Other·March 25, 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 during a Recertification survey. Representing the Department of Public Health: Health Facilities Evaluator, Nurse: 36394, RN, HFEN Health Facilities Evaluator, Nurse: 39085, RN, HFEN Total population: 57 Sample size: 15 Highest Severity and Scope: E

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

F550 03/24/2020 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, 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: KK1111 Facility ID: CA940000091 If continuation sheet 1 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, and interview, the staff failed to provide full bodily privacy during a bed bath by not drawing the privacy curtain for one of 15 residents (4), who needed assistance with bathing, was not visually exposed to others. This deficient practice had the potential for Resident 4 to loose dignity and cause psychosocial harm from being visually exposed. Findings: A review of the admission records indicated Resident 4 was readmitted on 8/2/18 with diagnoses that included hypertension (high FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 2 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 blood pressure), diabetes mellitus (irregular blood sugar levels), and generalized muscle weakness. A review of the Minimum Data Set (MDS), a standardized assessment and care planning tool dated 11/11/19 indicated Resident 4 was severely cognitively (ability to make decisions of daily living) impaired with daily decision making, and required physical assistance from staff for activities of daily living such as bathing, toileting and personal hygiene. During an observation on 2/8/20 at 9:46 a.m. certified nursing assistant (CNA 10) was giving Resident 4 a bed bath, however, the privacy curtains were not fully drawn next to the doorway, to provide total privacy. Resident 4 was completely visible from the hallway where the privacy curtain was not fully drawn. During an interview on 2/8/20 at 2:15 p.m. CNA 10 acknowledged she should have ensured the privacy curtains were fully drawn because it was Resident 4's right to be treated with dignity and to have full bodily privacy while receiving a bed bath. A review of the facility's policy titled "Residents Rights", revised 8/15/18 indicated that employees shall treat all residents with kindness, respect and dignity.

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

F558 03/24/2020 §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 3 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to provide the right size shower chair to transfer one of 15 residents (44), who was morbidly obese (excessive body fat), and needed assistance with transferring, to the shower room. This deficient practice resulted in Resident 44, who wished to take a shower, had not taken a shower since admission because the facility did not have the right size shower chair, which could result in body odor, skin breakdown, and low self-esteem. Findings: A review of the admission records indicated Resident 44 was admitted with diagnoses that included major depressive disorder (a mental disorder characterized by a long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts), and morbidly obesity. A review of the Minimum Data Set (MDS), a standardized assessment and care planning tool dated 1/16/20, indicated Resident 44 was cognitively intact and required a one to two person assistance with activities of daily living such as transferring and showering. The MDS assessment indicated taking showers was very important to Resident 44. During a concurrent observation and interview on 2/8/20 at 9:13 a.m., Resident 44 stated he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 4 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE had never taken a shower in the shower room. Resident 44 was upset and crying. Resident 44 stated that staff told him they do not have a way to get him to the shower room. During an interview on 2/9/20 at 10:12 a.m. certified nursing assistant (CNA) 2 stated she had taken care of Resident 44 many times, but had never been able to take him to the shower room because there was no shower chair to accommodate his size. CNA 2 stated she always gave him bed baths instead of taking him to the shower room. During an interview on 2/9/20 at 10:32 a.m. director of staff development acknowledged the facility should be able to accommodate Resident 44's to have the right size shower chair, which was the resident's right to take a shower, especially if it was his preference. A review of the facility's policy titled "Residents Rights", revised 8/15/18 indicated that employees shall treat all residents with kindness, respect and dignity.

