Other·January 25, 2019

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 the investigation of a complaint and Facility Reported Incident (FRI) investigation during an Abbreviated Standard Survey. Complaint number: CA00609659 FRI: CA00609537 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 36526 The inspection was limited to the specific complaint and FRI investigation and does not represent the findings of a full inspection of the facility. Three deficiencies were issued for complaint CA00609659 and FRI 609537

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

F550 01/10/2019 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect 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: 7MVJ11 Facility ID: CA940000011 If continuation sheet 1 of 15 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 12/28/2018 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 and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow its policy to ensure resident's dignity was maintained and ensure residents were provided privacy of body parts for one of three sampled residents (Resident 1). Resident 1 was left exposed naked with her pants down by certified nursing assistants 1 and 2 (CNA 1 and 2) after using the bathroom. This deficient practice resulted in Resident 1's privacy and dignity being violated and the roommate, Resident 2 being afraid of being FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7MVJ11 Facility ID: CA940000011 If continuation sheet 2 of 15 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 12/28/2018 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 hurt by the CNAs. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility on 4/8/16, and readmitted on 9/16/16. Resident 1's diagnoses included osteoporosis (bones become porous/brittle) and anemia (blood does not produce enough red blood cells [RBC-carries oxygen to the cells]). A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 9/25/18, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3 (0-7= severely impaired [thought process] skills). The MDS indicated Resident 1 required an extensive assistance of one-person physical assist for toilet use and transfers between surfaces. According to the MDS, Resident 1 was impaired of one side of the lower extremities and was dependent wheelchair for mobility. On 10/30/18 at 5:24 p.m., during an interview in the presence of Licensed Vocational Nurse 1 (LVN 1), Resident 1's roommate (Resident 2) stated that on 10/24/18, she witnessed CNAs 1 and 2 lift Resident 1 from the bathrooms floor and placed her in the wheelchair. Resident 2 stated that she saw one of the CNAs cleaning stool from the bathroom floor after. Resident 2 stated that she heard Resident 1 crying in pain while she was on the bathroom floor and neither of the CNAs called the nurse for help, then they transferred the resident to the bed with her pants down. Resident 2 stated that she asked the CNAs to lift the residents' pants up, but they just walked out of the room and ignored that Resident 1 was crying in pain. Resident 2 stated being afraid of CNAs 1 and 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7MVJ11 Facility ID: CA940000011 If continuation sheet 3 of 15 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 12/28/2018 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 returning and hurting her too. A review of Resident 2's Face sheet (Admission Record) indicated Resident 2 was admitted to the facility on 9/17/18. Resident 2's diagnoses included generalized weakness and high blood pressure. A review of Resident 2's MDS, dated 9/25/18, indicated the resident had a BIMS score of 9 (9 -12= moderately impaired [thought process] skills). On 10/30/18, at 5:34 p.m., during an interview, LVN 1 stated that on 10/24/18 she overheard Resident 1 crying. LVN 1 stated that upon entering the room, Resident 1 was uncovered from her vaginal area. On 10/30/18, at 6:02 p.m., during an interview, the Administrator (ADM) stated that CNAs 1 and 2 were placed on suspension until further review. On 11/1/18 at 2:50 p.m., during an interview, LVN 1 stated that CNAs 1 and 2 did not report Resident 1's fall incident to any of the change nurses. LVN 1 stated not knowing why the two CNAs left Resident 1's pants down and why both transferred the resident back into the bed. LVN 1 stated that when residents' have a fall or complain of pain, the CNA should notify the charge nurse. On 11/2/18 at 10:30 a.m., during a telephone interview, CNA 1 stated that she and CNA 2 assisted Resident 1 to the restroom, after Resident 1 had a bowel movement, both CNA 1 and 2 lifted resident from the toilet seat. CNA 1 stated that they tried to clean resident, but they were unable because Resident 1 was slipping down. CNA 1 stated that they placed the resident in the wheelchair and then transfer FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7MVJ11 Facility ID: CA940000011 If continuation sheet 4 of 15 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 12/28/2018 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 her to the bed. A review of the facility's policy titled, "Resident Bill of Rights," dated 5/2011 indicated that the residents have the right to be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs.

