Other·July 10, 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 a Recertification survey, one Complaint and three Facility Reported Incidents (FRIs). Complaint number: CA00369695 FRI number: CA00608399 FRI number: CA00615001 FRI number: CA00621258 Representing the Department of Public Health: Surveyor ID: 36356, RN, HFEN Surveyor ID: 36394, RN, HFEN Surveyor ID: 40821, RN, HFEN Surveyor ID: 40994, Pharmacy Consultant Resident Census: 95 Sample Size : 19 Highest Severity and Scope: G No deficiency was written as a result of Complaint number: CA00369695 and FRIs CA00608399 and CA00615001. Two deficiencies was written as a result of FRI CA00621258. 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: 7PBE11 Facility ID: CA940000011 If continuation sheet 1 of 78 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 05/24/2019 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

F578 Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/21/2019 §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 2 of 78 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 05/24/2019 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 provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to provide one of six sampled residents (2), the right to formulate an Advanced Directive. This deficient practice had the potential for Resident 2 or their responsible party not to make appropriate decisions when incapacitated. Findings: During a review of Resident 2's medical records (chart), the resident's Provider Orders for Life-Sustaining Treatment ([POLST], specific medical orders to be honored by health care workers during a medical crisis) section D, indicated the resident had no Advanced Directive. Further review of the resident's chart indicated there was no AD acknowledgment form, offering the resident an AD. A review of Resident 2's admission record indicated the resident was admitted on 5/25/18 and re-admitted on 12/23/18 with diagnosis of cellulitis (infection) of the right upper limb (body), diabetes mellitus type 2 (abnormal blood sugar levels), and end stage renal disease (kidney failure). A review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/7/19 indicated the resident had moderate cognitive impairment (ability to think, understand and make daily FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 3 of 78 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 05/24/2019 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 decisions). During an interview with the Social Services Director (SSD) on 05/23/19 at 10:27 a.m., confirmed there was no acknowledgment form in the chart. The SSD stated an Advance Directive form was needed to make sure the resident's wishes were respected in case of an emergency. The SSD stated she did not document on informing the resident or responsible party of their rights to formulate an Advanced Directive.

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

F610 05/21/2019 §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 observation, interview and records review, the facility, failed to thoroughly FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 4 of 78 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 05/24/2019 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 investigate an injury of unknown origin in order to rule out possible abuse for one of 19 sampled residents (3), who had a right shoulder proximal (nearer to the center of the body or the point of attachment) humerus (the bone of the upper arm that connects the shoulder to the elbow) fracture (broken bone). This deficient practice of not thoroughly investigating Resident 3's of right shoulder proximal humerus fracture, potentially resulted in not taking appropriate actions to determine, and prevent alleged violation from reoccurring. Findings: On 5/20/2019 at 8:55 a.m., a Recertification survey, and a Facility Reported Incident investigation regarding Resident 3's injury of unknown origin was initiated. A review of Resident 3's Admission Record (Face Sheet) indicated the resident was admitted to the facility on 11/1/18, with diagnoses included high blood pressure, dementia (a decline in mental ability severe enough to interfere with daily life), hemiplegia (paralysis of one side of the body), and hemiparesis (a slight paralysis or weakness on one side of the body). A review of Resident 3's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated 8/17/18, indicated Resident 3 required physical assistance by two or more staff member for transfers, one-person physical assistance with dressing, eating, toilet use, and personal hygiene. The resident required a wheelchair and mechanical lift (device is most commonly used to move those who are unable to stand on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 5 of 78 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 05/24/2019 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 their own or whose weight makes it unsafe to move or lift them manually) as assistive devices for locomotion, and transfers. A review of Resident 3's history and physical dated 12/24/2017, indicated the resident had dementia. A review of the licensed nurse's progress notes dated 10/17/19 at 8:45 a.m., indicated Resident 3 was found with right upper arm swelling, along with skin discoloration when her gown was removed while lying in the shower chair. The same notes at 12:30 p.m., indicated attending physician was notified and ordered an x-ray (a photographic image of the internal composition of a part of the body) of the right arm to rule out fracture. A review of Resident 3's x-ray report on the same day of the skin discoloration and swelling to the right arm (10/17/18) indicated the resident had a fracture on the right shoulder involving the proximal humerus. On 5/20/2019 at 9 a.m to 4:15 p.m., Resident 3 was observed lying in bed. The resident was noted to have a splint worn on her right arm that was diagnosed with a fracture on 10/17/2018. A review of Resident 3's care plan, at risk for fracture related to osteoporosis had goal indicated, the resident will maintain acceptable level of function to prevent fracture with injury on a daily bases. The interventions includes, assist Resident 3 with activities of daily living to prevent from undue trauma, provide gentle care and use assisting device for transfer and ambulation for safety reasons. On 05/20/19 at 3:33 p.m., during an interview, MDS nurse stated, Resident 3 had a proximal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 6 of 78 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 05/24/2019 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 humerus fracture, skin dislocation with swelling on the right shoulder on 10/17/19. The MDS nurse stated, Certified Nursing Assistant (CNA 3) discovered discoloration and swelling of the right shoulder after Resident 3 was transferred from bed to shower chair manually, by herself, and the resident night gown was removed. On 05/21/19 at 11:59 a.m., During an interview, the director of nursing (DON) stated, facility concluded Resident 3's swelling on right upper arm, skin discoloration on right inner upper arm (right shoulder fracture) occurred as a result of aging processes related to osteoporosis (porous bone), which was unavoidable, and was not an abuse. DON further stated, Resident 3 had a physician order for Life Sustaining Treatment (POLST) which indicated, "do not transfer to the hospital," which was why the resident was not transferred to the hospital for further evaluation of the fracture. When asked to provide documented evidence to show how the facility thoroughly investigated Resident 3's fractured arm in order to determine the incident was ruled out as abuse, the DON stated she could not produce documented investigation that involved interviews, observation, and training once the investigation was done. On 05/21/19 at 12:59 p.m., during an interview, CNA 3 acknowledged Resident 3 had to be transferred using a mechanical lift with the assistant of another person. When asked how Resident 3 was transferred from bed to a shower chair, CNA 3 stated she was facing the resident, placed her arms underneath both of the resident's underarms, lifted the resident, pivoted, and then sat the resident on the shower chair. When asked, CNA 3 stated she always transferred the resident manually and by herself. CNA 3 acknowledged Resident 3 had a right side weakness and was contracted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 7 of 78 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 05/24/2019 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 the right arm. CNA 3 stated she could not remember if Resident 3's right shoulder dislocated "heard a sound" when she hooked the lift sling (a cloth that attaches to mechanical lift for patient to sit on), and when lifting up the resident. On 05/21/19 at 1:19 p.m., during an interview, director of staff development (DSD) stated, she was surprised when Resident 3 had discoloration and swelling on her right arm. DSD confirmed x- ray result indicated Resident 3 had a proximal humerus fracture on the right shoulder. DSD stated upon interviewing, CNA 3 stated Resident 3 had been transferred from bed to shower chair manually. DSD stated CNA 3 told her while in the shower room, Resident 3's night gown was removed. DSD stated that was when skin discolorations, and swelling on Resident 3's right shoulder, and on the inner upper arm was discovered by CNA 3. DSD stated CNA 3 stated she reported the problem to staff nurse immediately. On 05/21/19 at 4:27 p.m., during an interview, infection Control (ICN) nurse stated, back to work after two days off, saw Resident 3 with a broken hand. ICN stated, records review indicated, "like x- ray reported dated 10/17/2018 indicated Resident 3 sustained a proximal humerus fracture when transferred from bed to shower chair, because CNA 3 did not use a mechanical lift, and did not ask for an assistance of another staff member. On 05/23/19 at 10:48 a.m., during an interview with the Administrator stated an alleged abuse incident involving a resident had to be reported to the Department of Public Health (DPH). Administrator stated, during staff interviews, and witnesses involved with the alleged abuse, or incident, will be deemed suspected until the investigation was completed. Administrator FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 8 of 78 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 05/24/2019 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 witnesses found to be involved with the incident will be discharged / terminated from the facility. Administrator stated in-service training would be be provided to all staff regarding the alleged incident in question. During an interview with the Administrator on the same day at 5:15 p.m., stated he was newly hired, about two to three months ago, and was not aware of Resident 3's fracture incident. A review of letter dated 10/18/18 addressed to the DPH indicated on 10/17/18, CNA 3 reported to charge nurse, Resident 3 had swelling and skin discoloration to the right upper arm. The letter indicated x-ray reported dated 10/17/28 indicated Resident 3 had fracture of the proximal humerus. The letter indicated investigation will be followed within five (5) days. A review of an undated facility's policy and procedures titled "Patient Abuse and Prevention," indicated facility and staff shall uphold resident's right to be free from any form of verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The policy also indicated the facility shall establish system to prevent patient abuse including those practices such as facility staff, other residents, consultant, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals. The policy indicated the procedures that included: screening, training, prevention, identification, investigation, protection/ reporting/response which shall be integrated into facility's daily operational procedures.

F641 Accuracy of Assessments FORM CMS-2567(02-99) Previous Versions Obsolete

F641 Event ID: 7PBE11 05/21/2019 Facility ID: CA940000011 If continuation sheet 9 of 78 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 05/24/2019 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) SS=D CFR(s): 483.20(g) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on observation, interviews, and records review, the facility failed to accurately assess and triggered on the Minimum Data Set ([MDS] a standardized resident assessment and care screening tool), section O, for one of 19 sampled residents (37) who was placed on hospice care (a type of care that focuses on the palliation of a chronically ill, terminally ill or seriously ill patient's pain and symptoms, and attending to the emotional and spiritual needs) due to acute respiratory failure ([ARF] when fluid builds up in the air sacs in the lungs). This deficient practice had the potential for resulting in Resident 37 not receiving personalized care related to the focused respiratory failure, since MDS assessment drove the plan of care. Findings: A review of Resident 37's admission records (face sheet), indicated the resident was admitted to the facility on 12/14/11, and readmitted 8/29/2018 with diagnoses of ARF, diabetes mellitus (abnormal blood sugar levels). A review of Resident 37's MDS assessment, dated 3/19/2019, indicated cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 37 required staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 10 of 78 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 05/24/2019 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 assistant with activities of daily living. However, section O of the MDS assessment was not assessed and triggered for the focused care are of hospice care. A review of the physician order dated 5/1/2019 indicated Resident 37 was placed on hospice care on 9/23/2018 due to acute respiratory distress. On 5/ 20/19 at 2:37 p.m., during interview and record review in the presence of MDS nurse confirmed Resident 37's MDS section O did not triggered for respiratory failure which was the focused care area why the resident was placed on hospice care since 8/29/18. MDS nurse promised to modify the MDS assessment and resend it to the Center for Medicare & Medical Services (CMS) database immediately. MDS nurse stated not assessing and triggering MDS accurately had the potential for staff not to properly provide personalized care to Resident 37, since MDS drove the plan of care. A review of the facility's policy and procedures titled "Resident Assessment Instrument: Minimum Data Set and Care Plan," dated 1/2014, indicated, all care areas in the MDS had to be accurately assessed and triggered in the MDS and care plan by all staff who had the professional standard of coordinating resident's treatment plan.