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

F609 03/24/2020 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 5 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow their policy and procedure to report an injury of unknown origin (the source of the injury was not observed by any person or the source of the injury could not be explained by the resident) to the Department of Public Health (DPH) Licensing and Certification agency, for one of 1 resident (13), who sustained a fracture (break) of the right fifth (5th) finger. This deficient practice of not knowing the cause for Resident 13's fractured right 5th finger, potentially delayed investigation and protection of the resident, and other residents from any abuse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 6 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: A review of Resident 13's Admission Record (Face sheet) indicated the resident was admitted on 5/29/19, and re-admitted on 7/19/2019, with diagnoses including unspecified anxiety disorder (characterized by feelings of worry, anxiety, or fear that interfere with one's daily activities), paraplegia (paralysis of the legs and lower body), and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). A review of Resident 13's history and physical assessment form dated 7/20/19 indicated Resident 13 did not have the capacity to understand and make decisions. A review of Resident 13's Minimum Data Set (MDS), a standardized assessment and care screening tool dated 11/28/19, indicated Resident 13 had no impairment with cognitive (ability to think and understand) skills for daily decision making, and was totally dependent on staff for activities of daily living. Resident 13 required a mechanical lift for transfers using the assistance of two staff members. A review of the licensed nurse's notes dated 10/14/19 at 6:30 a.m., indicated Resident 13's right hand and finger was reported swollen. The interventions included to elevate the hand with pillow while sleeping in bed. The nurse's note indicated Resident 13's hand was tender to touch. A review of Resident 13's x- ray (an imaging creates pictures of the inside of the body) results dated 10/14/19 indicated the resident had an acute fracture (a break in a bone that occurs quickly, rapidly and usually FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 7 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 traumatically) with shortening and angulation (describes a specific type of fracture displacement where the normal axis of the bone has been altered such that the distal portion of the bone points off in a different direction) at the base of the fifth proximal (nearer to the center of the body) phalanx (finger bone), intra articular (joint) fracture at the joint on his right hand. On 02/09/20 at 7:59 a.m., during an interview with the Resident 13, regarding the fracture that sustained on 10/14/19, the resident could not describe why the right 5th finger was fractured. During interview Resident 13 denied hitting his hands on the side rails. On 02/9/20 at 2:35 p.m., during an interview with a certified nursing assistant (CNA 3) stated Resident 13 had episodes of not wanting to go back to bed and would attempt to punch or hit staff. CNA 3 stated on 10/14/19, she was off, but when she came back to work, she saw Resident 13's swollen right hand. CNA 3 stated she reported Resident 13's swollen right hand to the charge nurse. CNA 3 stated the charge nurse immediately assessed Resident 13. However, when asked about investigating the incident, CNA 3 stated the DON or Administrator did not interview her about Resident 13's swollen right hand. On 02/09/20 at 7:58 a.m., during an interview with Director of the Staff Development (DSD), stated he was aware Resident 13 had a swollen right hand but the cause was not known. The DSD stated he was informed by the DON about Resident 13 hitting his hand on side rails, however there was no witness to the injury that caused the resident's fracture right 5th finger. On 02/08/20 at 4:08 p.m., during an interview FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 8 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with DON stated Resident 13's fractured right 5th finger was not reported to DPH. DON stated if Resident 13 had a broken finger and the cause was unknown, it had to be investigated to rule out abuse and reported to the right agency. During an interview on 02/09/20, at 4:50 p.m., the Administrator stated the DON and DSD informed him Resident 13's fractured right 5th finger was caused by a wheelchair. When asked what should have been done with Resident 13's fracture of unknown origin, the Administrator stated the facility had to investigate and report to the appropriate agencies. The Administrator stated the facility had to file a report of suspected dependent adult/elder abuse, and report to the following agencies such as the Ombudsman (resident advocate agency), police (law enforcement), and to the DPH. The Administrator stated the final investigation report was to be sent to DPH within five days. When asked if Resident 13's fractured right 5th finger was reported to the DPH Licensing and Certification agency as an unknown origin, the Administrator stated "no." A review of the facility's policy and procedure titled, "Injuries of Unknown Origin" last revised on 11/2016, indicated "Unexplained injuries are promptly and thoroughly investigated by the Director of Nursing Services and other staff appointed by the Administrator, to ensure resident safety is not compromised and action is taken whenever possible, to avoid further occurrences." A review of the facility's policy and procedures titled "Abuse- Prevention Program", last revised on 11/2018, indicated "The facility will report allegations of abuse and any reasonable suspicion of a crime against any individual who is a resident or is receiving care from the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 9 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 as required by law and regulation to the appropriate agencies."

F656 SS=E Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 03/24/2020 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 10 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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) 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 develop and implement a person-centered plan of care, with measurable objectives, and time frames, for two of 15 residents (27, 47) by: Resident 47, who was receiving hemodialysis (a process of filtrating waste product from the blood using artificial machine) treatments which not provided with a plan of care. Resident 47, who had a gastrostomy tube ([Gtube] a tube surgically inserted in to the abdomen to deliver nutrition and hydration) which was not provided with a plan of care. These deficient practices placed Resident 27, and 47 at risk for infections and complications. Findings: a. A review of Resident 27's Admission Records indicated the resident was readmitted on 12/17/2019 with diagnosis that included major depressive disorder (persistent feeling of sadness or loss of interest in things formally likes). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 11 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 27's history and physical assessment forms dated 12/19/2019, indicated the resident did not have the capacity to understand and make medical decisions. A review of Resident 27's Minimum Data Set (MDS), a standardized assessment and care screening tool dated 12/24/2019, indicated Resident 27's cognitive skills for daily decision making were intact but the resident required extensive, to total assistance from staff for activities of daily livings (such as bed mobility, transfer, personal hygiene, toileting, bathing, and dressing). A review of Resident 27's physician order summary dated 12/1/19, indicated the resident was receiving hemodialysis treatments three times a week; on Tuesday, Thursdays, and Fridays. The order indicated the resident was on a regular control carbohydrate, renal diet, along with fluid restriction of 1500 milliliter a day. The order indicated Resident 27 had a right upper chest Quinton catheter (access for hemodialysis or infusion of medicine) for hemodialysis treatments. A review of resident 27's paper chart in the presence of the director of nursing (DON) acknowledged hemodialysis care plan was not developed. DON stated this must be one of the care plan that fell in the "cracks". DON stated a plan of care should have been developed so as to better manage Resident 27's care because care plan drove the resident's care. b. On 02/08/20 at 10:06 p.m., during the initial tour Resident 47 was observed with G-tube feeding, that was off but still connected to the resident. A review of the physician's odder summary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 12 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 dated on 1/14/20 indicated Fibersource high protein nurishment (HN) 1.2 kilograms of calories at 75 milliliters per hour, for 20 hours via electric pump to provide 1500 milliliters calories per 1800 kilograms in 24 hours. The order indicated to start feeding at 1 p.m., and continue until total volume was infused. A review of Resident 47's Admission Records indicated resident was admitted to the facility on 1/14/20 and readmitted on 2/4/20, with diagnosis that included gastrostomy status. A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/21/20, indicated Resident 47's cognitive skills for daily decision making was severely impaired and the resident required extensive to total assistance of two staff with activities of daily living. A review of Resident 47's paper chart in the presence of the Director of Nursing (DON), acknowledged there was no care plan developed for the use of G-tube. During an interview with DON stated care plan for G-tube was supposed to be developed for continuity of care.

