated she did not eat breakfast on 4/25/18 since the ham was overly salty. b. A review of the Admission Record (face sheet) indicated that Resident 51 was admitted 11/29/17 with diagnoses that included FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 61 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 hypertension (high blood pressure) and Type 2 diabetes mellitus (high blood sugar). A review of the Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 3/7/18 indicated that Resident 51 had intact cognitive skills and needs oversight, encouragement or cueing and set-up help only for eating. A review of the Initial Nutritional Assessment dated 12/4/17 indicated that Resident 51 prefers Korean food and likes to eat kimchi, fruit and Korean food. A review of the diet card indicated that Resident 51 prefers Korean food. A review of the Vital Signs and Weight Record indicated that Resident 51's admission weight on 11/29/17 was 96.8 pounds. On 1/29/18 (two months after admission), Resident 51 weighed 87.6 pounds. Most recent weight (4/22/18) reflected that Resident 51 weighed 89 pounds. A review of the computerized clinical record titled "Nutrition- amount Eaten" indicated that Resident 51 ate 40% or less of 35 out of 42 meals served by the facility in the past two weeks (4/11/18 to 4/25/18). During a dining observation on 4/24/18 at 8 a.m., Resident 51 ate approximately 40% of breakfast served. During a subsequent dining observation and a concurrent interview on 4/25/18 at 7:32 a.m., Resident 51 stated she did not like her food. According to Registered Nurse 4 (RN 4), Resident 51 stated French toast was too soggy. During an interview on 4/25/18 at 10 a.m., (with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 62 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 Activities Director (AD) Korean speaking) Resident 51 stated she likes kimchi (a staple in Korean cuisine, is a traditional side dish made from salted and fermented vegetables), fruit, dry seaweed and rice for breakfast for many years. Director/AD). During an interview on 4/25/18 at 10:30 a.m., Certified Nurse Assistant 16 (CNA 16) stated that Resident 51 only ate 20% of breakfast and did not like eggs and told her "food, not good." CNA 16 stated she tells the charge nurse about it and documents the food intake in the computer. During an interview on 4/25/18 at 10:40 a.m., RN 1 stated that Resident 51 usually eats small portions only. RN 1 stated that Resident 51 stated that food "not good for me." RN 1 stated that Resident 51 did not like French toast so she went to the kitchen to get Resident 51 regular roast. RN 1 stated that Resident 51 likes Korean soup or pancake for breakfast. During an interview on 4/25/18 at 11 a.m., RN 4 stated that Resident 51 had significant weight loss in January but Resident 51's weight had been stable in the last 3 months. RN 4 stated that they serve Resident 51 diabetic house nourishment three times a day to supplement Resident 51's food intake. During a follow-up dining observation on 4/26/18 at 7:30 a.m., Resident 51 had American food for breakfast with a CNA present to encourage Resident 51 to eat. During a follow-up interview on 4/26/18 at 9:56 a.m., with the interpreter, Resident 51 stated that she did not like her food and was not happy about her meal. Resident 51 stated she likes Korean or Japanese food. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 63 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 4/26/18 at 10:22 a.m., DS stated "we don't cook Korean food for breakfast; we only serve American food" and "we don't practice it here in this facility-cooking Korean food for breakfast." The DS stated that they have kimchi, rice and seaweed available in the kitchen but they only serve it for lunch and dinner and it was not indicated on her diet card that Resident 51 preferred Korean food. The DS stated that she will check the diet card and stated that she needs to check all the diet cards for each resident to have an accurate list.