F655 SS=D Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 05/21/2019 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 11 of 78 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 05/24/2019 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 that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to(A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan(i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 12 of 78 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 05/24/2019 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 ensure one of 19 sampled residents (3) baseline care plans were personalized, that reflected the resident's stated goals and objectives, and included interventions that addressed current diagnosis of dementia (loss of memory and other mental abilities severe enough to interfere with daily life). The deficient practice resulted in Resident 3's diagnosis of dementia not be care planned that would ensure proper care for the resident. Findings: A review of Resident 3's Admission Record (Face Sheet) indicated the resident was admitted to the facility on 11/1/18, with diagnoses including high blood pressure, dementia (a general term for a decline in mental ability severe enough to interfere with daily life), hemiplegia (paralysis of one side of the body), and hemiparesis (a slight paralysis or weakness on one side of the body). A review of Resident 3's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated 8/17/18, indicated the resident required physical assistance by two or more staff members for transfer and one-person physical assistance with dressing, eating, toilet use, and personal hygiene. A review of Resident 3's History and Physical (H&P) exam dated 12/24/17 indicated Resident 3 did not have the capacity to understand, and make decisions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 13 of 78 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 05/24/2019 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 05/22/19 at 12:08 p.m., during an interview with License Vocational Nurse/Treatment Nurse after reviewing the clinical records, acknowledged Resident 3 had no care plan to address the risk factors for being diagnosed with dementia. On 05/23/19 at 11:35 a.m., during an interview and record review in the presence of the registered nurse (RNS 1) and Medical Record personnel, stated a comprehensive baseline care plan that addressed dementia for Resident 3 was not developed. RNS 1 stated the facility had just started the implementation of the comprehensive care plans in January 2019 and promised to develop one. A review of the facility's policy and procedures titled "Care Plans - Baseline" indicate the following: 1. The Center must develop and implement a baseline person-centered care plan within 48 hours of admission. 2. To assure the resident's immediate care needs are met and maintained. 3. The resident and resident representative will be provided a summary of the baseline care plan that include initial goals of the resident, services and treatment to be administered by the facility that meet professional standards of quality care.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 05/21/2019 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 14 of 78 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 05/24/2019 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(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 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 interview and record review, the facility failed to create a care plan with objectives, and measurable goal related to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 15 of 78 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 05/24/2019 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 diagnosis of anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) for one of nine sampled residents (30). This deficient practice increased the risk for Resident 30's anxiety disorder would not be effectively treated with appropriate interventions, and could not assess the success of care planned interventions, potentially resulting in negative impact to the health and well-being of the resident. Findings: On 05/22/19 at 02:59 PM, during a record review, Resident 30's clinical record indicated originally admitted to the facility on 3/20/15 with diagnoses including, but not limited to: anxiety disorder, dementia (a group of thinking and social symptoms that interferes with daily functioning) and major depressive disorder ([MDD] a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 30's physician order dated 4/17/19 indicated prescribed lorazepam (a medication used to treat anxiety disorder) 0.5 milligram (mg) to be given every 12 hours as needed for anxiety manifested by "inability to relax." A review of Resident 30's anxiety care plan dated 3/13/18 did not specify an objective measurable goals for the reduction of behaviors related to anxiety disorder (e.g. resident will have no more than three episodes per week, etc.). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 16 of 78 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 05/24/2019 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 Interdisciplinary Team ([IDT] a group of individuals from different medical backgrounds tasked with creating and revising plans of care for the residents) notes indicated the IDT reviewed Resident 30's anxiety care plan in May 2018, August 2018, November 2018, and February 2019. However, none of the IDT team notes from those dates acknowledged the care plan did not contain an objective, and measurable goals that would reduce behaviors related to anxiety. Further review of the IDT notes, did not advise to add an objective, measurable goal to the anxiety care plan in order to assess the success of care planned interventions. On 05/22/19 at 04:05 PM, during an interview, the director of nursing (DON) stated that Resident 30's care plan for behaviors related to anxiety does not contain an objective, measurable goal and thus is not residentcentered. The DON stated that, as written, the care plan is inadequate to meet Resident 30's needs as there is no way to objectively assess whether the care planned interventions are successful or not. According to the facility's undated policy titled "Care Plans - Comprehensive" indicated that "Each resident's comprehensive care plan is designed to: Reflect treatment goals, timetables and objectives in measurable outcomes."

F657 SS=E Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 05/21/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 17 of 78 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 05/24/2019 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 be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to revise the behavioral care plan for two of nine sampled residents (7 and 26) when behavioral data indicated care plan interventions were not meeting the residents' goals for behavior reduction. This deficient practice caused Resident 7 and 26 to continue to receive care interventions that were not adequate to address behaviors related to their medical conditions increasing the risk of a negative impact to their health and well-being of the residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 18 of 78 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 05/24/2019 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. On 05/22/19 at 12:02 PM during a record review Resident 7's clinical record indicated originally admitted to the facility on 4/26/18 with diagnoses including, but not limited to: anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and major depressive disorder ([MDD] a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 7's physician order dated 12/21/18 indicated prescribed clonazepam (a medication used to treat mental illness) 0.5 milligram (mg) once daily for anxiety manifested by "inability to relax." A review of Resident 7's antianxiety care plan dated 12/21/18 indicated the resident's clinical goal for the use of clonazepam to treat anxiety was "behavior will decrease in occurrence every month for three months." The Resident 7's Psychotropic Summary Sheet indicated the facility staff observed a documented total number of episodes of "inability to relax" that equaled nine in December 2018, 47 in January 2019, 53 in February 2019, and 62 in March 2019. However, a review of Resident 7's Resident Care Conference Review dated 2/7/19 indicated the interdisciplinary team ([IDT] a group of individuals from different medical backgrounds tasked with creating and revising plans of care for residents living in skilled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 19 of 78 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 05/24/2019 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 nursing facilities) reviewed Resident 7's entire plan of care, but made no recommendations to revise the antianxiety care plan despite the fact the number of observed behaviors were increasing. On 05/22/19 at 12:46 PM, during an interview, the director of nursing (DON) confirmed IDT team had not revised Resident 7's antianxiety care plan despite an increase in the number of episodes of "inability to relax" that was observed and documented by facility staff. The DON stated clonazepam did not appear to be meeting the clinical goal outlined in Resident 7's antianxiety care plan. The DON stated did not personally participate in IDT meetings, but the behavioral data should be available to the IDT when they are reviewing the care plans. The DON stated they would have to retrain the facility staff who participate in IDT meetings to make sure they address any increase in behaviors when revising and reviewing the residents' care plans. b. On 05/22/19 at 11:15 AM, during a review of Resident 26's clinical record indicated originally admitted to the facility on 5/18/18 with diagnoses including, but not limited to: anxiety disorder and MDD. A review of Resident 26's physician order dated 12/2/18 indicated prescribed lorazepam (a medication used to treat mental illness) 0.5 mg every 12 hours for anxiety disorder manifested by "expressing nervousness." A review of Resident 26's antianxiety care plan dated 11/24/18 indicated the resident's clinical goal for the use of lorazepam was "behavior will decrease in occurrence every month for three months." The Resident 26's Psychotropic Summary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 20 of 78 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 05/24/2019 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 Sheet indicated the number of episodes of "expressing nervousness" that was observed, and documented by the facility staff was 20 in November 2018, 90 in December 2018, 48 in January 2019, 57 in February 2019, 41 in March 2019 and 67 in April 2019. A review of Resident 26's Resident Care Conference Review dated 2/21/19 indicated the IDT reviewed Resident 26's entire plan of care, but made no recommendations to revise the antianxiety care plan despite the fact the number of observed behaviors were exceeding the resident's clinical goal. On 05/22/19 at 12:27 PM, during an interview, the DON stated the number of episodes of "expressing nervousness" for Resident 26 were more than the care plan allowed and it did not meet the clinical goal of decreasing the behaviors every month over the next three months. The DON stated that IDT had not revised the antianxiety care plan despite the fact lorazepam did not seem to be effective at meeting Resident 26's clinical goal. According to the facility's undated policy titled "Care Plans - Comprehensive" indicated that "Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's conditions change." The policy further indicated "The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: when the desired outcome is not met." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 21 of 78 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 05/24/2019 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