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

F657 03/24/2020 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must 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-FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 13 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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) 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 develop and implement individualized comprehensive care plans that included measurable objectives and timetables to meet three of 15 residents (11, 32, 44) needs by: a. Resident 11 did not have a care plan for hemodialysis (a process of purifying the blood of a person whose kidneys are not working normally using a machine) treatments b. Resident 32 did not have care plans to address the risks, side effects, and monitoring for the use of an anticoagulant (increase the time it takes for blood to clot) medication c. Resident 44 did not have a care plan to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 14 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 address the risks, side effects, and monitoring for the use of an antidepressant medication These deficient practices had the potential for Resident 11, 32, and 44 to experience any irregularities or problems, to go unmonitored by staff, resulting in harm. Findings: a. A review of the admission records indicated Resident 11 was admitted on 11/7/19 with diagnoses that included end stage renal disease (kidney failure), with dependence on hemodialysis treatments. A review of the Minimum Data Set (MDS), a standardized assessment and care planning tool dated 12/4/19 indicated Resident 11 was cognitively (ability to make decisions of daily living) intact with daily decision making, and required assistance with activities of daily living such as getting dressed, toileting and personal hygiene. A review of the medical records indicated Resident 11 had hemodialysis treatments three times a week, on Tuesdays, Thursdays and Saturdays. The records indicated Resident 11 had a hemodialysis access shunt (an implanted tube to blood vessels in the arm that provides gets attached to the dialysis machine for filtration of waste) on the left upper arm. During a concurrent interview and record review of Resident 11's medical record, on 2/8/20 at 4:17 p.m., with Registered Nurse (RN 10) confirmed there was no care plan for hemodialysis treatments. During interview RN 10 stated there should be one, so the staff knew what to monitor for this resident and what FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 15 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to report to the physician. b. A review of the admission records indicated Resident 32 was admitted on 12/3/19 with diagnoses that included kidney and heart disease caused by hypertension (high blood pressure), atrial fibrillation (irregular, rapid heart beat), and generalized muscle weakness. A review of the Minimum Data Set (MDS), a standardized assessment and care planning tool indicated Resident 32 was moderately cognitively impaired with daily decision making, and required physical assistance in activities of daily living. A review of Resident 32's medication administration record dated January and February 2020 indicated Resident 32 received apixaban (an anticoagulant) 2.5 milligram, twice a day, dated 12/23/19. During a concurrent interview and record review Registered Nurse (RN 10) confirmed there was no care plans for Resident 32, who was administered apixaban. During interview RN 10 stated there should be a care plan to monitor for side effects of the medication and to notify the physician if needed. c. A review of the admission records indicated Resident 44 was admitted with diagnoses that included major depressive disorder (a mental disorder characterized by a long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts), morbid obesity (excessive body fat that increases the risk of health problems), and anemia (low blood count). A review of the Minimum Data Set (MDS), a standardized assessment and care planning FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 16 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 tool dated 1/16/20 indicated Resident 44 was cognitively intact and required a one to two person assistance with activities of daily living. A review of Resident 44's medication administration record dated January and February 2020 indicated Resident 44 received Nortriptyline (an antidepressant) 10 milligrams, three times a day, dated 10/11/19. During a concurrent interview and record review on 2/8/20 at 4:30 p.m. RN 10 acknowledged there was no care plan for the antidepressant that was administered to Resident 44. During interview RN 10 stated there should be a care plan to monitor the risk factors, and any side effects of the medication such as anxiety, sleep problems and constipation. A review of the facility's policy titled "Care Plan" revised 11/2016 indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident.