F804 SS=E Nutritive Value/Appear, Palatable/Prefer Temp F804 CFR(s): 483.60(d)(1)(2) 05/26/2018 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; §483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to serve food at appropriate temperatures. This deficient practice had the potential for decreased appetite, which could lead to weight loss. Findings: During an interview on 4/24/18 at 10:00 a.m., two (2) of six residents, who were alert and oriented, expressed concern regarding the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 64 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 serving temperatures of the food. Both residents stated that breakfast was usually served cold. A review of the breakfast menu indicated turkey sausage was served on 4/22/18, chopped ham was served on 4/25/18, and turkey sausage was again served on 4/26/18. A review of the Food Temperature Log for April 2018 did not indicate temperatures for the turkey sausage and chopped ham. During an interview on 4/25/18 at 7:53 a.m., Dietary Supervisor (DS) stated the kitchen was supposed to record temperatures for the food served to the resident. DS was unaware that the facility's Food Temperature Log for breakfast did not record cooked meat temperatures. A review of the facility's breakfast menu for 4/26/18 included hot cereal, fried eggs, turkey sausage, toast with jelly and butter, fruit juice, and milk, coffee, or tea. During an observation on 4/26/18 at 6:21 a.m., Dietary Staff 2 took temperatures of the cups filled with milk and juice. The temperature of the milk was 32 degrees Fahrenheit (F) and the juice was 31 degrees F. Dietary Staff 2 proceeded to place the cups of milk and juice on the resident trays. On 4/26/18 at 6:32 a.m., Cook 2 took the temperatures of the fried eggs and hot cereal on the steam table. The fried egg measured 178 degrees F, and the hot cereal was 182 degrees F. On 4/26/18 at 6:52 a.m., Cook 2 took the following temperatures on the steam table: chopped sausage 162 degrees F, ground sausage 162 degrees F, baked eggs 189 degrees F. During an observation on 4/26/18 at 7:19 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 65 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 test tray with mechanical soft ground diet left the kitchen. During an interview on 4/26/18 at 7:37 a.m., the Dietary Supervisor (DS) stated that the residents should receive the food trays as soon as possible once the trays leave the kitchen. Two Certified Nursing Assistants (CNAs) were passing out trays to resident rooms. Both CNAs stopped to help residents while food trays remained in the carts. No other CNAs were observed assisting with food tray distribution. During an observation on 4/26/18 at 7:38 a.m., the test tray was served, which was 19 minutes after it left the kitchen. The following temperatures were taken: juice 57 degrees F, milk 58.8 degrees F, hot cereal 124.7 degrees F, steamed eggs 107.4 degrees F, and chopped sausage 89 degrees F. The milk tasted warm while the sausage turkey tasted cold. DS agreed regarding the temperatures of the food, stating that the tray distribution was slow. During an interview on 4/26/18 at 8:31 a.m., Resident 17 stated that she had to send back the breakfast tray since the food was cold.

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

F812 05/26/2018 §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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 66 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 (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 ensure the kitchen was maintained in a sanitary manner. This deficient practice had the potential to promote an unsanitary environment for food storage, preparation, cleaning, and ingestion. Findings: a. During an initial kitchen observation on 4/23/18 at 1:45 p.m., Dietary Staff 1 came out of the refrigerator and went into the dry food storage area. Dietary Staff 1 was not wearing a hair net inside of the kitchen. In a concurrent interview on 4/23/18 at 1:45 p.m., the Dietary Supervisor (DS) stated that it was the facility's policy to wear a hair net in the kitchen. A review of the facility's policy and procedure, updated 10/2008, entitled "Personal Hygiene" indicated "Hair must be appropriately restrained or completely covered." b. During an observation on 4/23/18 at 1:48 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 67 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 p.m., a hand sanitizer bottle was placed above the soap dispenser. The hand sanitizer bottle was 1/4 full. In a concurrent interview on 4/23/18 at 1:48 p.m., the DS acknowledged that the hand sanitizer bottle was used. DS stated that the hand sanitizer was used when the water heater underwent repairs, shutting off the hot water to the kitchen for a couple of minutes. DS stated that soap and water was more effective than hand sanitizer. A review of the facility's policy and procedure, updated 10/2008, entitled "Personal Hygiene" indicated "Hands must always be washed prior to beginning work, ...after smoking, using the restroom, or handling any unsanitary items." c. During an observation on 4/23/18 at 1:48 p.m., the trash can immediately next to the sink did not have a foot pedal to dispose paper towels after washing hands. The trash can required manual lifting of the lid. In a concurrent interview on 4/23/18 at 1:48 p.m., the DS stated that lifting the trash can's lid can transfer dirt from the lid to the hand. d. During an observation on 4/23/18 at 1:56 p.m. in the dry food storage, there was a tenpound bag of soybeans stored in a large container. The soybean bag, which had been opened, was secured with saran wrap. There was no date indicating when the bag of soybeans was opened. During a concurrent interview on 4/23/18 at 1:56 p.m., Dietary Staff 1 acknowledged the bag of soybeans was not marked with the date it was opened. e. During an observation on 4/23/18 at 2:04 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 68 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 p.m., the refrigerator had a shallow container with a bag of mozzarella cheese and an opened package of hot dogs. During a concurrent interview on 4/23/18 at 2:04 p.m., the DS stated that the cheese and hot dogs were not supposed to be in stored in the same container. f. During an observation on 4/23/18 at 2:14 p.m., a drain pipe which drained the preparation table that was between the coffee machine and steam table, went into the kitchen floor drain. No air gap was observed between the pipe and the top of the floor drain. During a concurrent interview on 4/23/18 at 2:14 p.m., the DS acknowledged there was no air gap between the pipe and the floor drain. the DS also acknowledged that sewage could back up into the piping from the kitchen's floor drain. The Maintenance Supervisor (MS) also observed the piping. MS was unaware that an air gap was necessary to prevent back flow into the pipes. g. A review of the facility's breakfast menu for 4/25/18 included hot cereal, scrambled eggs, ham, and French toast. During an observation on 4/25/18 at 7:11 a.m., there was no more ham available for at least seven (7) meal trays. Cook 1, who was wearing disposable gloves, went into the refrigerator and came out holding a ham. Cook 1 opened the ham's plastic packaging and chopped the ham. Cook 1 then sautéed the ham in a pan over the stove. Cook 1 washed her gloved hands in water but did not use soap. Cook 1 proceeded to handle the serving scoops on the steam table and chopped bread with the same gloves. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 69 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 4/25/18 at 7:11 a.m., Cook 1 acknowledged not changing gloves after handling the ham. During an interview on 4/25/18 at 7:40 a.m., DS stated that Cook 1 should have removed her gloves after chopping the ham, washed hands with soap and water, and then put on a new pair of gloves. A review of the facility's policy and procedure, updated 10/2008, entitled "Personal Hygiene" indicated "Hands must always be washed after ...handling any unsanitary items." h. During an observation on 4/25/18 at 8:16 a.m., Cook 1's nails were painted a peach shade and extended approximately ¼ inch from the fingertip. A review of the facility's policy and procedure, updated 10/2008, entitled "Personal Hygiene" indicated "Fingernails must be kept short and clean at all times" and "Nail polish is not permitted."