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

F658 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/21/2019 §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: c. A review of Resident 75's face sheet (admission record), indicated the resident was admitted on 11/8/18 with diagnoses of encephalopathy (abnormal brain function or structure), muscle weakness and acute kidney failure (condition in which the kidneys suddenly can not filter waste from the blood). A review of Resident 75's "Physician Orders for Infusion Therapy" dated 5/20/19 indicated, Resident 75's physician ordered to insert IV catheter (line that can be used to administer IV fluids or other medication), to start half liter of IV hydration for three days. During an interview and observation on 5/21/19 at 8:42 a.m., Resident 75 was observed receiving IV hydration on her right arm. Registered Nurse (RN 2) stated, IV hydration was ordered 5/20/19 but resident refused, so it was started 5/21/19 at 7:00 a.m. However, a review of Resident 75's IV medication/flowsheet, showed here was no documentation when the IV catheter inserted and IV hydration started. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 22 of 78 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 05/24/2019 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 5/21/19 at 9:13 a.m., RN 2 acknowledged she failed to document both IV insertion and administrations. During an interview on 5/24/19 at 8:25 a.m., RN 1 stated, during IV administration, RNs would sign date, time and initial in the IV medication/flowsheet right after inserting IV line for hydration to the residents, sign again when the IV hydration or medication was finished and/or completed. Based on observation, interview, and record review, the facility failed to meet professional standards of care for three of 19 sampled residents (28, 3, 75) by: 1. Ensure Resident 28's gastronomy tube ([GT] a small surgical opening in the stomach used for feeding, medication and fluid) feeding (formula) was not infused at a higher rate other than the rate prescribed by the physician. 2. Ensure Resident 28's physician was notified regarding increased GT infusion rate from 55 milliliter (cc) to 60 cc per hour. 3. Ensure Resident 28's GT was flushed with water after it was disconnected to prevent clogging. 4. Ensure Resident 3's GT site was kept clean, and did not show signs, and symptoms of skin irritation. 3. Ensure For Resident 75, Intravenous ([IV] medication or hydration administered onto a vein) hydration was not documented in the IV medication/flow sheet. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 23 of 78 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 05/24/2019 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 These deficient practices had the potential of resulting to excessive feeding amount at a shorter time that could result in fluid overload, abdominal distention and vomiting for Resident 28; Resident 3 for having skin irritation and possible infection at the GT site, and Resident 75 for not knowing the total amount of IV fluids given to the resident and potential for dehydration. Findings: a. On 05/20/19, during the initial tour, and continued observations from 8:35 a.m., to 10:08 a.m., Resident 28 was lying in bed. Resident 28 GT feeding Jevity 1.5 calories infusing via pump with a set rate 60 cc per hour. However, the formula tube feeding bottle was hung with a set rate documented at 55 cc per hour. A review of Resident 28 Admission record (face sheet) indicated the resident was admitted to the facility on 8/16/2018, with diagnoses that included to GT, and dysphagia (inability to swallow any substance by mouth). A review of Resident 28's physician order dated 5/20/2019, and 9/19/2018, indicated GT with Jevity at 55 cc per hour for 20 hours per day to provide 1100 cc/1650 kilogram of calories (KCAL) via pump. The order indicated to flush GT with 250 cc of water every six hours. However, there was no documentation in Resident 28's clinical records to show the physician was consulted with, and ordered to increase the rate from 55 cc to 60 cc's per hour. A review of the Minimum Data Set (MDS), a standardized resident assessment and care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 24 of 78 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 05/24/2019 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 screening tool, dated 3/6/2019, indicated Resident 28 cognitive skills for daily decisionsmaking were moderately impaired. The MDS also indicated the resident required extensive to total care with activities of daily living ([ADLs] transfer, bathing, eating, dressing, and personal hygiene), section K of the MDS was coded, and triggered for GT placement. On 05/20/19 at 10:10 a.m., during an interview, registered nurse (RN 3) stated the night before the certified nursing assistant (CNA) turned off Resident 28's GT pump and forgot to turn it back on. RN 3 stated upon arriving in the morning Resident 28's GT feeding amount was lowered than expected. RN 3 stated the charge nurse who worked the night was asked why the GT feeding amount was lowered. RN 3 stated previous nurse said after the resident was repositioned, CNAs forgot to turn on the feeding. RN 3 confirmed at 7 a.m., GT feeding rate was increased from 55 cc to 60 cc per hour to meet the ordered amount which was 11000 cc. When asked if the physician was notified regarding the increased rate; RN 3 stated no. When questioned if GT feeding rate could be increased without the physician order, RN 3 stated no. RN 3 further stated increasing the rate from the normal rate could cause GI distention or vomiting due to excess amount of feeding infused at a shorter time. b. A review of Resident 3's Admission Record (Face Sheet) indicated the resident was admitted to the facility on 11/1/18, with diagnoses including high blood pressure, and gastronomy tube placement. A review of Resident 3's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated 8/17/18, indicated Resident 3 required physical assistance by two or more staff members for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 25 of 78 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 05/24/2019 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 transfer, and one-person physical assistance with dressing, eating, toilet use and personal hygiene. The resident required a wheelchair and a mechanical lift as assistive devices for locomotion and transfers. A review of Resident 3's History and Physical (H&P) exam dated 12/24/17 indicated the resident did not have the capacity to understand and make decisions. A review of the physician order dated 5/20/2019, and 2/22/2018, indicated Resident 3 had an order for Jevity 1.2 at 50 cc per hour for 20 hours per day to provide 1000 cc/1200 kilogram of calories (KCAL) per day via pump. The order indicated to flush GT with 250 cc of water every six hours. Keep abdominal binder for GT placement. On 5/20/2019 at 10:57 a.m., observed, in the present of the treatment nurse (TXN), Resident 3's GT tube was not dated. During a concurrent interview TXN stated GT tubes are supposed to be dated with the date, time and the staff's initial, to know who hung or changed the GT feeding bottle and its tubing. TXN stated if GT tubes are not dated it would be difficult to know when to replace them with a clean tubing. TXN further stated if tubing are not replaced with clean ones, germ had the tendency to grow in tubing casing infection to the resident. A review of the non-pressure skin condition form dated 2/20/2019 to 2/26/2019 indicated Resident 3 had developed redness and discharge at the GT site. The notes dated 3/6/2019 to 3/15/2019, indicated GT site and stoma was irritated and still had large amount of discharge coming out from the GT site. However, there was no documented evidence to show Resident 3's physician was notified. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 26 of 78 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 05/24/2019 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 change in condition (COC) form dated 5/21/2019 at 6 p.m., indicated Resident 3 had redness and irritation at the GT site. A review of the physician telephone order indicated an order for keflex (antibiotic) 500 milligram via GT twice a day for GT site irritation for seven days (7). On 05/22/19 at 12:08 p.m., during an interview, TXN stated physician assistant (PA) had been visiting Resident 3. TXN said PA visited Resident 3 on 5/22/2019 at 11 a.m.. However, the was no documentation in Resident 3's clinical records. TXN stated the PA will fax his notes later. TXN stated sending his notes by fax was the routine and was not sure when the notes would be received. On 05/22/19 at 12:31 p.m., during an interview, registered nurse supervisor (RNS 1) stated the PA will send his documentation for Resident 3 by fax. When asked why Resident 3's GT site was irritated, had discharge coming from the site, but was not being treated, RNS 1 stated Keflex 500 milligram was ordered on 5/21/2019. RNS 1 stated the resident had not been using abdominal binder lately. However,