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

F677 03/24/2020 §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 15 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 17 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 residents (15), who needed assistance with personal hygiene, and bathing, was given a complete and thorough bed bath, according to the facility's policy and procedures by: 1. Ensuring gloves were changed, and hands were washed to reduce contamination from a soiled incontinent brief (diaper) before washing other body parts. 2. Ensuring separate wash cloths were used and water was changed after washing potentially soiled body parts. 3. Ensuring underarms, back, perinea area,, thigh, feet, and toes were washed, and dried well. 4. Ensuring Resident 15's body was not exposed during the entire bed bath. These deficient practices of not following the facility's bed bath policy and procedures, and not following infection control standard precautions (are a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin, and mucous membranes), had the potential of exposing Resident 15, and at risk for body odor, urinary tract infection ([UTI] infection of the bladder), and poor wound healing. Findings: On 02/08/20 at 9:21 a.m., during observation certified nursing assistant (CNA 1) prepared two wash basins at Resident 15's bedside table. One basin had soapy water and the other contained plain water. During observation, CNA 1 removed Resident 15's incontinent brief FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 18 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 (diaper) that had faces and dark drainage from sacral (tail bone) wounds with the gloved hands. CNA 1, used the same gloves, soaked a corner of a towel in soapy water basin, and used it on Resident 15's face, chest area, breasts, and stomach. However, CNA 1 did not wash underarms, inner thighs, back, foot and or the toes. CNA 1 used the same towel to wipe the perinea, instead of washing the area. CNA 1 did not apply lotion to Resident 15's body. CNA 1 did not change gloves, did not wash hands the bed bath. CNA 1 then put clothing on the resident, before placing the resident into a wheelchair. Resident 15 was also exposed during the entire bed bath. A review of Resident 15's admission form indicated the resident was admitted on 9/4/19 with diagnoses that included bacterial infection of the blood, and pressure ulcers stage 4 (are localized areas of tissue necrosis that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time). A review of Resident 15's History and Physical examination form dated 9/18/19 indicated the resident did not have the capacity to understand and make decisions. A review of Resident 15's Minimum Data Set (MDS), a standardized assessment and care screening tool dated 12/9/2019, indicated the resident cognitive skills for daily decision making were severely impaired, and the resident required total dependence from staff with activities of daily living (ADLs). A review of the risk for activities of daily living care plan dated 9/7/2019, for Resident 15 indicated decline related to impaired cognition, and the generalized weakness. The goal of the care plan indicated Resident 15 will be well FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 19 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 groomed and appropriately dressed on a daily basis. The care plan interventions indicated the resident will be assist with ADLs as needed. A review of the ADL inservice sheet dated 3/25/2019, indicated CNA 1's name was not included on the form. On 02/09/20 at 01:47 p.m.,during an interview with the Director of Staff Development (DSD) stated the proper procedure for a bed bath included the use of two basins with water, wash cloths, towels, soap and water and change of clothes or gowns. The DSD stated the procedure required the resident be cleaned from the cleanest part to the dirtiest part of the body, which meant starting from the face downwards. The DSD stated if cleaning the resident was started from the bottom, the staff should change gloves, change the water in the basins, change washcloths, wash hands, and put on a new set of gloves. The DSD stated the reason for the sequence to the procedures was because of reducing introduction of bacteria or infection if perinea care or private parts, if not dried well after washing with fresh soapy water. The DSD stated the resident had to be covered at all times to ensure privacy during bed baths. A review of the facility's policy and procedures titled "Bed Bath" revised 2/2018, indicated to first wash the resident's face, neck and ears, then the shoulder, armpit, arm, and hand. The policy indicated after laying a towel across the resident's chest, wash the resident's abdomen, then wash the leg and foot, especially the skin between the toes. The policy indicated to repeat for the resident's other leg and foot, and to empty the wash basin and refill with clean warm water. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 20 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F684 Quality of Care CFR(s): 483.25

