Other·December 16, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health (DPH) during an investigation of a Facility Reported incident (FRI) FRI: CA00654995 Representing the DPH: #19152 The inspection was limited to the specific FRI investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for FRI CA00654995 with an intent issued for "Willful Material Falsification (WMF)."

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 11/30/2020 §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 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: DRXI11 Facility ID: CA940000025 If continuation sheet 1 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056417 (X3) DATE SURVEY COMPLETED 11/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIEW HEIGHTS CONVALESCENT HOSPITAL 12619 Avalon Blvd Los Angeles, CA 90061 (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 by: Based on interview and record review the facility's nursing staff failed to monitor the whereabouts for one of three sampled residents (Resident A). Resident A was found in the bed of a male resident (Resident B) and later alleged another resident (Resident C) pulled her pants and panties down and had sex with her. A certified nursing assistant (CNA) assigned to monitor Resident A documented Resident A was in her room when she was actually in the room of Resident B and Resident C. This deficient practice resulted in Resident A being in Resident B and Resident C's room and having sex with both of them without the knowledge of staff and had the potential to result in claims of sexual assault or other harm. Findings: On 9/18/19, at 4:14 p.m., during an interview, the Director of Nursing (DON) stated Resident A was in Resident B's room, they were, according to Resident A kissing and caressing and at some point Resident B left the room. The DON stated Resident A reported that Resident C (Resident B's roommate), who was also in the room, propositioned Resident A to have sex. Resident A told Resident C no but Resident C pulled Resident A's pants and panties down and penetrated her a little. Resident B returned to the room and Resident A asked Resident B to have sex with her, which they did. During rounds staff found Resident A in bed with Resident B with her pants off. The DON stated the police were notified and Resident A told them she was not forced to have sex with Resident B or Resident C, it was consensual. The DON stated they have protocols in place that include every 15 minute FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DRXI11 Facility ID: CA940000025 If continuation sheet 2 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056417 (X3) DATE SURVEY COMPLETED 11/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIEW HEIGHTS CONVALESCENT HOSPITAL 12619 Avalon Blvd Los Angeles, CA 90061 (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 rounds to monitor zones, however, CNA 1, who was assigned to monitor the zone that Resident A was on, documented Resident A was in her room when Resident A was actually in the room with Resident B and Resident C having sex with them. The DON stated CNA 1 was suspended A review of Resident A's Admission Records indicated she was admitted to the facility on 1/31/18 with a diagnosis of schizophrenia (a mental disorder often characterized by abnormal social behavior and failure to recognize what is real. A Minimum Data Set (MDS) Assessment, a care plan and screening tool, dated 8/17/19, indicated Resident A's cognitive skills for daily decision-making were consistent and reasonable. The MDS indicated Resident A had disorganized thinking, episodes of hallucinations and delusions and displayed verbal behavioral symptoms directed toward others. The MDS indicated Resident A was independent in her activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting), ambulated independently and had no functional limitations in range of motion ([ROM] the distance and direction a joint can move to its full potential). A review of an Interdisciplinary Team Conference report, dated 9/24/2020, indicated on 9/16/2020, a resident (Resident A) was found in a male peer's room engaging in consensual sex. Resident A stated she had sex with his roommate and verbalized that both episodes were consensual. A review of nursing Progress Notes, dated 9/16/2020, indicated at approximately 2:25 p.m., during staffing rounds the resident (Resident A) was found in a male resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DRXI11 Facility ID: CA940000025 If continuation sheet 3 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056417 (X3) DATE SURVEY COMPLETED 11/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIEW HEIGHTS CONVALESCENT HOSPITAL 12619 Avalon Blvd Los Angeles, CA 90061 (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 room lying on one of the male's beds. Resident A stated she closed the male peer's (Resident B) privacy curtain, laid on the bed and they began to kiss and caress. Resident B briefly left the room and upon return Resident A asked him if he wanted to have sex with her. Resident A and Resident B engaged in consensual sex. At approximately 4:10 p.m., Resident A reported while she was in Resident B's room during Resident B's absence another male peer (Resident C) opened the privacy curtain and began propositioning her to have sex with him. Per Resident A, Resident C pulled her pants an underwear down and tried to put his private parts in her, he did a little bit. Resident A stated she told Resident C no because she wanted to be with Resident B and when Resident B returned that's when they had sex. On 9/26/2020, at 4:01 p.m., during a telephone interview, the Director of Staff Development (DSD)stated the purpose of monitoring residents every 15 minutes is to know where all residents are to insure the safety of the residents'. The DSD stated CNA 1 told her Resident A was not where she (CNA 1) documented she (Resident A) was and she knew she did not monitor accurately. The DSD stated she and the DON made the decision to suspend CNA 1 for two days. A review of the facility's South Front Group B monitoring form, dated 9/16/19, completed by CNA 1, indicated Resident A was in her room at 1:45 p.m. 2 p.m., 2:15 p.m., and 2:30 p.m. On 10/1/19, at 12:28 p.m., during a telephone interview, CNA 1 stated that day she was sent to multiple areas to monitor and she lost track of Resident A. CNA 1 stated she knows she should not have documented Resident A was in her room if she was not there. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DRXI11 Facility ID: CA940000025 If continuation sheet 4 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056417 (X3) DATE SURVEY COMPLETED 11/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIEW HEIGHTS CONVALESCENT HOSPITAL 12619 Avalon Blvd Los Angeles, CA 90061 (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 facility policy and procedure titled "Staff Rounds (Monitoring)" dated 2019 indicated the purpose is to provide continuous monitoring of the residents. It is the policy of this facility to provide continuous monitoring of the residents by making rounds or walking the hallways of the facility. Staff will make frequent rounds of the facility to ensure the safety of the residents on a continual basis. CNAs are required to monitor the hallways at all time while on duty. Staff should report to the supervisor or charge nurse immediately if there is any unusual occurrence during rounds. A facility policy and procedure titled "Zoning Locations" dated 2019 indicated it is the policy and practice of the facility to provide a safe environment to our residents. A safe environment entails staff to monitor essential areas. Staff members will be assigned to zone in essential areas to prevent incidents and intervene when necessary. Essential areas are defined as "zoning locations." A sign in sheet will be utilized to record staff members responsible of monitoring assigned zones. Staff members are to be released by an appointed staff member prior to leaving assigned zone (e.g., change of shift, lunch breaks, breaks, etc.). A facility policy and procedure titled, " Resident Safety Monitoring" Revised 2014 indicated the purpose is to establish guidelines for assuring the safety and well being of resident who are at risk for unsafe behavior are monitored appropriately. Monitoring the resident's whereabouts and behavior every fifteen minutes. Staff has visual observation of the resident, and the resident's behavior is constantly being monitored by all staff. The assigned staff is no further than an arms length from the resident at all times. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DRXI11 Facility ID: CA940000025 If continuation sheet 5 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056417 (X3) DATE SURVEY COMPLETED 11/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VIEW HEIGHTS CONVALESCENT HOSPITAL 12619 Avalon Blvd Los Angeles, CA 90061 (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: DRXI11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA940000025 (X5) COMPLETE DATE If continuation sheet 6 of 6