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 05/21/2019 §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 interview and record review, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 27 of 78 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 05/24/2019 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 facility failed to ensure Certified Nursing Assistant 3 (CNA 3) transferred one of 3 sampled residents (3) from bed to a shower chair in accordance with the comprehensive assessment and plan of care to prevent injury. The facility failed to: 1. Ensure CNA 3 used a mechanical lift (an assistive device/machine used by a caregiver to facilitate safe patient transfers. They are often used to transfer individuals who are unable to stand or bear their full weight between a bed and a chair or other similar resting places. It involves a pad that connects to the lift frame and a hydraulic or electric pump used to lift, and transfer the resident between surfaces), and utilized the assistance of another staff when transferring Resident 3 from bed to a shower chair. 2. Implement Resident 3's plan of care for the risk for injury by not using a mechanical lift and another staff's assistance when transferring Resident 3. As a result, on 10/17/18 at 8:45 a.m., Resident 3, while transferred by CNA 3 from bed to a shower chair, sustained a right shoulder fracture (broken bone) of the proximal (nearer to the center of the body or the point of attachment) humerus (the long bone in the upper arm), with skin discoloration (changes), swelling, and pain to the right arm. Findings: A review of Resident 3's Admission Record (Face Sheet) indicated Resident 3 was admitted to the facility on 11/1/16, with diagnoses including high blood pressure, dementia (a general term for a decline in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 28 of 78 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 05/24/2019 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 mental ability severe enough to interfere with daily life), hemiplegia (paralysis of one side of the body) and hemiparesis (a slight paralysis or weakness on one side of the body). According to Resident 3's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated 8/17/18, Resident 3 required two or more persons' physical assistance for transfers and oneperson physical assistance with dressing, eating, toilet use and personal hygiene. The MDS assessment indicated the resident had an impairment upper extremity, including shoulder, elbow, wrist, and hand one one side of the body. The MDS assessment indicated there was functional limitations in range of motion (the full movement potential of a joint) on both lower extremities. The resident required a wheelchair and a mechanical lift as an assistive device for locomotion and transfers. A review of Resident 3's History and Physical exam, dated 12/24/17, indicated Resident 3 did not have the capacity to understand and make decisions. A review of Resident 3's Fall Risk Assessment form, dated 8/3/18, indicated Resident 3 had impaired gait (manner of walking) with the score of 14 or greater, representing a high risk for fall. A review of Resident 3's plan of care, developed on 11/2/16, for the Risk for Fall related to general weakness, poor safety awareness, unsteady gait, limited mobility, and impaired gait, indicated the goal was for Resident 3 to be free from falls or injury. The interventions included staff should provide visual check every two hours or as needed, educating staff of Resident 3's assistance with activities of daily living (ADLs), ensuring the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 29 of 78 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 05/24/2019 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 wheelchair was locked during transfers, and using a mechanical lift during Resident 3's transfer with another staff assistance. A review of Resident 3's care plan, developed on 11/2/16, for the Self-Deficit in Activity related to dementia and impaired cognition indicated the resident's transfer had to be provided with the use of assistive device. A review of the licensed nurse's progress notes, dated 10/17/18, timed at 8:45 a.m., indicated while in the shower room, when Resident 3's gown was removed, the right upper arm was noted with skin discoloration, and it was swollen. On the same day at 12:30 p.m., the licensed nurses notes indicated Resident 3's attending physician was notified, and ordered an x-ray (a photographic image of the internal composition of a part of the body) of the right arm to rule out fracture. A review of the facility's Investigative Report notes dated 10/19/18, indicated the facility did not address the proper methods of transferring Resident 3 from a bed to a shower chair, although CNA 3 was supposed to use the mechanical lift with the help of another staff, as indicated in Resident 3's comprehensive assessment. The primary physician was notified and a stat (immediately) x-ray was done, which revealed Resident 3 had a fracture. The notes indicated the primary physician ordered Resident 3's transfer to the hospital for an evaluation and treatment. The notes indicated Resident 3's representative refused a transfer to the hospital. In connection to this statement Resident 3's Physician Order for Life Sustaining Treatment (an approach to end-of-life planning based on conversations between patients, loved ones, and health care professionals), dated 11/2/16, indicated a 'do not transfer' to a hospital, and 'do not attempt' FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 30 of 78 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 05/24/2019 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 any resuscitation (the action or process of reviving someone from unconsciousness or apparent death). A review of CNA 3's written statement, dated 10/17/19 at 1 p.m., indicated on 10/17/18 at 8:30 a.m., CNA 3 transferred Resident 3 from a bed to a shower chair by herself. While in the shower room, CNA 3 removed Resident 3's night gown and noticed Resident 3 had skin discoloration and swelling on her right arm. CNA 3 instructed CNA 7 to watch Resident 3, and left the shower room to notify the infection control nurse (INC), who came immediately. However, the written statement did not indicate the method and/or device Resident 3 was transferred with and what happened in the shower room. On 5/23/19 at 2:25 p.m., during a phone interview, CNA 3 stated she transferred Resident 3 by placing both of her arms under the resident's armpits, she then manually lifted, then pivoted, before placing the resident on the shower chair. A review of Resident 3's x-ray report dated 10/17/18, ordered due to skin discoloration and swelling of the right arm (10/17/18) revealed Resident 3 had a fracture of the right shoulder involving the proximal humerus. A review of the nursing notes and physician order, dated 10/17/18 timed at 12:45 p.m., indicated the attending physician ordered to transfer Resident 3 to a General Acute Care Hospital (GACH 1). According to the licensed nurses notes, dated 10/17/18, timed at 12:45 p.m., Resident 3's representative (RR) was informed of the physician order for Resident 3 to be transferred to GACH 1, however RR refused. RR recommended only comfort measures and pain management. According to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 31 of 78 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 05/24/2019 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 these licensed nurses notes the attending physician was notified immediately regarding the RR request. A review of licensed nurses notes, dated 10/18/18 timed at 10 p.m., indicated Resident 3's fractured right shoulder was immobilized (device that keeps arm and shoulder in a fixed position). A review of Resident 3's Joint Mobility Assessment diagram, dated 2/2/18, indicated Resident 3 had right arm range of motion, including shoulder, elbow, wrist and hand, within functional limits. A review of Resident 3's Joint Mobility Assessment diagram, dated 2/1/19, indicated Resident 3 had severe functional limitation in the right arm including shoulder, elbow, wrist and hand, due to the right shoulder fracture. A review of the Physical Therapy (PT) notes, dated 10/19/18, indicated Resident 3 was evaluated due to the right shoulder discoloration and swelling. According to PT's notes Resident 3 had right shoulder pain level of eight out of ten (on a pain rating scale from zero to ten, zero meant no pain and ten was the worse pain possible). According to PT's notes, dated 11/09/18, Resident 3 had right shoulder pain of seven out of ten on a pain rating scale. On 05/23/19 at 1:53 p.m., during an interview, PT stated Resident 3 was evaluated on 10/17/18, because of skin discoloration and swelling of the right upper arm. PT stated, Resident 3 had a proximal fracture of the right shoulder due to improper transferred from a bed to a shower chair by CNA 3. A review of the physician's order dated 10/19/18, timed at 9 a.m., indicated an order to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 32 of 78 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 05/24/2019 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 apply right shoulder immobilizer. A review of a letter, dated 10/18/18, addressed to the Department of Public Health, indicated on 10/17/18, CNA 3 reported to the licensed nurse in charge that Resident 3 had right upper arm discoloration, and swelling. On 5/10/19 at 9:46 a.m., Resident 3 was observed in bed with the immobilizer on her right upper arm. Concurrently, during an interview, Resident 3 was not able to be interviewed, and was nonverbal (unable to express self). On 5/20/19, at 3:33 p.m., during an interview, MDS nurse confirmed Resident 3 had skin discoloration and swelling on her right shoulder, when observed in the shower room. MDS nurse stated CNA 3, manually transferred the resident from a bed to a shower chair instead of using a mechanical lift, and another CNA for physical assistance. MDS nurse stated the proximal humerus fracture (right shoulder) could have happened, while CNA 3 manually transferred Resident 3 to the shower chair. On 5/21/19, at 11:59 a.m., during an interview, the director of nursing (DON), confirmed CNA 3 manually transferred Resident 3 from a bed a shower chair on 10/17/18. DON acknowledged Resident 3 had to be transferred with a mechanical lift (assistive device) and two persons (CNAs) physical assistance, as coded in Resident 3's comprehensive assessment to prevent fall and injury. DON confirmed Resident 3 had a right shoulder fracture on 10/17/18. On 5/21/19, at 12:59 p.m., during an interview, CNA 3 stated Resident 3 had to be transferred using mechanical lift with the physical assistance of another CNA. When asked how FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 33 of 78 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 05/24/2019 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 transferred Resident 3 from a bed to a shower chair, CNA 3 stated she was facing the resident, while placing her arms underneath Resident 3's armpits, lifted, and pivoted the resident, before sitting her on a shower chair. During an interview, CNA 3 stated she always transferred Resident 3 manually by herself. CNA 3 acknowledged Resident 3 had functional limitations in her upper and lower extremities. On 5/21/19 at 01:19 p.m., during an interview, Director of Staff Development (DSD), stated CNA 3 was supposed to use a mechanical lift with the physical help of another CNA. DSD stated CNA 3 had been educated on methods of transferring Resident 3 using a mechanical lift machine. DSD acknowledged CNA 3 received in-services training on the use of mechanical lift for a residents transfer, however, CNA 3 choose not to use mechanical lift with Resident 3's transfer. DSD stated CNA 3 was not supposed to manually transfer Resident 3 from a bed to a shower chair for safety reasons, and to prevent fall and injury. On 5/21/19, at 01:38 p.m., during an interview, the registered nurse (RN 2) confirmed CNA 3 did not use the mechanical lift on 10/17/18, and Resident 3 sustained the right shoulder fracture. RN 2 stated, Resident 3 was nonverbal, bed ridden, was out of bed sometimes with physical assistance of two CNAs, and the use of mechanical lift. On 05/21/19 at 04:27 p.m., during an interview, the infection control nurse stated during a stand up meeting on 10/18/18, it was reported Resident 3 could not move her right shoulder an x-ray report, dated 10/17/18, indicated Resident 3 had right shoulder fracture due to improper transfer method by CNA 3. The infection control nurse stated Resident 3 had to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 34 of 78 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 05/24/2019 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 be transferred from bed to a shower or a wheel chair with the use of mechanical lift, and the assistance of two CNAs to prevent fall and injury. On 05/21/19 at 04:37 p.m., during an interview, CNA 4 stated Resident 3 had to be transferred with the use of mechanical lift and two CNAs. On 05/23/19 at 11:06 a.m., during a telephone interview, RR confirmed the facility contacted her and informed regarding Resident 3's right shoulder fracture on 10/17/18. RR confirmed she refused Resident 3's transfer to the GACH 1.

F732 SS=D Posted Nurse Staffing Information CFR(s): 483.35(g)(1)-(4)

F732 05/21/2019 §483.35(g) Nurse Staffing Information. §483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. §483.35(g)(2) Posting requirements. (i) The facility must post the nurse staffing data FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 35 of 78 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 05/24/2019 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 specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. §483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. §483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to post the daily nursing staffing hours, that was accurate, computed, and posted to reflect the total number of staff scheduled to work to meet the care, and services for the resident population, that was available to the residents, and visitors for review. This deficient practice had the potential of denying the residents, and visitors access to nursing staffing information, which may not show enough staff was provided on a daily basis to care, and to meet their needs. Findings: On 05/20/19 at 9:37 a.m., to 5 p.m., until 05/23/19 at 10:37 a.m., to 5 p.m., respectively the facility failed to post the daily staffing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 36 of 78 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 05/24/2019 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 information that was accessible, and was readily available for the resident, visitors, and the public. A review of the daily staffing schedule binder in the present of director of staff development, 3 papers titled "Census and Nursing Hours per Patient day (NHPPD) dated 5/20/2019, 5/21/2019, and 5/22/2019 at 6 a.m., indicated the beginning patient census was 94; scheduled total nursing hours equaled to 360, and scheduled NHPPD was 3.82. However, the schedule did not indicate a breakdown of registered nurses, licensed vocational nurses, certified nurses aids, and the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. On 05/23/19 at 10:32 a.m., during an interview, director of staff development (DSD) confirmed daily staffing hours were not computed accurately and were not posted daily. DSD stated the facility had just started the daily staffing hours computation 3 days ago. On 05/23/19 at 10:35 a.m., an interview the director of nursing (DON) acknowledged and stated the facility was not computing nursing staffing information, that included daily staffing hours for the licensed and unlicensed staff. DON stated the facility will start today moving forward. A review of an undated facility's policy and procedures indicated, the facility shall maintains adequate staffing on each shift to ensure that resident's needs and services are met. The policy indicated the facility's payroll records setting forth the average number and type of personnel on each shift during at least one week. NHPPD shall be documented daily FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 37 of 78 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 05/24/2019 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 posted in an accessible and readily available to staff resident and visitors daily.