F684 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/24/2020 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to implement nursing standards of practice for four of 15 residents (26, 38, 158) by: a. Resident 26, 38, and 158, the medications were documented as administered, prior to administering the pills. b. Resident 26's medications were left at bedside to take later, instead of ensuring the resident took all the pills. These deficient practices had the potential for Resident 26, 38, and 158 clinical records to be inaccurate, when the medications were not observed as taken, before documenting them as taken. Findings: a. During an observation of medication pass with licensed vocational nurse (LVN 10), the nurse documented Resident 26, 38, and 158's medications as administered, before actually FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 21 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 administering the medications. The following revealed: On 2/8/20 at 4:35 p.m., LVN 10 documented medications were administered before she prepared the resident's medication to be administered to Resident 38 On 2/8/20 at 4:49 p.m. LVN 10 documented medications were administered before she prepared the resident's medication to be administered to Resident 26. On 2/8/20 at 5:00 p.m. LVN 10 documented medications were administered before she prepared the resident's medication to be administered to Resident 158. During an interview on 2/9/20 at 10:50 a.m., registered nurse (RN 10) acknowledged the correct process for passing medications to the residents was to review the orders, take out the medications, tell the resident why and what type of medications they were getting, before administering their medications. RN 10 stated afterwards it was appropriate to documents the medications as given, or refused, if the resident refused to take them. RN 10 sated it was actually important to monitor the resident's taking their medications, because it was to treat an illness. RN 10 stated it was important to know if the medications were effective and to monitor if the resident was having side effects, or became sick from something else. b. A review of the admission sheet indicated Resident 26 was admitted on 10/28/19 with diagnoses that included dysphagia (difficulty swallowing), bipolar disorder (a mental illness with symptoms of extreme high moods and extreme low moods), and gout (a form of arthritis characterized by sever pain, redness and tenderness in joints). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 22 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 Minimum Data Set (MDS), a standardized assessment and care planning tool dated 12/19/19 indicated Resident 26 was cognitively (ability to make decisions of daily living) intact with daily decision making, and required assistance in activities of daily living such as getting dressed, and eating. A review of Resident 26's physician orders dated 12/12/19 indicated the following: 1. megestrol acetate (an appetite stimulant), 40 milligrams (mg) per milliliter (ML) oral suspension, give 10 ML by mouth twice a day. 2. Allopurinol 100 mg twice a day for gout. 3. Zenpep/pancrealipase 25,000 units 1 capsule three times a day for absorption of nutrients (an ingredient of food that provides for growth and maintenance of life). 4. Depakote DR 250 mg twice a day for bipolar disorder On 2/8/20 at 4:49 p.m. LVN 10 poured the megestrol acetate in a cup, and gave it to Resident 26 to drink. LVN 10 then placed a cup of medications containing the allopurinol, Zenpep and Depakote, handed them to Resident 26 and exited the room. LVN 10 did not stay to watch Resident 26 take allopurinol, Zenpep and Depakote medications. On 2/9/20 at 11:10 a.m. RN 10 acknowledged that LVN 10 should have stayed with Resident 26 to make sure the resident took all of the medications. RN 10 stated it was a standard of practice and important for Resident 26's safety, to make sure the resident swallowed the medications, so the symptoms were treated. A review of the facility's policy titled "Specific Medication Administration Procedures" dated January 2017 indicated the safe and effective manner to administer medications was to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 23 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 identify the resident using two identification methods before administering medications. The policy stated after administration, return to the medication cart, replace medication container, and document administration in the medication administration records.

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

F690 03/24/2020 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 24 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 function as possible. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility staff failed to assess, notify the physician regarding the indwelling catheter ([F/C] a flexible tube inserted into the bladder that drains urine from the bladder in to a bag outside of the body) containing cloudy urine, which was not covered, and secured to reduce the risks of trauma to the penis for one of 2 residents (15). This deficient practice had the potential of resulting in lack of dignity, urinary tract infection ([UTI] infection of the bladder), irritability, trauma, and pain for Resident 15. Findings: On 02/8/20 at 09:46 a.m., Resident 15 was observed with a F/C tubing, that was not secured to the resident's thigh. Resident 15 was F/C tubing and bag was cloudy, had sediments (particles), and was dark in color (coffee color). On 02/09/20 at 09:21 a.m., Resident 15 was observed with a F/C bag, that was not covered with a dignity bag, and the bag was visible from the hallway. Resident 15's F/C bag had amber colored urine that contained sediments, which was not secured to the resident's thigh. On 02/09/20 at 09:28 a.m., during a bed bath, Resident 15 was observed with certified nursing assistant (CNA 1), who was providing a bed bath to the resident. CNA 1 lifted the F/C bag that contained urine, placed it on the bed, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 25 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 which made all the urine that was in the bag, flow back into the resident's bladder. During observation, each time CNA 1 turned Resident 15 on to the side, the resident burst into crying. CNA 1 continued to provide Resident 15 with a bed bath. When CNA 1 asked Resident 15 if he was in pain, the resident cried louder. A review of Resident 15's admission records indicated the resident was admitted to the facility on 7/20/2019 and was re-admitted on 9/4/19 with diagnoses that included bacterial infection of the blood, and pressure ulcers stage 4 (are localized areas of tissue necrosis that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time). A review of Resident 15's History and Physical (H&P) examination form dated 9/18/19 indicated the resident did not have the capacity to understand and make decisions. A review of Resident 15's Minimum Data Set (MDS), a standardized assessment and care screening tool dated 12/9/2019, indicated the resident cognitive skills for daily decision making was severely impaired, and the resident required total dependence from staff with activities of daily living. A review of Resident 15's physician order summary dated 9/19/2019 indicated to insert an indwelling catheter, French (size) #16 extra large, and place to gravity for wound management, and diagnosis of neuromuscular dysfunction of bladder (refers to urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination). The order indicated to secure F/C to the leg with statlock (securely anchors the catheter in place, reducing the risk of urethral erosion, bladder spasms, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 26 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 trauma) device to prevent pulling of the F/C tubing. The order indicated to monitor urine characteristic for signs and symptoms of UTI (such as amber colored urine, foul odor, sediments, and cloudy urine), and monitor the leg strap daily for placement. The orders indicated to notify the physician when there are sediments in urine. A review of Resident 15's care plan for indwelling catheter dated 9/4/2019, related to neurogenic bladder with interventions that included to monitor F/C for kinks and leaking, sediments, cloudiness, strong odor, blood, amount, and notify the doctor of any burning, elevated temperature, and abdominal pain. On 02/9/20 at 03:25 p.m., during an interview with the director of nursing (DON) stated Resident 15 had episodes of neuromuscular bladder dysfunction. According to the DON, staff would be inserviced not to place the F/C bag on the bed to prevent back flow of urine that could cause UTI and pain. On 2/9/20 at 4:11 p.m., during record review, and interview with licensed vocational nurse (LVN 1) stated Resident 15's F/C bag had to be placed in a privacy bag to protect the privacy and dignity of the resident. When asked if the urine characteristic assessed, documented, and physician notified, LVN 1 said no. LVN 1 stated he should have notified the physician immediately so as not to delay any treatments for Resident 15. LVN 1 further stated the F/C tubing had to be secured to prevent pulling, trauma, and pain to Resident 15's penis. On 2/9/2010 at 4:20 p.m., during an interview with the director of staff development stated, CNAs had been in-serviced on how to provide morning care to the resident's who had a F/C by not lifting or placing the bag on the bed so FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 27 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 as to prevent back flow of urine.