F849 SS=D Hospice Services CFR(s): 483.70(o)(1)-(4)

F849 05/26/2018 §483.70(o) Hospice services. §483.70(o)(1) A long-term care (LTC) facility may do either of the following: (i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices. (ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 70 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 §483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements: (i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services. (ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following: (A) The services the hospice will provide. (B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter. (C) The services the LTC facility will continue to provide based on each resident's plan of care. (D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. (E) A provision that the LTC facility immediately notifies the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. (3) A need to transfer the resident from the facility for any condition. (4) The resident's death. (F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 71 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 services provided. (G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. (H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions. (I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility. (J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation. (K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff. §483.70(o)(3) Each LTC facility arranging for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 72 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident. The designated interdisciplinary team member is responsible for the following: (i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services. (ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family. (iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians. (iv) Obtaining the following information from the hospice: (A) The most recent hospice plan of care specific to each patient. (B) Hospice election form. (C) Physician certification and recertification of the terminal illness specific to each patient. (D) Names and contact information for hospice personnel involved in hospice care of each patient. (E) Instructions on how to access the hospice's 24-hour on-call system. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 73 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 (F) Hospice medication information specific to each patient. (G) Hospice physician and attending physician (if any) orders specific to each patient. (v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents. §483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24. This REQUIREMENT is not met as evidenced by: Based on record review and interview, the facility failed to have an updated written agreement with hospice (Care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure. The goal is to enable patients to be comfortable and free of pain, so that they live each day as fully as possible.) in one of two-sampled hospice residents (Resident 43) medical record. This failure has the potential to affect the coordination of care provided to the resident. Findings: A review of Resident 43's admission record indicated the resident was admitted to the facility on 3/21/17. Admitting diagnoses include hemiplegia and hemiparesis (paralysis on one side of body) following unspecified cerebrovascular disease (disease of the blood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 74 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 vessels supplying the brain) affecting left dominant side, unspecified dementia without behavioral disturbance (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and muscle weakness. A review of Resident 43's hospice certification indicated Resident 43's was certified for hospice services for 60 days dated from 2/7/18 to 4/7/18 and was signed by the physician. During a concurrent review of Resident 43's medical record and interview with the Director of Nursing (DON) on 4/26/18, the DON acknowledged that the updated certification was not in the medical record. The DON further stated there was no excuse for not having the updated certification in the medical record. The DON also stated it is the responsibility of licensed nurses to check for updated certification for hospice care.