F755 SS=E Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 05/21/2019 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 38 of 78 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 05/24/2019 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 observation, interview, and record review, the facility failed to accurately account for the use of controlled substances (medications with a high potential for abuse) in one of two inspected medication carts and for one of two sampled residents (61). The deficient practice of failing to accurately account for the use of controlled substances increases the risk of availability of medications for the facility's residents when needed and also put the facility at increased risk for the potential loss, diversion (transfer of a medication from a legal to an illegal use), or accidental exposure to controlled substances. Findings: a. On 5/22/19 at 2:51 p.m., Resident 61 was observed in the toilet with Restorative Nurse Assistant (RNA 2). RNA 2 stated the resident was unable to transfer from her wheelchair to the toilet without assistance. On 5/22/19 at 4:16 p.m., during an interview with Licensed Vocational Nurse (LVN 3), stated she was coming into the beginning of her shift on 1/11/19 when Certified Nurse Assistant (CNA 9) reported she found Resident 61 on the floor beside her bed. LVN 3 stated when she entered the resident's room, she found the resident sitting on the floor mat, on the floor beside her bed. LVN 3 stated the resident was assessed and no injuries were found. LVN 3 stated Resident 61 did not complain of pain. A review of the nursing Progress Notes dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 39 of 78 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 05/24/2019 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 1/15/19 at 7:30 a.m. indicated Resident 61 complained of pain 8 out of 10 (using the numeric pain scale, 0 being no pain and 10 being the worst pain experienced) on the right side of her hip, right wrist, and was given Tylenol 325 milligrams (mg) two tablets by mouth. The resident's physician (MD 2) was contacted and x-rays were ordered. A review of MD 2's order for Resident 61 dated 1/15/19 indicated an order for right wrist, bilateral (both) hip and lumbosacral x-rays. A review of Resident 61's physician order dated 1/15/19 indicated an order for Tylenol #3 [acetaminophen 300 milligrams (mg) with 30 mg of codeine] one tablet every 12 hours as needed for moderate pain. A review of Resident 61's Controlled Drug Record for Tylenol #3, indicated the medication was given to the resident on the following days: 1/16/19 at 12 p.m. 1/20/19 at 8:30 p.m. 1/21/19 at 12 p.m. 1/22//19 at 2 p.m. 1/25/19 at 11:30 p.m. 1/30/19 at 12 a.m. However, a review of Resident 61's Medication Administration record (MAR) for the month of January 2019 with Medical Records Coordinator (MR) on 5/23/19 at 9:58 a.m., indicated there was no signatures confirming Tylenol #3 was administered to the resident. A review of the back side of form indicated the nurse's notes was also blank. During an interview with the Director of Nursing (DON) on 5/24/19 at 3:00 p.m., stated the MAR was a record of the medications administered to the resident. The DON stated if the MAR was not signed, in nursing practice, it was not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 40 of 78 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 05/24/2019 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 given. A review of the facility's undated policy titled "Narcotic Count Sheet" indicated the policy was to ensure that controlled drugs are accounted to maintain an accurate accountability of medication. The licensed nurse will document the controlled medication given to the MAR (back part). A review of the facility's undated policy titled " Medication and Treatment Administration", indicated the licensed nurse administering the medication shall record the date, time, dose of drug administered to the resident in the clinical record (e.g. MAR, Treatment Record). After documentation, licensed nurse shall sign entry. If the signature is already recorded in the resident's clinical record, initials may be used. b. On 05/21/19 at 10:38 AM during an observation of the medication cart #1, a discrepancy was found between the Controlled Drug Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication) for Resident 22's prescription for hydrocodone/acetaminophen (a medication used to treat moderate pain) 5/325 milligram (mg). A review of Resident 22's Controlled Drug Record for hydrocodone/acetaminophen indicated there should had been nine doses of medication left, however, the medication card contained only eight doses. During a concurrent interview, the licensed vocational nurse (LVN 1) stated she had given FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 41 of 78 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 05/24/2019 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 22 the missing dose of hydrocodone/acetaminophen that morning, but had forgotten to sign the Controlled Drug Record after the dose was given. LVN 1 stated the facility's policy was to sign the Controlled Drug Record right away when the medication was given to the resident.

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

F756 05/21/2019 §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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 42 of 78 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 05/24/2019 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 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 interview and record review, the facility failed to ensure the physician responded to recommendations from the consultant pharmacist either to agree and take action or to disagree and provide clinical rationale for one of 10 sampled residents (30). The deficient practice of failing to ensure the attending physician responded to recommendations from the consultant pharmacist increased the risk that Residents 30 and 101 could receive medication therapy that was not optimal to treat their medical conditions or that did not meet the standard of care resulting in a potential negative impact to their health and well-being. Findings: On 05/22/19 at 02:59 PM, during a record review, Resident 30's clinical record indicated that she was originally admitted to the facility on 3/20/15 with diagnoses including, but not limited to: anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), dementia (a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 43 of 78 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 05/24/2019 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 group of thinking and social symptoms that interferes with daily functioning) and major depressive disorder ([MDD] a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 30's physician order dated 4/17/19 indicated that she was prescribed lorazepam (a medication used to treat anxiety disorder) 0.5 milligram (mg) to be given every 12 hours as needed for anxiety manifested by "inability to relax." The order did not specify a duration of therapy or a stop date. A review of the consultant pharmacist's recommendation to the prescribing physician dated 4/29/19 indicated that because the order for lorazepam was to be given as needed (PRN or not taken on a regularly scheduled basis) and because lorazepam was considered a psychotropic medication (any medication that affects brain activities associated with mental processes and behaviors), the order should be limited to 14 days or if needed for longer, the order should specify the total duration of therapy with appropriate clinical rationale provided. A review of Resident 30's clinical record indicated that the physician had not responded to the consultant pharmacist's recommendation either to agree or disagree. On 05/22/19 at 04:05 PM, during an interview, the director of nursing (DON) stated a PRN order for lorazepam should be limited to 14 days only. The DON stated since Resident 30's lorazepam was started on 4/17/19 with no stop date, it had been in effect longer than 14 days. The DON acknowledged the consultant pharmacist made a recommendation on 4/29/19 to limit Resident 30's lorazepam to 14 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 44 of 78 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 05/24/2019 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 days. The DON stated that apparently the physician has not responded to this recommendation. A review of the facility's undated policy titled "Pharmacist Medication Regimen Review" indicated "The consultant pharmacist medication regimen review and nursing medication documentation review reports are processed as follows: The consultant pharmacist or facility provides the report to the responsible physician and the director of nursing within seven working days of review and the physician provides a written response to the report to the facility within two weeks after the report is sent."

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 08/20/2019 §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--§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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 45 of 78 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 05/24/2019 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 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 interview and record review, the facility failed to ensure as needed or not taken on a regularly scheduled basis (PRN) orders for psychotropic medications (any medication that affects brain activities associated with mental processes and behaviors) were limited to 14 days only for one of nine sampled residents (30). The deficient practice of failing to ensure Residents 30's PRN order for a psychotropic medication was not limited to 14 days had the potential to negatively impact her health and well-being by causing preventable medicationrelated adverse effects (unwanted, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 46 of 78 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 05/24/2019 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 uncomfortable, or dangerous effects that a medication may have) including, but not limited to: drowsiness, dizziness, and increased risk of fall. Findings: On 05/22/19 at 02:59 PM, during a record review, Resident 30's clinical records indicated originally admitted to the facility on 3/20/15 with diagnoses including, but not limited to: anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), dementia (a group of thinking and social symptoms that interferes with daily functioning) and major depressive disorder ([MDD] a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 30's physician order dated 4/17/19 indicated prescribed lorazepam (a medication used to treat anxiety disorder) 0.5 milligram (mg) to be given every 12 hours as needed for anxiety manifested by "inability to relax." However, the order did not specify a duration of therapy or a stop date. A review of the consultant pharmacist's recommendation dated 4/29/19 indicated to the prescribing physician that because the order for lorazepam was to be given PRN and because lorazepam was considered a psychotropic medication, Resident 30's order should be limited to 14 days or if needed for longer, the order should specify the total duration of therapy with appropriate clinical rationale provided. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 47 of 78 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 05/24/2019 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 05/22/19 at 04:05 PM, during an interview, the director of nursing (DON) stated a PRN order for lorazepam should be limited to 14 days only. The DON stated since Resident 30's lorazepam was started on 4/17/19 with no stop date, it had been in effect longer than 14 days. The DON acknowledged the consultant pharmacist made a recommendation on 4/29/19 to limit Resident 30's lorazepam to 14 days. The DON stated apparently the physician had not responded to the recommendations.

F760 SS=E Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 05/21/2019 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure two of nine (14, 25) sampled residents medication regimens were free from significant medication errors by failing to check the expiration date of an insulin (a medication used to control high blood sugar) vial before it was injected. This deficient practice resulted in Residents 14 and 25 each receiving two doses of expired insulin by increasing their risk of developing an infection or poor control of blood sugar, causing confusion, falls, coma, potentially due to the medication becoming ineffective. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 48 of 78 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 05/24/2019 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 05/20/19 at 11:00 AM, during an observation of the medication refrigerator in medication room 2, among other medications found to be stored were the following: 1. A vial of Novolin R (a brand of regular insulin) for Resident 14 labeled with an expiration date of 5/17/2019. 2. A vial of Humulin R (a brand of regular insulin) for Resident 25 labeled with an expiration date of 5/17/2019. On 05/20/19 at 11:17 AM, during an interview, the registered nurse (RN 2) stated the vials of insulin for Resident 14 and 25 were expired and should have been discarded. RN 2 stated the nurse who worked the overnight shift was responsible for ensuring the medication storage areas, including the refrigerator, did not contain expired medications. RN 2 stated she did not know why the nurse responsible for removing expired medication from the refrigerator had not removed Resident 14 and 25's expired insulin. a. During a concurrent record review, Resident 14's clinical records indicated that she was admitted to the facility on 6/22/17 with diagnoses including, but not limited to: type 2 diabetes mellitus (T2DM - a medical condition caused by too much sugar in the blood). A review of Resident 14's physician order dated 9/2/17 indicated that she was to receive Novolin R by injection twice daily according to a sliding scale (a dosing scale in which the dose of insulin is dependent on a blood sugar reading) in order to treat T2DM. A review of Resident 14's medication administration record (MAR - a record of when FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 49 of 78 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 05/24/2019 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 what medications are given to a resident) for May 2019 indicated that she had received six units of Novolin R by subcutaneous (under the skin) injection at 4:30 PM on 5/18/19 and three units at 4:30 PM on 5/19/19. b. During a concurrent record review, Resident 25's clinical record indicated that she was admitted to the facility on 2/1/18 with diagnoses including, but not limited to: T2DM. A review of Resident 25's physician order dated 8/14/18 indicated that she was to receive Humulin R by injection twice daily according to a sliding scale in order to treat T2DM. A review of Resident 25's MAR for May 2019 indicated she had received three units of Humulin R by subcutaneous injection at 12:00 AM on 5/17/19 and three units at 12:00 PM on 5/17/19. On 05/20/19 at 11:53 PM, during an interview, the registered nurse supervisor (RN 1) stated expired vials found in the refrigerator were the only vials of insulin available for Resident 14 and 25. RN 1 stated from May 17 to May 19, 2019 the insulin Residents 14 and 25 received, was expired. RN 1 stated she intended to have the pharmacy replace the expired vials of insulin right away because giving expired insulin could "harm the residents." RN 1 stated the facility's policy was to check the expiration dates on medications prior to administering them to the residents and she intended to speak with the nurses responsible for administering the expired insulin to find out why they had not done so in these cases. According to the facility's undated policy titled "Policy and Procedure on Medication and Treatment Administration" indicated that "It is the policy of this facility to administer FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 50 of 78 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 05/24/2019 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 medication or treatment ... within the scope of professional standards of practice." A review of the facility's undated policy titled "Policy and Procedures on Expiration of Drugs" indicated that "It is the policy of this facility, in keeping with good pharmaceutical practice, to monitor expiration of drugs and administer only those drugs that have not expired."