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

F755 03/24/2020 §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. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 28 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview and record review, the facility failed to implement their policy to track, and monitor the medications used from emergency kit, discontinued noncontrolled, and disposition (is the process of destroying) of the unused residents medication. This deficient practice had the potential of resulting in the divergence (medication at the hands of people not prescribed for) of the resident's medication. Findings: a. On 02/08/20 at 10:54 a.m., during medication storage area inspection and interview, the emergency kit dated 1/22/20 was noted opened and temporary sealed with a red tag. During interview the director of nursing (DON) stated the emergency kit was used for the residents, with the red tag meaning the kit had been opened. However, DON acknowledged there was no records to justify which medications were removed and used for what resident. The medication room was observed with boxes of delivered items stored on the floor, which made it crowded and cluttered. DON acknowledged and stated she was aware of the medication room being disorganized and the medication removed from emergency kit was not logged out. b. On 02/08/20 at 011:05 a.m., during medication storage area inspection and interview, there was a full plastic basin, that contained different classification of medications, which had been stored underneath the cabinet. DON was unable to account for the different classification of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 29 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 medications. There was no record to show when the residents medications was discontinued. DON was unable to account for what the medications were, when the medications in the bin was discontinued, and for whom did it belonged to. DON was unable to account for quantity of the medications that was placed in the bin. When asked, DON stated "I can not tell what they are." DON stated going forward, proper documentation and accountability would be available in the future. According to the facility's policy and procedures titled "Disposal of Medications and MedicationRelated Supplies" updated 1/2017, indicated medication should be immediately removed from the medication cart upon receipt of an order to discontinue, stored in a secure area, documented the type of medication, quantity, date destroyed by two licensed nurses for noncontrolled medications.

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

F756 03/24/2020 §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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 30 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 (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 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 document the justification for duplicate anticoagulant therapy for one of 15 residents (32). This deficient practice had the potential to increase Resident 32's risk for adverse (unwanted, harmful) reactions from prolonged, duplicate use of anticoagulant therapy, such as excessive bleeding, or bruising. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 31 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 admission records indicated Resident 32 was admitted on 12/3/19 with diagnoses that included kidney and heart disease caused by hypertension (high blood pressure), atrial fibrillation (irregular, rapid heartbeat), and generalized muscle weakness. A review of the Minimum Data Set (MDS), a standardized assessment and care planning tool indicated Resident 32 was moderately impaired with cognitive skills for daily decision making, and required physical assistance in activities of daily living. A review of Resident 32's medical record indicated a physician order dated 12/23/19 to administer apixaban (a blood thinner) 2.5 milligrams (mg) twice a day for deep vein thrombosis (a blood clot usually in the legs) prophylaxis (prevention). The physician order dated 12/23/19 indicated to administer aspirin (a blood thinner) chewable tablet, 81 mg daily for stroke (damage caused by an interruption of blood supply [usually a blood clot] to the brain). During a concurrent interview and record review on 2/9/20 at 2:57 p.m. director of nursing (DON) confirmed there was no documentation in Resident 32's medical record to provide a rationale for administering two blood thinners. DON acknowledged the risk for bleeding could be increased since Resident 32 was taking two anticoagulants.