F867 SS=E QAPI/QAA Improvement Activities CFR(s): 483.75(g)(2)(ii)

F867 05/26/2018 §483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility's Quality Assessment and Assurance Committee (QA&A) failed to implement the facility's plan of correction from the last reFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 75 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 certification survey. As a result of this failure, the facility had repeat and additional deficient practices identified in the areas of Quality of Care and Food and Nutritional Services during the current re-certification survey. Findings: A review of the facility's plan of correction from the last re-certification survey on 4/16/17 indicated that a new Dietitian was hired and would begin employment in July. During an interview on 4/23/18 at 1:48 p.m., the Dietary Supervisor (DS) stated that she began working at the facility one month prior. During an interview on 4/25/18 at 11:16 a.m., the Registered Dietitian (RD) stated that she had been employed as a facility consultant for 15 to 20 years. During an interview on 4/25/18 at 12:08 p.m., the Administrator, Director of Nursing (DON), RD, and DS described the facility's process of tracking weight loss and implementing interventions. DS stated that the facility's method of tracking weight loss was confusing and difficult to follow since four groups of residents were weighed at different times. The DS stated that the previous Dietary Supervisor provided an orientation for two days but did not offer clarification regarding the process of tracking weight loss. During an interview on 4/26/18 at 2:16 p.m., the Administrator and DON stated that facility did not hire another RD. Administrator clarified that the facility's previous Dietary Supervisor did not have the appropriate qualifications but continued to work at the facility until March 2018. Administrator and DON acknowledged the facility did not fulfill the plan of correction FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 76 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 from the last re-certification survey. Cross reference F 692 and F 800.