F761 SS=F Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 05/21/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 51 of 78 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 05/24/2019 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 observation, interview, and record review, the facility failed to: a. Properly monitor the storage conditions of medications and vaccines (biological preparations that provide active acquired immunity to a particular disease.) b. Remove and dispose of medications that are expired or are no longer usable from the general medication storage areas. c. Store medications according to the manufacturer's storage requirements. d. Label medications with an "open date" when required to ensure that they are discarded in accordance with the timeline specified by the manufacturer. The deficient practices of failing to monitor medication storage conditions properly, or discard medications which are expired, store medications appropriately according to the manufacturer's requirements, and label medications with an "open date" when required increased the risk of the facility's residents receiving medications which may have become ineffective or toxic resulting in a negative impact on their health and well-being. Findings: a. On 05/20/19 at 11:00 AM during an observation of medication room 2, the refrigerator and room temperature logs were found to have several dates on which the temperatures for the medication refrigerator and storage room were not documented. A review of the May 2019 refrigerator log FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 52 of 78 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 05/24/2019 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 indicated the temperature was required to be documented twice daily (AM and PM) and was found to be missing the following dates: 5/1/19 (AM), 5/3/19 (PM), 5/8/19 (AM), 5/13/19 (AM), 5/13/19 (PM), 5/18/19 (AM), 5/18/19 (PM), 5/19/19 (AM) and 5/19/19 (PM). A review of the May 2019 medication room temperature log indicated the temperature was to be logged once daily and was found to be missing the following dates: 5/1/19, 5/4/19, 5/5/19, 5/8/19, 5/11/19, 5/12/19, 5/13/19, 5/15/19, 5/18/19 and 5/19/19. During a concurrent interview, the registered nurse (RN 2) acknowledged that both the refrigerator and medication room temperature logs were missing several dates and stated the nurses responsible for documenting the temperatures on those dates most likely forgot to perform their duty. RN 2 stated the policy was to monitor and document the temperature for the medication refrigerator twice daily and the storage room once daily. b. On 05/20/19 at 11:00 AM, during an observation of the medication refrigerator in medication room 2, the following medications were found to be stored beyond their expiration date: 1. Two vials of Novolin R (a type of insulin used to treat high blood sugar) labeled with an expiration date of 5/17/2019. 2. One vial of Humulin R (a type of insulin used to treat high blood sugar) labeled with an expiration date of 5/17/2019. 3. One vial of Humulin R labeled with an expiration date of 5/20/19. 4. One used vial of Procrit (a medication used to increase red blood cells) marked "single use only." 5. One open foil packet of ipratropium/albuterol nebulizer solution (a medication used to treat FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 53 of 78 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 05/24/2019 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 breathing problems) vials labeled with an open date of 11/20/18. Review of the manufacturer's instructions printed on the foil packet indicated that once the foil pack was opened, the vials were to be used within one week. On 05/20/19 at 11:17 AM, during an interview, RN 2 stated the vials of insulin and Procrit were expired and should had been discarded. RN 2 stated the nurse who worked overnight shift was responsible for ensuring the medication storage areas, including the refrigerator, did not contain expired medications. RN 2 stated she did not know why the nurse responsible for removing expired medication removed them. On 05/20/19 at 03:16 PM, during an inspection of medication cart #3, the following medications were found to be expired: A. One Combivent Respimat inhaler (a medication used to treat breathing problems) was found labeled with an open date of 1/1/19. Review of the manufacturer's product labeling indicated that the inhaler is to be discarded three months after opening. B. One open foil packet of ipratropium/albuterol nebulizer solution vials labeled with an open date of 5/2/19. During a concurrent interview, RN 2 stated that the Combivent Respimat was expired and should have been discarded. c. On 05/20/19 at 11:00 AM, during an observation of the medication refrigerator in medication room 2, the following medications were found to be stored in a manner contrary to the manufacturer's requirements: A. Three Basaglar pens (an auto-injection device containing insulin used to treat high blood sugar) labeled with open dates and stored in the refrigerator. Review of the manufacturer's storage requirements indicated that once opened or first used, the pens should FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 54 of 78 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 05/24/2019 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 not be refrigerated. B. Two unopened vials of Novolin R and one vial of Humulin R were found in baskets labeled "med cart 2" and "med cart 3." Review of the manufacturer's storage requirements indicated that unopened vials of Novolin R and Humulin R should be kept in the refrigerator. On 05/20/19 at 11:17 AM, during an interview, RN 2 stated that Basaglar has been stored incorrectly and that the unopened insulins kept in the baskets labeled "med cart 2" and "med cart 3" are stored at room temperature for approximately one to two hours each day when the baskets are brought to the medication carts. RN 2 stated that unopened vials of insulin, including Novolin R and Humulin R, should be continuously refrigerated until opened per the manufacturer's instructions. d. On 05/20/19 at 11:00 AM, during an observation of medication room 2, one foil packet of ipratropium/albuterol nebulizer solution was found to be opened but not labeled with an open date. A review of the manufacturer's product labeling indicated that once the foil pack was opened, the vials were to be used within one week. On 05/20/19 at 11:53 AM, during an interview. The registered nurse supervisor (RN 1) stated that all medications are good for 28 days once opened. When shown the product labeling for ipratropium/albuterol nebulizer solution RN 1 stated she was unaware of the manufacturer's requirements regarding the timeline for the use of that product. RN 1 stated she intends to discard all of the medication found stored incorrectly and replace the orders through the pharmacy. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 55 of 78 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 05/24/2019 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 05/20/19 at 03:16 PM, during an inspection of medication cart #3, the following medications were found opened without a label indicating the "open date" as required by the manufacturer's specifications: A. One Ventolin HFA inhaler (a medication used to treat breathing problems). Review of the manufacturer's specifications indicated that once removed from its protective foil pouch, the inhaler should be replaced after 12 months. B. One opened foil packet of ipratropium/albuterol nebulizer solution. During a concurrent interview, RN 2 acknowledged that the products had not been labeled with an open date and indicated that she intended to have the pharmacy replace them as she could not be sure how long they had been opened. On 05/21/19 at 10:38 AM, during an observation of medication cart #1, the following medications were found opened without a label indicating the "open date" as required by the manufacturer's specifications: A. One Ventolin HFA inhaler B. One opened foil packet of ipratropium/albuterol nebulizer solution. During a concurrent interview, the licensed vocational nurse (LVN 1) acknowledged that the products had not been labeled with an open date and indicated that she intended to have the pharmacy replace them as she could not be sure how long they had been opened. A review of the facility's undated policy titled "Policy and Procedures on Expiration of Drugs" indicated that "It is the policy of this facility, in keeping with good pharmaceutical practice, to monitor expiration of drugs and administer only those drugs that have not expired" and "No drugs shall be kept after expiration dates on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 56 of 78 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 05/24/2019 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 labels." A review of the facility's undated policy titled "Storage of Medication" indicated that "Medications and biologicals are stored properly, following manufacturer's recommendations or those of the supplier to maintain their integrity and to support safe administration."