F757 SS=E Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 03/24/2020 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when usedFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 32 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and records review, the facility failed to implement their policy to ensure two of 2 residents (27, 33), prescribing physician informed and obtained a consent from the resident or their responsible party, prior to administering psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) by: Resident 27, who was administered Lexapro (antidepressant), there was no documented record the informed consent for psychotropic medication was obtained by a prescribing practitioner Resident 33, Ativan (antianxiety), and Risperdal (antipsychotic), there was no documented evidence the informed consent for psychotropic medication was obtained by a prescribing practitioner FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 33 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 in a broad range of adverse consequences such as medication interactions, bleeding, poly-pharmacy or unnecessary medication for Residents 27 and 33. Findings: a. A review of Resident 27's Admission Record indicated the resident was readmitted on 12/17/2019 with diagnosis that included major depressive disorder (persistent feeling of sadness or loss of interest in things formally likes) single episode, unspecified. A review of Resident 27's history and physical assessment form dated 12/19/2019, indicated the resident did not have the capacity to understand and make medical decisions. A review of Resident 27's Minimum Data Set (MDS), a standardized assessment and care screening tool dated 12/24/2019, in the presence of the MDS nurse indicated Resident 27's cognitive skills for daily decision making was intact but the resident required extensive assistant to total with activities of daily livings (such as bed mobility, transfer, personal hygiene, toileting, bathing, and dressing). A review of Resident 27's physician order summary dated 12/17/2019, indicated an order for Lexapro 10 milligram, give 1 tablet by mouth every day for depression manifested by sad, pained, worried facial expression (informed consent obtained by physician) for depression manifested by sad facial and worried facial expression. However, a review of the clinical records, the informed consent form for Lexapro 10 milligram did not have prescribing practitioners name, signature or date, which FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 34 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 was also confirmed by the director of nursing (DON). A review of Resident 27's nurse's notes dated 2/1/20 to 2/8/20, had no documented episodes of sad facial expression, worried or pained. The behavior monitoring form dated 2/1/20 to 2/9/20 indicated zero episodes of sad, pained, worried facial expressions. On 02/9/20 at 02:03 p.m., during an interview with the DON stated informed consent had to be obtained by the physician from the resident or the resident's responsible party. DON stated the staff can only witness or verify that physician obtained a consent, prior to giving the medication. b. A review of Resident 33's Admission Record, indicated the resident was admitted to the facility on 9/24/2019 with diagnoses that included anxiety disorder unspecified, unspecified psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) not due to substance and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), unspecified. A review of Resident 33's history and physical assessment form (H&P) dated 12/28/2019 indicated the resident did not have the capacity to understand and make medical decisions. However, H / P indicated the resident was diagnosed with dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 33's Minimum Data Set (MDS), a standardized assessment and care screening tool dated 1/20/2020, indicated the resident's cognitive skills for daily decision FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 35 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 making was severely impaired and the resident required total assistance from staff with activities of daily living. A review of Resident 33's physician order summary dated 12/27/2019, indicated: 1. Ativan 0.5 milligram 1 tablet by mouth two times a day for anxiety manifested by (M/B) verbalization of nervousness. There was no informed consent obtained by the physician in clinical records. 2. Risperdal 0.5 milligram 1 tablet by mouth twice a day (BID) for psychosis M/B crusting or verbal aggressive as antecedent (someone or something existing or happening before, the cause or origin) to harm staff for psychosis. 3. Ativan 2 milligrams per 0,5 milliliter every 4 as needed for agitation. A review of the clinical records revealed an informed consent form for both Ativan and Risperdal, but the form did not have the physician's name, signature or date, which was acknowledged by the director of nursing (DON). A review of Resident 33's behavior monitoring form dated 1/26/20 1/31/20 and 2/1/20 to 2/7/20, indicated zero episodes of verbalization of nervousness, or cursing and verbal aggressiveness as antecent to harm staff. On 02/08/20 at 03:12 p.m., during an interview with the DON stated informed consent had to be obtained by the physician from the resident or the resident's responsible party. DON stated the staff can only witness or verify that physician obtained a consent, prior to giving the medication. According to the facility's policy and procedures titled "Psychotherapeutic Drug Management FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 36 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 /Informed Consent" revised 2/13/2019, indicated before initiating the administration of psychotherapeutic drugs, informed consent must be obtained by the physician and the facility staff shall verify that the resident's record contains documentation that the resident has given informed consent to the proposed treatment or procedure. The policy indicated verification of the informed consent must be maintained in the resident's clinical record.