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

F880 05/26/2018 §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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 77 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 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. §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 observation, interview, and record review, the facility failed to: a. Clean cloth gait belts (device used to transfer residents from one position to another or while walking residents that have problems FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 78 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 balance) between resident use with an appropriate cleaning agent. Certified Nursing Assistants also wore cloth gait belts were also worn around the waists while working in the facility. b. Clean equipment in-between resident care with an appropriate cleaning agent. c. Remove soiled gowns prior to entering a clean laundry area. These deficient practices had the potential to spread infection throughout the facility. Findings: a. During an observation on 4/23/18 at 2:26 p.m., Certified Nursing Assistant 1 (CNA 1), CNA 2, CNA 3, and CNA 8 wore cloth gait belts around their waists. On 4/23/18 at 2:31 p.m., CNA 4 wore a cloth gait belt around the waist. On 4/23/18 at 2:54 p.m., CNA 5 wore a cloth gait belt around her waist. On 4/23/18 at 2:56 p.m., CNA 6 wore a cloth gait belt around the waist while pushing a cart with water jugs to resident rooms. During an observation on 4/24/18 at 7:22 a.m., CNA 3, CNA 7, CNA 8, and CNA 9 wore cloth gait belts around their waists while distributing trays in the dining room. On 4/24/18 at 7:35 a.m., CNA 4 wore a cloth gait belt around the waist while feeding a resident. On 4/24/18 at 7:47 a.m., CNA 10 wore a cloth gait belt around the waist while placing completed meals in the food tray carts. On 4/24/18 at 7:51 a.m., CNA 11 and 12 wore cloth gait belts around their waists. On 4/24/18 at 7:58 a.m., CNA 13's uniform covered a cloth gait belt wrapped around her hips. On 4/24/18 at 7:59, CNA 14 wore a cloth gait belt around the waist. On 4/24/18 at 8:04 a.m., CNA 15 brought in empty FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 79 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 soiled linen and trash bins from the parking lot while wearing a cloth gait belt around the waist. On 4/24/18 at 11:07 a.m., CNA 16 exited the restroom while wearing a cloth gait belt around the waist. On 4/24/18 at 11:16 a.m., CNA 17 wore a cloth gait belt around the waist. During an observation on 4/25/18 at 9:33 a.m., CNA 2 and CNA 20 provided ambulation services to Resident 14. CNA 2 placed the gait belt around Resident 14's waist while sitting in the wheelchair. CNA 2 assisted Resident 14 from a sitting to a standing position, using a four-wheeled walker. CNA 2 held onto the cloth gait belt while assisting Resident 14 to walk in the facility's hallway with the fourwheeled walker. At the end of the session, Resident 14 returned to a sitting position in the wheelchair. CNA 2 removed the gait belt around Resident 14's waist and fastened the gait belt around CNA 2's waist. During an observation on 4/25/18 at 9:45 a.m., Resident 55, who was sitting in a wheelchair, agreed to work with CNA 2 for ambulation. CNA 2 removed the gait belt from CNA 2's own waist and fastened it around Resident 55's waist prior to transferring from a sitting to standing position. Resident 55 stood from the wheelchair and walked around the facility's hallway using the four-wheeled walker. At the end of the session, CNA 2 removed the cloth gait belt from Resident 55's waist. On 4/25/18 at 9:55 a.m., CNA 2 fastened the cloth gait belt back onto CNA 2's waist and placed the fourwheeled walker in a closet. CNA 2 did not clean the cloth gait belt and the four-wheeled walker after working with Resident 14 and prior to working with Resident 55. During an observation on 4/25/18 at 10:03 a.m., CNA 7 wore a cloth gait belt around the waist. CNA 7 and CNA 15 assisted Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 80 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 33 from the bed to a seated position at the edge of bed. CNA 7 removed the cloth gait belt from around CNA 7's waist and fastened it to Resident 33's waist. CNA 7 and CNA 15 then transferred Resident 33 to a shower chair. CNA 7 removed the cloth gait belt from Resident 33's waist and placed it back onto CNA 7's waist. During an interview on 4/25/18 at 1:44 p.m., CNA 2 stated that she cleaned the cloth gait belt by hand with bleach and soap on her day off. During an observation on 4/25/18 at 2:00 p.m., the Director of Staff Development (DSD) provided the cloth gait belt, which was issued to staff. The cloth gait belt had washing instructions to wash in lukewarm water without bleach and to dry on a low setting. During an interview on 4/25/18 at 2:21 p.m., CNA 7 stated that she cleaned the cloth gait belt in-between residents with bleach disinfecting wipes. CNA 7 stated that she cleaned the cloth gait belt after showering Resident 55. CNA 7 also washed the gait belt every two days at home. In a review of the bleach disinfecting wipes container, the manufacturer instructions indicated that the wipes were used to clean, disinfect, and deodorize hard, nonporous surfaces. The manufacturer instructions also indicated that it was a violation of Federal law to use the product in a manner inconsistent with its labeling. During an interview on 4/26/18 at 8:02 p.m., the DSD stated the cloth gait belts were made of cloth and should be cleaned on a daily basis. the DSD stated the bleach disinfecting wipes should be used to clean the cloth gait belt after FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 81 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 use with a resident with transmission-based precautions. The DSD reviewed the bleach disinfecting wipes' manufacturer instructions. The DSD stated that the disinfecting wipes were for hard surfaces, not for cloth gait belts. The DSD also stated that shared equipment, like walkers, should be disinfected in-between residents' use. A review of an article, published on 10/3/14, entitled "Rehabilitation Services" by the Association for Professionals in Infection Control and Epidemiology indicated that shared equipment "must be cleaned and disinfected between each use." The article further indicated that "Gait belts should not be worn around the waist of...staff or (if cloth) used on multiple patients due to the inability to clean the gait belt between patients." b. During an observation on 4/24/18 at 1:33 p.m. in the facility's parking lot, Laundry Room Staff 1 wore a disposable gown, mask, and gloves to remove soiled plastic bags from the laundry bins and replace them with clean plastic bags. After replacing the plastic bags in the bins, Laundry Room Staff 1 walked through laundry room wearing the soiled gown. Laundry Room Staff 1 returned the roll of plastic bags to a metal cabinet in the laundry room's clean area where clean clothes were sorted and folded. In a concurrent interview, Laundry Room Staff 1 acknowledged wearing the soiled gown in the clean area of the laundry room. Laundry Room Staff 1 stated that the soiled gown should have been removed prior to returning the plastic bags to the laundry room. During an observation on 4/25/18 at 9 a.m., Laundry Room Staff 2 wore a disposable gown, two pairs of gloves, one pair of heavy-duty plastic gloves, a mask, and eye shield prior to sorting soiled linen. Laundry Room Staff 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 82 of 83 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: _______________ 056218 (X3) DATE SURVEY COMPLETED 04/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BELL CONVALESCENT HOSPITAL 4900 Florence Ave Bell, CA 90201 (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 placed soiled bibs in a separate pile, stating the laundry staff washed the bibs separately. Laundry Room Staff 2 removed the heavy-duty plastic gloves and one pair of disposable gloves after sorting the soiled laundry. Laundry Room Staff 2, who was still wearing the disposable gown, mask, and goggles, then went into the laundry room's clean area to retrieve a plastic bag for the soiled bibs. In a concurrent interview, Laundry Room Staff 2 stated the gown, mask, and goggles should have been removed prior to entering the clean area of the laundry room. A review of the facility's undated policy and procedure entitled "Laundry Department" indicated that employees "in the soiled areas shall wear an outer garment over their uniforms and gloves. Protective garments shall be removed and hands washed each time the employee leaves the soiled area." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZZ11 Facility ID: CA940000011 If continuation sheet 83 of 83