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

F812 05/21/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 57 of 78 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 05/24/2019 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 following: Label and date refrigerated and dry food items. Use hairnet and beard net/guard while in the food preparation area. Cold foods were held at 41 degrees Fahrenheit (F) or lower. Kitchen equipment was cleaned and sanitized ( cleaning something to make it free of bacteria or disease causing elements). Nourishments were stored at a proper temperature. These deficient practices had the potential to cause foodborne illness (an infection or irritation of the gastrointestinal tract caused by food or beverages that contain harmful bacteria, parasites, viruses, or chemicals) due to unsafe food handling practices causing vomiting, diarrhea, abdominal pain, fever, and chills. Findings: a. During an initial kitchen tour on 5/20/19 at 7:45 a.m., Kitchen staff/Cook (Cook 3) was observed walking from a walk-in-freezer towards the kitchen's entrance. However, Cook 3 was not wearing a hairnet, but applied a hairnet immediately when she reached the hairnet storage, beside the entrance door. b. During a concurrent observation of facility's kitchen and an interview with Cook 1 on 5/20/19, the reach in refrigerator had the following food items that were opened. However, the items were either left in the reach in refrigerator after "use by" date, or did not have a "use by" date: 1. The mayonnaise had an open date of 4/30/19, but did not have a "use by" date, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 58 of 78 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 05/24/2019 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 2. The apple sauce with "use by" date of 5/18/19, 3. The container of fruit cocktail with a "use by" date of 5/18/19. During an interview Cook 1 stated, she was not sure how long the items should be kept in the refrigerator. c. During a concurrent interview and observation of the kitchen on 5/20/19 at 7:55 a.m., the following was observed: 1. The container of cornflakes was not labeled when it was opened, and had a "use by' date, 2. The breadsticks with opened date of 8/10/18, 3. There was one container of Kimchi (one-third full), without a date to show when it was opened, and to indicate a 'use by' date. During an interview on 5/20/19 at 7:55 a.m., Cook 1 stated, a Korean kitchen staff would smell the Kimchi to check if it was still good. d. During an interview and observation on 5/20/19 at 8:30 a.m., one fixed can opener was observed with black particles after wiping it with a tissue paper. Cook 1 stated, kitchen equipment was to be cleaned, and sanitized after each use. e. During a follow up kitchen tour on 5/21/19 at 11:23 a.m., a male kitchen staff (MKS), who had a visible beard, was not wearing a beard net or beard guard to protect the foods. Dietary Supervisor (DS) stated, no beard net/guard was available in the facility and was not aware male staff had to wear one. f. During an interview and observation on 5/21/19 at 11:55 a.m., one deep stainless bowl containing prepared and ready to be served cucumber salad was observed with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 59 of 78 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 05/24/2019 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 temperatures of 55-60 degrees Fahrenheit (F), which was checked twice, and verified by using surveyor's thermometer. DS stated the temperature of the cucumber salad should be held at 41 degrees F or lower. DS further stated that they will not serve the cucumber salad anymore, but instead the facility will serve a food substitute. g. During observation, and interview on 5/21/19 at 2:44 p.m., a refrigerator inside the employee's lounge with a sign indicating "For employees only," was checked with certified nursing assistant (CNA 8). The following food items were kept in the refrigerator: 1. Two, 3 gallons of milk, one dated 5/13/19, and and another dated 5/20/19, 2. One yogurt dated 12/17, and 3. One mighty shakes carton dated 5/16/19. During an interview on 5/21/19 at 2:44 p.m., CNA 8 stated that those food items are nourishment for residents. During an interview on 5/24/19 at 8:48 a.m., Maintenance and Laundry supervisor (MS) stated, he never performed temperature checks on the employee's refrigerator, thus there was no temperature log available. h. During an observation on 5/23/19 at 3:03 p.m., Cook 2 entered the kitchen entrance door, and was observed, instead of wearing, was holding a hairnet in her shirt pocket. A review of an undated facility's policy and procedure titled "Dietary Department" indicated: 1. The following are requirements for dietary employees: 1. Personnel requirements a. Wear a hair covering FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 60 of 78 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 05/24/2019 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 b. Keep mustaches and sideburns neatly trimmed. 2. The following are guidelines for food preparation and serving: a. All equipment must be cleaned and sanitized before use. b. Cold foods must be kept at 45 degrees Fahrenheit or below c. Keep refrigerator foods in shallow pans in order to expedite cooling. 3. The following are guidelines for storage of food: a. Properly label all non-food items and food items. 4. Guidelines for Equipment Care a. Clean and sanitize... and equipment after each use. A review of facility's policy and procedures titled "Food Storage" updated 11/09, indicated: a. Fresh milk... It should be stored and carefully rotated in refrigeration at 41 degrees Fahrenheit or less. b. Label and date all storage containers or bins.

F813 SS=E Personal Food Policy CFR(s): 483.60(i)(3)

F813 05/21/2019 §483.60(i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 61 of 78 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 05/24/2019 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 observation, interview and record review, facility failed to ensure proper storage, handling, and reheating, residents foods brought in from outside sources. The following were not followed and or provided: a. Safe and sanitary resident's food storage and reheating appliance. b. Resident's food that were easily distinguishable from facility and/or employee's food. c. Properly labeled and dated food items. d. Family and staff education regarding food storage and reheating process of resaident's foods brought in from outside. e. Routine and proper refrigerator temperature monitoring. This deficient practice had the potential to cause foodborne illness (an infection or irritation of the gastrointestinal tract caused by food or beverages that contain harmful bacteria, parasites, viruses, or chemicals), and lead to vomiting, diarrhea, abdominal pain, fever, and chills. Findings: a. During an interview and observation on 5/21/19 at 7:20 a.m., witnessed by Medical Records Supervisor (MR), an anonymous family member (ANONFM) was observed reheating food brought from outside in the employee's lounge microwave. ANONFM left after MR informed her she needed to reheat her food in another microwave. MR stated, ANONFM always come in the morning to feed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 62 of 78 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 05/24/2019 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 resident/family member. During a concurrent interview, ANONFM stated, she was reheating her food using the employee designated microwave, that was inside the employee's lounge, for a long time. ANONFM also stated, most of the time she brought food from outside, reheated it and fed her family member who was a resident in the facility, but nobody informed her that they were not allowed to use the microwave in the employee's lounge. ANONFM also verified the microwave had caked on food particles. During an interview on 5/21/19 at 10:28 a.m., Restorative Nursing Assistant (RNA 3) stated, family members are allowed to bring food from outside. RNA 3 stated, most family members stayed and ate with residents. RNA 3 also stated, most of the time, there were no leftovers but in case there were leftovers they would bring it to kitchen for storage. During an interview on 5/21/19 at 10:33 a.m., Certified nursing assistant (CNA 3) stated that families can bring food from outside but there was no separate refrigerator to store the resident's foods, and they used employee refrigerator. CNA 3 stated there were only two refrigerators in the kitchen, one in the employee's lounge and one main refrigerator in the kitchen. During an interview and observation on 5/21/19 at 2:40 p.m., Activities Supervisor (AS) stated, there were no refrigerator and microwave inside the dining/activity room. AS further stated, the resident's families would use employee lounge to reheat the food brought from outside, and store foods in the employee refrigerator. During an observation, and interview on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 63 of 78 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 05/24/2019 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 5/21/19 at 2:44 p.m., the refrigerator inside the employee lounge had a posted sign indicating "For employees only." The following items was stored inside of the employee refrigerator, which was verified with CNA 8: 1. One loaf of bread without a 'use by' date, 2. Two small packets of mayonnaise that had no expiration dates, 3. Foods, and 4. Nourishment for the facility residents. During an interview on 5/21/19 at 2:44 p.m., CNA 8 was unable to identify the items stored in the employee refrigerator, such as loaf of bread, and foods, were brought by residents/families or it belonged to the employees. CNA 8 stated the refrigerator was "filthy." During an interview on 5/22/19 at 8:15 a.m., Assistant Activities (AA) stated, the resident's families could bring foods from the outside. AA stated foods from families could be reheated in the employee's lounge and if needed to be refrigerated or for any leftovers, families stored them in the employee designated refrigerator. AA also stated, there were only one refrigerator and microwave for both employees and the residents/families to use. During an interview on 5/24/19 at 7:45 a.m., Licensed Vocational Nurse (LVN 2) stated families are allowed to bring food; most of the time families asked staff to reheat the food in the microwave then brought it into the room. LVN 2 stated, since it was mostly AS, AA and CNAs who received the food from families, she was not aware if the family's or resident's food items could be stored in the employee designated refrigerator. During an interview on 5/24/19 at 7:53 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 64 of 78 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 05/24/2019 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 Director of Staff Development (DSD) stated, family members can bring foods from outside, but it had to be labeled with their name and date if stored in the designated employee refrigerator. DSD stated, families and CNAs were allowed to reheat food from outside using the microwave inside the employee lounge. DSD further stated, maintenance was responsible for refrigerator temperature monitoring and housekeeper cleaned the refrigerator every Friday. During an interview on 5/24/19 at 8:20 a.m., Registered Nurse (RN 1) stated, family members were notified that they can bring food from outside but had to check resident's condition and diet first with charge nurses. RN 1 but were not allowed to store resident's food or food from outside in the employee refrigerator. RN 1 further stated, she was not aware of food reheating policy. During an interview on 5/24/19 at 8:25 a.m., Director of Nursing (DON) stated, food from outside should be labeled with the resident's name. date and it could be stored in the employee designated refrigerator. DON stated, staff could reheat the food in the microwave inside the employee lounge; foods could be reheated for one minute, or depending on the kind of food to be reheated. DON also stated, it was maintenance personnel's responsibility to monitor refrigerator temperature and housekeeper to clean it every week. During an interview and observation on 5/24/19 at 8:48 a.m., Maintenance and Laundry supervisor (MS) stated, employee designated refrigerator temperature was never checked, thus no temperature log was available. MS stated, housekeeper cleaned refrigerator every Friday, foods without label was to be thrown away. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 65 of 78 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 05/24/2019 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 facility's policy and procedures titled "Non-Facility food" not dated indicated: In order to maintain a safe environment for all residents in the facility the following Policy and procedure shall be followed and enforced: 1. Families/friends/other sources (Food providers) are required to inform the charge nurse of their intentions to bring food to a resident. Only after receiving consent may food be taken to any given room. 2. Foods not placed in proper containers and properly marked (date/time) or outdated, shall be disposed of daily. It is the responsibility of the CAN and the charge nurse to verify this compliance. A review of facility's policy and procedures titled "foods brought by family/visitors" revised 2/14 indicated he following: 1. Perishable foods must be stored in resealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and the "use by" date. 2. The nursing staff is responsible for discarding perishable foods on or before the "use by" date. A review of facility's undated policy and procedures titled "Refrigerator-Reach in" and "Microwave Oven" indicated: Sanitation of Equipment Refrigerator a. Frequency: Daily 1. Wipe up spills on shelves, sides, and floor of refrigerator. Use clean sanitizing solution and clean cloth. 2. Wash doors inside and out, doorframe and front, and gaskets. b. Weekly Microwave Frequency: Daily FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 66 of 78 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 05/24/2019 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 Wipe down inside with special attention to inside of oven door to provide adequate seal to prevent microwave leakage.