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

F609 01/10/2019 §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 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7MVJ11 Facility ID: CA940000011 If continuation sheet 5 of 15 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 12/28/2018 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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement its policy of reporting abuse to the abuse coordinator for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 not receiving prompt and adequate treatment after sustaining a fall in the facility's restroom. Findings: A review of Resident 1's Face sheet (Admission Record) indicated Resident 1 was admitted to the facility on 4/8/16, and readmitted on 9/16/16. Resident 1's diagnoses included osteoporosis (bones become porous/brittle) and anemia (blood does not produce enough red blood cells [RBC] to carry oxygen to the cells). A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 9/25/18, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3 (0-7= severely impaired [thought process] skills). The MDS indicated Resident 1 required an extensive assistance and was dependent in care of a one-person physical assist for toilet use and transfers between surfaces. The MDS indicated Resident 1 was impaired of one side of the lower extremities and was wheelchair dependent for mobility. A review of a Situation, Background, Assessment and Recommendation ([SBAR]internal communication form), dated 10/24/18 and timed at 5:50 p.m., indicated Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7MVJ11 Facility ID: CA940000011 If continuation sheet 6 of 15 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 12/28/2018 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 had left lateral pelvic (lower part of the trunk of the body between the abdomen and the thighs) pain of 5 out of 10 (the pain scale of 0 to 10, [0 being the worse]), and the left lower extremity shorter than the right lower extremity. A review of the facility's investigation with a conclusion, dated 10/26/18 indicated that Resident 1 slipped from the toilet during adult diaper change. A review of the GACH's report indicated Resident 1 was admitted on 10/27/18 with left hip pain, shortening of the left leg with swelling after a fall that occurred two days prior. The summary indicated Resident 1 underwent an open reduction and internal fixation ([ORIF] surgery used to stabilize and heal a broken bone by realigning the bone fracture into the normal position) surgery of the left hip and required a blood transfusion due to the blood loss during surgery. On 10/30/18 at 5:24 p.m., during an interview in the presence of Licensed Vocational Nurse 1 (LVN 1), Resident 1's roommate (Resident 2) stated that on 10/24/18, she witnessed CNAs 1 and 2 lift Resident 1 from the bathrooms floor and placed her in a wheelchair. Roommate stated that she saw one of the CNAs cleaning resident's stool from the bathroom floor after lifting Resident 1. Resident 2 stated that she heard Resident 1 crying in pain while she was on the bathroom floor and neither of the CNAs called the nurse for help, but transferred Resident 1 back to the bed with her pants down. Resident 2 stated that she asked the CNAs to lift the residents' pants up, but they just walked out of the room and ignored that Resident 1 was crying in pain. Resident 2 stated being afraid of CNAs 1 and 2 returning and hurting her too. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7MVJ11 Facility ID: CA940000011 If continuation sheet 7 of 15 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 12/28/2018 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 10/30/18, at 5:34 p.m., during an interview, LVN 1 stated that on 10/24/18, the day of the fall incident, she overheard Resident 1 crying. LVN 1 stated that upon entering the room, Resident 1 was in the bed uncovered and her vaginal area was exposed. LVN 1 stated Resident 1's left leg appeared shorter than the right leg. On 10/30/18, at 5:50 p.m., during an interview, CNA 3 stated on 10/24/18 she walked into Resident 1's room to pick up the dinner tray and saw CNAs 1 and 2 lifting Resident 1 from the floor. CNA 3 stated she did not report the incident to the charge nurse because she thought CNAs 1 and 2 were going to report it. On 11/1/18 at 2:50 p.m., during an interview, LVN 1 stated that CNAs 1 and 2 did not report Resident 1's incident to any of the change nurses. LVN 1 stated not knowing why the two CNAs left Resident 1's pants down and why both transfer the resident back into the bed. LVN 1 stated that when residents' have a fall or complain of pain, the CNA should notify the charge nurse. On 11/2/18 at 10:30 a.m., during a telephone interview, CNA 1 stated that she and CNA 2 assisted Resident 1 to the restroom, and after Resident 1 had a bowel movement, both she and CNA 2 lifted the resident from the toilet seat. CNA 1 stated that CNA 2 mentioned she did not like taking Resident 1 to the restroom because she was unable to stand on her own and that was when the resident started sliding down to the bathroom floor. CNA 1 stated she and CNA 2 tried to clean the resident, but they were unable because Resident 1 was slipping due to poor balance. CNA 1 stated, Resident 1 was "like dead weight." CNA 1 stated that they placed the resident in the wheelchair and then transferred her to the bed. CNA 1 stated that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7MVJ11 Facility ID: CA940000011 If continuation sheet 8 of 15 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 12/28/2018 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 she did not report the resident's fall to the charge nurse or the pain that the resident was experiencing. On 11/2/18 at 12:05 p.m., during a telephone interview, CNA 2 stated that Resident 1 was not able to stand on her own while she was being assisted in the restroom. CNA 2 stated that she did not report to the nurses that Resident 1 was complaining of pain or that the resident slipped to the floor while in the restroom. A review of the facility's undated policy titled, "Patient Abuse and Prevention," indicated that neglect was the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The policy indicated that the facility was responsible to ensure that staff followed general guidelines in protecting and reporting.