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

F812 03/24/2020 §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 to Store, prepare, distribute FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 37 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 serve food in accordance with professional standards for food service safety. These deficient practices had the potential for the food to become contaminated with harmful microorganisms causing foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins), placing the residents at increased risk of exposing the susceptible residents. Findings: a. On 2/8/2020 at 07:32 a.m., during the initial tour of the kitchen and inspection of the facility food preparation area, the following were observed: 1. There was no pre mixed sanitizing bucket at the preparatory table. The dietary aide 1 was observed wiping the table with a dry tissue after preparing fruit juice. 2. The cook was observed picking up the sanitizing bucket from underneath the cabinet, filled it with water from the tap, and cleaned the preparatory table for cooking, without preparing the sanitizing solution. 3. The kitchen manager walked out of the kitchen and came back to the kitchen without performing hand hygiene. b. On 2/8/2020 at 07:55 a.m., the following items were observed in the refrigerator without dates, as to when the items were taken from the freezer or when the used by date was and: 1. Three bowls of thawed cooked pork cook, 2. One dish of thawed beef, 3. Cooked beans and crush mixed chili peppers stored with raw beef, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 38 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 4. Refrigerator number 3 and 4 had shelves that were overcrowded with food items, which did not allow for air circulating around the foods, and had the tendency to cause cross contamination. 5. A box of potatoes was stored next to the door, which allowed rays of the sun to shine on the potatoes 6. At 08:00 a.m., dietary Aide 2 walked into the kitchen from the back door, without washing her hands first, placed her belongings into the non perishable food stored area. Dietary aide 2 walked out of kitchen, returned back to the kitchen, and started slicing fruits, without first washing her hand. 7. At 08:08 a.m., dietary aide 1 walked out of the kitchen, pulled in a cart with used trays from the floor, and started preparing food without first washing the hands. On 02/09/20 at 11:14 a.m., during an interview with kitchen manager stated everyone who walked into the kitchen, had to perform hand hygiene, wear gloves before touching or performing any duty, in order to prevent food bone illnesses. The kitchen manager stated all food items had to be labeled with delivery date, opened date and used by dated. Kitchen manager stated any food that was removed from the freezer and placed in the refrigerators, for example meats for thawing, had to be labeled with a used by date and the time. The kitchen manager stated all food items had to be labeled with dates and time to prevent foodborne illness. The kitchen manager stated the staff was supposed to prepare two sanitary buckets, one for the cook and one for the dietary aide. When questioned why the kitchen only was using one sanitary bucket, kitchen manager had no comments. The kitchen manager stated the preparatory area or surfaces had to be sanitized immediately after food preparation with the use of the sanitary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 39 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 solution, and disposable wipes, after soaking them into the sanitary solution. The kitchen manager stated disposable wipes had to used and discarded at the end of the day. According to an undated facility's policy and procedures "Cross Contamination" indicated clan and sanitized work environment shall be maintain in especially in the kitchen to minimize the chance of cross contamination (a process by which bacteria or microorganism are transferred from one substance or object to another which resulted into a harmful effect) by not storing raw and ready to eat food side by side, wash hands and surfaces often, wash and and change gloves before and after handling raw food, ready to eat food, after changing task and dated all items with receiving dates, removal dates from the refrigerator and used by dates.

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

F880 03/24/2020 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 40 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 41 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 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 ensure a central line (a plastic catheter inserted into a large vein typically in the neck or near the heart for therapeutic medication administration) had a dry, clean dressing that was dated, and the central line port (the end of the catheter [when in use] that is connected to tubing that contains medication) was protected from contamination by placing a cap on it for one of 15 residents (157). These deficient practices had the potential to cause physical harm by introducing bacteria into Resident 157's body, causing further infections. Findings: During observation on 2/8/20 at 9:27 a.m., Resident 157 had a central line to the left upper arm, to deliver antibiotic (medication to fight infection) was covered with a blood-filled dressing, and the dressing had no indication of when it was last changed. The single port of the central line was exposed (uncovered) and was touching Resident 157's pillow. A review of the admission records indicated Resident 157 was admitted on 2/4/20 with diagnoses that included sepsis (a condition FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 42 of 43 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: _______________ 056446 (X3) DATE SURVEY COMPLETED 02/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARAMOUNT CONVALESCENT HOSPITAL 8558 Rosecrans Ave Paramount, CA 90723 (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 resulting from the presence of infectious organisms in the blood and the body's response to their presence, potentially leading to the various organ failure, shock, and death), urinary tract infection, and infection of the amputated (cut off) stump (the bit that's left beyond a healthy joint is called a residual limb, or more commonly, a stump) of the left and right lower extremities. A review of the admission assessment dated 2/4/20 indicated Resident 157 was alert but confused and required assistance for activities of daily living such as getting dressed, toileting and personal hygiene. During a concurrent observation and interview on 2/9/20 at 3:27 p.m. Registered Nurse (RN 10) stated Resident 157's central line dressing should have been changed since it was soiled with blood. RN 10 also stated the port should have been capped to protect Resident 157 from further infections. According to an undated facility's policy titled "Central Access Guidelines and Procedures" indicated the facility should provide an assessment and monitoring period following insertion of central venous access devices to detect and intervene in potential complications arising. The policy indicated the licensed nurse shall observe the exit site (of the catheter) for excessive bleeding or hematoma (bleeding under the skin), and bruising. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KK1111 Facility ID: CA940000091 If continuation sheet 43 of 43