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

F880 05/21/2019 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 67 of 78 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 05/24/2019 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 infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §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: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 68 of 78 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 05/24/2019 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 1. Adopt and implement hand hygiene policy and procedures (a way of cleaning one's hands that substantially reduces potential harmful microorganisms on the hands) that followed the accepted national standards. 2. Ensure the facility staff involved in direct contact with the resident, and their environment, followed hand hygiene procedures based on accepted national standards, during medication administration, for seven of 7 randomly observed residents (19, 21, 38, 42, 67, 78, 95). These deficient practices increased the risk of spreading communicable disease (an infection transmissible by direct contact with an affected individual or the individual's body fluids or by indirect means) from staff to resident or resident to resident, potentially resulting in serious health complications including hospitalization or death. Findings: a 1. On 05/20/19 at 08:02 AM, during an observation of medication administration, the registered nurse (RN 2) was observed donning (putting on) gloves in order to perform a blood pressure check for Resident 78. After completing the blood pressure check, RN 2 removed her gloves and began to prepare medications without performing hand hygiene (washing her hands with soap and water or using an alcohol-based hand sanitizer.) a 2. On 05/20/19 at 08:10 AM, during an observation of medication administration, RN 2 was observed removing her gloves after performing a blood pressure check for Resident 42. RN 2 then began to prepare medications without performing hand hygiene. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 69 of 78 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 05/24/2019 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 3. On 05/20/19 at 08:47 AM, RN 2 was observed completing medication administration for Resident 95. Upon leaving the room, RN 2 was not observed performing hand hygiene before she moved on to the next resident. On 05/20/19 at 03:51 PM, during an interview, RN 2 stated she changes gloves frequently during medication administration without washing her hands or using hand sanitizer. RN 2 stated that "I can wear gloves instead of washing my hands or using hand sanitizer." b 1. On 05/21/19 at 08:01 AM, the licensed vocational nurse (LVN 1) was not observed performing hand hygiene prior to checking blood pressure for Resident 19. b 2. On 05/21/19 at 08:15 AM, LVN 1 was not observed performing hand hygiene prior to checking blood pressure for Resident 67. b 3. On 05/21/19 at 08:23 AM, LVN 1 was not observed performing hand hygiene prior to administering an insulin (a medication used to treat high blood sugar) injection for Resident 38. b 4. On 05/21/19 at 08:37 AM, LVN 1 was not observed performing hand hygiene prior to checking blood pressure for Resident 21. A review of the facility's undated policy titled "Handwashing" indicated that "Brief resident care activities involving direct contact (e.g. taking a blood pressure) do not require handwashing." However, according to The Centers for Disease Control and Prevention (a federal agency that conducts and supports health promotion, prevention and preparedness activities in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 70 of 78 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 05/24/2019 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 United States, with the goal of improving overall public health), Centers for Disease Control and Prevention's Guidelines for Hand Hygiene in Health-Care Settings, published 10/25/2002, page 27 indicated that among "Indications for Hand Hygiene" are "Contact with a patient's intact skin (e.g. taking a blood pressure ...)" and "After glove removal." On 05/21/19 at 03:16 PM, during an interview, the director of nursing (DON) stated that hand hygiene should occur before and after all direct resident care activities, including taking a blood pressure or giving an injection, before gloves are donned, and again once they are removed. The DON stated the facility's policy as written did not appear to align with standard nursing practice or accepted national standards on hand hygiene and should be revised. The DON stated, based on her observation, she was aware the facility staff did not always follow proper hand hygiene procedures, and she was working with her staff to retrain them on following proper hand hygiene standards, and procedures.

F881 SS=D Antibiotic Stewardship Program CFR(s): 483.80(a)(3)

F881 05/21/2019 §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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 71 of 78 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 05/24/2019 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: 1. Include in its infection prevention and control program ([IPCP] a comprehensive program used to help recognize, prevent, and help control the spread of infection in the facility) best practice clinical criteria used to guide the selection and duration of antibiotic (medications used to treat infections) therapy when necessary to treat residents who have been determined to have a true infections (the establishment of an infective agent in or on a suitable host, producing clinical signs and symptoms). 2. Establish a system to monitor for the use of antibiotics in the facility. These deficient practices increased the risk that: 1. Residents may receive treatment with antibiotics not best suited to treat their infections or for a suboptimal period of time resulting in their infection not being treated appropriately or completely. 2. The residents may experience preventable adverse effects (unwanted, uncomfortable, or dangerous effects which may impair a resident's ability to function at their highest possible level of physical, mental, and psychosocial well-being) related to antibiotic use including, but not limited to: nausea, vomiting, and diarrhea. 3. Antibiotic therapy may become ineffective at treating residents' future infections. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 72 of 78 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 05/24/2019 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 05/21/19 at 02:14 PM, during a review of the facility's IPCP program, the IPCP did not contain any written protocols or clinical criteria to help guide the appropriate selection and duration of antibiotic therapy in the residents who had been determined to have true infections. The IPCP program did not contain any data or the trends of antibiotic usage or any tools with which to communicate antibiotic prescribing trends to the facility's prescribing physicians. During a concurrent interview, the infection control nurse (ICN) stated she had served as the facility's infection preventionist (individual selected by the facility to be responsible for implementing the IPCP) since January 2019. The ICN stated that despite the fact she worked 40 hours per week, at the direction of the director of nursing (DON), and the administrator (ADM), she only spent one day per week on infection control duties and the other four days per week were spent doing direct resident care activities. The ICN stated she did not feel that amount of time was sufficient to fully implement an infection control and antibiotic stewardship (an oversight program used to guide appropriate selection and duration of antibiotic therapy) program. ICN stated there was no data kept on trends of antibiotic usage, no communication of antibiotic prescribing trends to the facility's prescribing physicians, and no written protocols on the selection of antibiotics present in the IPCP. The ICN stated antibiotic selection to treat infections was at the sole discretion of the prescribing physician and the facility did not evaluate their use after they were prescribed. A review of the facility's undated policy titled "Policy for Antibiotic Stewardship Program" indicated the team of individuals responsible for implementing the antibiotic stewardship FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 73 of 78 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 05/24/2019 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 program (ASP team) will "review data and monitor antibiotic usage patterns on a regular basis" and "report on the number of antibiotics prescribed and the number of residents treated each month." The policy also indicated "the infection preventionist will collect and review data such as: type of antibiotic ordered, route of administration, antibiotic costs" and "whether the antibiotic was changed during the course of treatment." The policy further indicated "feedback will be given to physicians by the ASP team on their individual prescribing patterns of cultures ordered and antibiotics prescribed, as indicated."

F921 SS=E Safe/Functional/Sanitary/Comfortable Environ CFR(s): 483.90(i)

F921 05/21/2019 §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, facility failed to ensure safe and sanitary environment was provided for two of 19 sampled residents (23, 87), and staff. The facility failed to provide the following: a. The facility failed to maintain Residents 23, and 87's bathroom ceiling fan in a safe, functioning manner to prevent injuries. Residents 23, 30 and 87's bathroom ceiling fan was loose, and it almost fell off. b. The facility failed to provide the residents, their families, and staff a sanitary, and clean refrigerator, and microwave oven to store, and heat their foods. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 74 of 78 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 05/24/2019 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 1. A review of Resident 23's face sheet (admission record), indicated an admission date of 10/12/17 with diagnoses of muscle weakness and difficulty walking. A review of Resident 23's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/18/19 indicated Resident 23 had a Brief Interview for Mental Status ([BIMS] an assessment of cognition) score of 6 (a score of 0-7 indicated severely impaired cognition). A concurrent review of Resident 23's MDS, for Resident 23's Functional Status (individual's ability to perform normal daily activities required to meet basic needs) indicated resident needs supervision on bed mobility and limited assistance with toilet use. a 2. A review of Resident 87's face sheet (admission record), indicated the resident was admitted on 2/28/19 with diagnoses of muscle weakness, essential hypertension (high blood pressure with unknown cause) and type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar.) A review of Resident 87's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/21/19 indicated Resident 87 had a Brief Interview for Mental Status (BIMS-an assessment of cognition) score of 10 (a score of 8-12 indicates moderately impaired cognition). A concurrent review of Resident 87's MDS, "Functional Status" (individual's ability to perform normal daily activities required to meet basic needs) indicated Resident 87 needs extensive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 75 of 78 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 05/24/2019 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 assistance with bed mobility and transfers. During an observation on 5/20/19 at 9:55 a.m., Certified Nursing Assistant (CNA 8) verified Resident's 23, and 87's bathroom ceiling was loose, which was almost falling off, potentially injuring the residents, staff, and visitors. CNA 8 stated the ceiling fan was loose before the inspection, but was unable to remember when she first noticed it. During an interview on 5/22/19 at 9:00 a.m. Maintenance Supervisor (MS) stated nobody reported the loose ceiling fan to him. MS stated it was the staff's responsibility to report it to maintenance regarding equipment and furniture that needed repairs. MS stated, maintenance logbook was available in the nursing station, which was used as a means of communication between staff, and maintenance. MS also stated, he was collecting logbook every morning, and if the repair was urgent, the staff should had called him. A review of facility's maintenance logbook showed there was no notice about Resident 23, and 87's damaged ceiling fan, that was loose, and was almost falling off. A review of an undated facility's policy and procedures titled "Maintenance Department" indicated: A clean and safe facility and grounds are maintained through a comprehensive program of scheduled inspections. 1. General guidelines a. Floor, wall and ceiling surfaces must be smooth, dry and cleanable. Any cracks may harbor bacteria. B. During the facility entrance on 5/20/19 at 9:03 a.m., employee's lounge was observed with dirty floor and foul odor. b. During an observation, and interview, on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 76 of 78 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 05/24/2019 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 5/21/19 at 2:44 p.m., verified with certified nursing assistant (CNA 8), there was a refrigerator inside the employee's lounge with a sign indicating "For employees only." The refrigerator was observed with food particles, and stains. On the inside of the refrigerator there were leftover foods, and a brown colored stains on the top, bottom and side drawers. The food containers and plastic bags were not organized, with empty bottles, and packets/sachets. CNA 8 was unable to identify if the loaf of bread and foods were brought in by the residents, their families or other employees. c. During an observation and interview on 5/21/19 at 7:20 a.m., the microwave oven inside the employee lounge was observed with food crumbs, and red to brown stains on all the sides, including the microwave dish, which was verified by an Anonymous family member (ANONFM). A review of an undated facility's policy and procedures titled "Refrigerator-Reach In" and "Microwave Oven" not dated, indicated: Sanitation of Equipment Refrigerator a. Frequency: Daily 1. Wipe up spills on shelves, sides, and floor of refrigerator. Use clean sanitizing solution and clean cloth. 2. Wash doors inside and out, doorframe and front, and gaskets. Microwave Frequency: Daily Wipe down inside with special attention to inside of oven door to provide adequate seal to prevent microwave leakage. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7PBE11 Facility ID: CA940000011 If continuation sheet 77 of 78 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 05/24/2019 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) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: 7PBE11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA940000011 (X5) COMPLETE DATE If continuation sheet 78 of 78