F726 SS=G Competent Nursing Staff CFR(s): 483.35(a)(3)(4)(c)

F726 01/10/2019 §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7MVJ11 Facility ID: CA940000011 If continuation sheet 9 of 15 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 12/28/2018 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 plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility's staff failed to follow its policy when there was an incident or a change in a resident's condition and report all findings for one of three sampled residents (Resident 1). Resident 1 slid down to the bathroom floor after being assisted by CNAs 1 and 2 to the toilet. The fall resulted in Resident 1 sustaining a bilateral (both sides) fixated (broken bone pieces that are out of alignment) hip fracture (broken bone) with suboptimal (less than the highest quality) left screw migration (movement from one part to another). These failures of CNAs 1 and 2 to report Resident 1's fall resulted in a delay in care, diagnosis, treatment, and pain to the pelvic area requiring a transfer to the general acute care hospital (GACH) and undergoing surgery (2 days after incident). Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7MVJ11 Facility ID: CA940000011 If continuation sheet 10 of 15 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 12/28/2018 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 1's Face sheet (Admission Record) indicated Resident 1 was admitted to the facility on 4/8/16, and readmitted on 9/16/16. Resident 1's diagnoses included osteoporosis (bones become porous/brittle) and anemia (blood does not produce enough red blood cells [RBC] to carry oxygen to the cells). A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 9/25/18, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3 (0-7= severely impaired [thought process] skills). The MDS indicated Resident 1 required an extensive assistance and was dependent in care of a one-person physical assist for toilet use and transfers between surfaces. The MDS indicated Resident 1 was impaired of one side of the lower extremities and was wheelchair dependent for mobility. A review of the "Fall Risk Assessment," dated 9/25/18 indicated Resident 1 had a score of 16 (score of 10 or higher indicated high risk). A review of a plan of care, dated 9/25/18 and titled, "Risk for Falls/Injury Related to General Weakness and unsteady Gait," indicated Resident 1 would remain free from falls or injuries. The staff's interventions included visual checks, assist resident with activities of daily living (ADL) as needed, and assist the resident to the toilet. A review of a Situation, Background, Assessment and Recommendation ([SBAR]internal communication form), dated 10/24/18 and timed at 5:50 p.m., indicated Resident 1 had left lateral pelvic (lower part of the trunk of the body between the abdomen and the thighs) pain of 5 out of 10 (the pain scale of 0 to 10, [0 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7MVJ11 Facility ID: CA940000011 If continuation sheet 11 of 15 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 12/28/2018 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 being the worse]), and the left lower extremity shorter than the right lower extremity. A review of the facility's investigation with a conclusion, dated 10/26/18 indicated that Resident 1 slipped from the toilet during adult diaper change. A review of the physician's order, dated 10/24/18 and timed at 5:55 p.m., indicated an x-ray of the pelvis STAT (medical abbreviation for urgent or rush) for Resident 1. A review of Resident 1's X-ray results, dated 10/24/18 and timed at 8:35 p.m ., indicated a fixated bilateral hip fracture with suboptimal left screw migration. A review of Resident 1's physician's order, dated 10/25/18 and timed at 12:52 a.m., indicated to administered Tylenol (mild pain medication) 650 milligrams (mg) every four (4) hours as needed (PRN) for pain for 72 hours. A review of Resident 1's physician's order, dated 10/26/18 and timed at 11 a.m., indicated to administered Tylenol # 3 ([Acetaminophen with codeine] narcotic pain medication) every six (6) hours as needed (PRN) for pain management until 11/2/18. On 12/11/18 at 10:43 a.m., during a concurrent interview and review of the Medication Administration Sheet (MAR) for the month of 10/2018 (10/24/18 through 10/28/18), the Medical Records Director (MRD) stated and confirmed Resident 1 received four (4) doses of two tablets (8 tablets) of Tylenol 650 mg by mouth on 10/25/18 and 10/26/18 for pain 3 out of 10. On 10/26/18 and 10/27/18 the resident received one dose of Tylenol #3 for pain 5 out of 10. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7MVJ11 Facility ID: CA940000011 If continuation sheet 12 of 15 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 12/28/2018 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 physician's order, dated 10/27/18 and timed at 10 a.m., indicated Resident 1 was transferred to a GACH, two days after the fall incident, per Resident 1's family request. A review of the GACH's report indicated Resident 1 was admitted on 10/27/18 with left hip pain, shortening of the left leg with swelling after a fall that occurred two days prior. The summary indicated Resident 1 underwent an open reduction and internal fixation ([ORIF] surgery used to stabilize and heal a broken bone by realigning the bone fracture into the normal position) surgery of the left hip and required a blood transfusion due to the blood loss during surgery. On 10/30/18 at 5:24 p.m., during an interview in the presence of Licensed Vocational Nurse 1 (LVN 1), Resident 1's roommate (Resident 2) stated that on 10/24/18, she witnessed CNAs 1 and 2 lift Resident 1 from the bathrooms floor and placed her in a wheelchair. Resident 2 stated that she saw one of the CNAs cleaning resident's stool from the bathroom floor after lifting Resident 1. Resident 2 stated that she heard Resident 1 crying in pain while she was on the bathroom floor and neither of the CNAs called the nurse for help, but transferred Resident 1 back to the bed with her pants down. Resident 2 stated that she asked the CNAs to lift the residents' pants up, but they just walked out of the room and ignored that Resident 1 was crying in pain. Resident 2 stated being afraid of CNAs 1 and 2 returning and hurting her too. A review of Resident 2's Face sheet (Admission Record) indicated Resident 2 was admitted to the facility on 9/17/18. Resident 2's diagnoses included generalized weakness and high blood pressure. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7MVJ11 Facility ID: CA940000011 If continuation sheet 13 of 15 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 12/28/2018 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 2's MDS, dated 9/25/18, indicated the resident had a BIMS score of 9 (9 -12= moderately impaired [thought process] skills). On 10/30/18, at 5:34 p.m., during an interview, LVN 1 stated that on 10/24/18, the day of the fall incident, she overheard Resident 1 crying . LVN 1 stated that upon entering the room, Resident 1 was in the bed uncovered and her vaginal area was exposed. LVN 1 stated Resident 1's left leg appeared shorter than the right leg . On 10/30/18, at 5:50 p.m., during an interview, CNA 3 stated on 10/24/18 she walked into Resident 1's room to pick up the dinner tray and saw CNAs 1 and 2 lifting Resident 1 from the floor. CNA 3 stated she did not report the incident to the charge nurse because she thought CNAs 1 and 2 were going to report it. On 10/30/18, at 6:02 p.m., during an interview, the Administrator (ADM) stated that CNAs 1 and 2 were placed on suspension until further review. On 11/1/18 at 2:50 p.m., during an interview, LVN 1 stated that CNAs 1 and 2 did not report Resident 1's fall incident to any of the change nurses. LVN 1 stated not knowing why the two CNAs left Resident 1's pants down and why both transfer the resident back into the bed. LVN 1 stated that when residents' have a fall or complain of pain, the CNA should notify the charge nurse. On 11/2/18 at 10:30 a.m., during a telephone interview, CNA 1 stated that she and CNA 2 assisted Resident 1 to the restroom, and after Resident 1 had a bowel movement, both she and CNA 2 lifted the resident from the toilet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7MVJ11 Facility ID: CA940000011 If continuation sheet 14 of 15 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 12/28/2018 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 seat. CNA 1 stated that CNA 2 mentioned she did not like taking Resident 1 to the restroom because she was unable to stand on her own and that was when the resident started sliding down to the bathroom floor. CNA 1 stated she and CNA 2 tried to clean the resident, but they were unable because Resident 1 was slipping due to poor balance. CNA 1 stated, Resident 1 was "like dead weight." CNA 1 stated that they placed the resident in the wheelchair and then transferred her to the bed. CNA 1 stated that she did not report the resident's fall to the charge nurse or the pain that the resident was experiencing. On 11/2/18 at 12:05 p.m., during a telephone interview, CNA 2 stated that Resident 1 was not able to stand on her own while she was being assisted in the restroom. CNA 2 stated that she did not report to the nurses that Resident 1 was complaining of pain or that the resident slipped to the floor while in the restroom. A review of the facility's undated policy and procedure (P/P) titled, "Fall Prevention and Reduction Program," indicated that each staff must report all incidents he/she are involved in or witnessed to, to his/her immediate supervisor or to the licensed nurse in charge or a resident's care. Residents identified to be at greater risk for falls or further falls should be monitored closely to prevent further occurrences of fall incidents ...CNAs should document account of the incident if they have witnessed the fall incident or found the resident after the fall. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7MVJ11 Facility ID: CA940000011 If continuation sheet 15 of 15