Other·June 9, 2017

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 Complaint Visit. Complaint # CA00527062 - Substantiated Category: Injury of Unknown Origin Representing the Department of Public Health: 36396 The inspection was limited to the specific components investigated and does not represent the findings of a full inspection of the facility.

F225 SS=D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 06/05/2017 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against 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: S1QZ11 Facility ID: CA950000003 If continuation sheet 1 of 8 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: _______________ 055181 (X3) DATE SURVEY COMPLETED 05/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN GABRIEL CONVALESCENT CENTER 8035 Hill Dr Rosemead, CA 91770 (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 his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1QZ11 Facility ID: CA950000003 If continuation sheet 2 of 8 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: _______________ 055181 (X3) DATE SURVEY COMPLETED 05/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN GABRIEL CONVALESCENT CENTER 8035 Hill Dr Rosemead, CA 91770 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to immediately report (within 24 hours) an injury of unknown source to the State survey and certification agency for 1 of 3 sampled residents (Resident 1). This deficient practice had the potential to put Resident 1's safety at risk. Findings: A review of the admission face sheet indicated Resident 1 was admitted to the facility on 5/1/15 with diagnoses that included diabetes mellitus (high blood sugar levels over a prolonged period resulting to frequent urination, increased thirst, and increased hunger), dementia (long term and gradual decrease in the ability to think and remember affecting a person's daily functioning), hypertension (long term medical condition in which blood pressure is high) and atrial fibrillation (an abnormal heart rhythm characterized by rapid and irregular beating). A review of document titled "History and Physical Examination" dated 7/26/16 indicated Resident 1 did not have the capacity to understand and make decisions. A review of Minimum Data Set (MDS), a comprehensive assessment tool, dated 1/17/17 indicated that Resident 1 had a brief interview for mental status (BIMS - screens for cognitive impairment) score of 2 (a score of 0-7 indicates severe cognitive impairment), required limited assistance with one person physical assist for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1QZ11 Facility ID: CA950000003 If continuation sheet 3 of 8 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: _______________ 055181 (X3) DATE SURVEY COMPLETED 05/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN GABRIEL CONVALESCENT CENTER 8035 Hill Dr Rosemead, CA 91770 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE transfer, walk in room, toilet use, required extensive assistance with one person physical assist for personal hygiene and bathing. A review of Resident 1's "License Nurse Record" dated 3/7/17 indicated Resident 1 refused RNA ambulation and her left leg felt weak when ambulating. During a concurrent observation and interview of Resident 1 on 3/31/17 at 1:15 p.m., Resident 1 was observed sitting up on a wheelchair at her bedside. Resident 1 stated that she did not have any fall incidents and no injuries. During an interview with the Director of Staff Development (DSD) on 3/31/17 at 1:18 p.m., DSD stated that Resident 1 is confused with poor memory. During an interview with Certified Nursing Assistant (CNA 1) on 3/31/17 at 1:20 p.m., CNA 1 stated that she showered Resident 1 in the morning of 3/9/17. CNA 1 stated Resident 1 did not fall in the shower and had no complaints of pain after the shower. During an interview with the Licensed Vocational Nurse (LVN 1) on 3/31/17 at 1:30 p.m., LVN 1 stated he was informed by the family of Resident 1 that Resident 1 had claimed that she fell prior to going out on pass on 3/9/17. LVN 1 stated Resident 1 and the family member still went out on pass on 3/9/17 around lunch time. After they returned LVN 1 interviewed and assessed Resident 1. Resident 1 told him that she did not fall. LVN 1 stated he assessed Resident 1 and found no pain and no swelling to Resident 1's left hip. LVN 1 further stated that he reported the incident to the attending physician, who ordered an x-ray (photo image of a body part to check for internal structures including bone). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1QZ11 Facility ID: CA950000003 If continuation sheet 4 of 8 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: _______________ 055181 (X3) DATE SURVEY COMPLETED 05/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN GABRIEL CONVALESCENT CENTER 8035 Hill Dr Rosemead, CA 91770 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's "Physician Telephone Orders" dated 3/9/17 indicated an order of XRay of left hip, thigh, knee, lower leg and foot. A review of document titled, "Imaging Report of left hip with pelvis" dated 3/9/17 indicated an acute, displaced femoral neck fracture (broken thigh bone near the hip joint), addendum included mineralization appears age appropriate, for osteopenia/osteoporosis determination, recommend a DEXA (Dualenergy X-ray absorptiometry) scan {a means of measuring the amount of mineral in bone and is used to diagnose osteopenia (a condition in which bone mineral density is lower than normal) and osteoporosis(disease where increased bone weakness increases the risk of a broken bone}. A review of Resident 1's "Physician Telephone Orders" dated 3/10/17 indicated an order to transfer Resident 1 to General Acute Care Hospital for femoral neck fracture. During an interview with the Director of Nursing (DON) on 3/31/17 at 1:46 p.m., the DON stated that she interviewed Resident 1, who told her that she did not fall. The DON stated that Resident 1 claimed that her legs were weak a couple of days prior to 3/9/17. The DON stated nobody knew how the fracture happened and the attending physician said that the fracture could have occurred during ambulation combined with co-morbidities (presence of one or more diseases or disorders) including osteopenia/osteoporosis. The DON stated that DEXA scan was not done to Resident 1 to confirm the diagnosis of osteopenia/osteoporosis. During an interview with the Administrator on 3/31/17 at 2:00 p.m., Administrator stated that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1QZ11 Facility ID: CA950000003 If continuation sheet 5 of 8 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: _______________ 055181 (X3) DATE SURVEY COMPLETED 05/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN GABRIEL CONVALESCENT CENTER 8035 Hill Dr Rosemead, CA 91770 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the department managers of the facility made a determination that Resident 1's injury was not a reportable incident. Administrator also stated that nobody knows how Resident 1 sustained the fracture. Administrator also stated that the facility's determination that led to Resident 1's fracture was due to Resident 1's co-morbidities. Administrator further stated that Resident 1's fracture was not an injury of unknown source. During an interview with Resident 1's daughter on 5/18/17 at 8:51 a.m., Resident 1's daughter stated that she was not aware if Resident 1 had a fall incident. Resident 1's daughter also stated that Resident 1 is confused and could not tell her how Resident 1 got the fracture. A review of General Acute Care Hospital (GACH) notes titled, "History and Physical", dated 3/13/17 indicated left hip fracture as the reason for admission and plan for orthopedic consult. A review of GACH notes titled, "Operative Report" dated 3/11/17 indicated Resident 1 underwent left hip hemiarthroplasty (a surgical procedure in which the femoral head of the hip joint is replaced by a prosthetic implant). The Operative Report did not indicate that evidence of osteoporosis was found during Resident 1's hip replacement operation. A review of GACH notes titled, "Discharge Summary Report" dated 3/16/17 indicated Resident 1 was discharged back to skilled nursing facility on 3/16/17. Resident 1's discharge diagnoses included: Status post left hip fracture with need for hip replacement, urinary tract infection, and diabetes. No diagnoses of osteopenia/osteoporosis were indicated. A review of an undated facility policy and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1QZ11 Facility ID: CA950000003 If continuation sheet 6 of 8 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: _______________ 055181 (X3) DATE SURVEY COMPLETED 05/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN GABRIEL CONVALESCENT CENTER 8035 Hill Dr Rosemead, CA 91770 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE procedure titled, "Patient Abuse and Mistreatment", indicated: IV. Identification - Facility shall institute procedure of identifying unusual occurrences and events, such as suspicious bruising of residents, unexplained skin tears, fractures, etc. (etcetera), that may constitute abuse. Such procedural guidelines shall also provide for directions of necessary investigative efforts. a. Facility administrator and/or designee shall ensure the prevention, monitoring and identification of unusual occurrences and events that may constitute abuse. b. Any incidences or occurrences that may constitute abuse shall be recorded on the Incident Report Form and reported to Director of Nurses, facility Administrator and facility Abuse Coordinator (if different from the facility administrator) immediately after and/or no later than 24 hours after the identification of the unusual occurrences or events constituting abuse or probable abuse. (Please note that facilities are required to report to the Department of Health Services any incident of unknown origin. It is therefore, very vital to take extra caution in documenting that the incident is of unknown origin, unless proven otherwise). A review of an undated facility policy and procedure titled, "Abuse Allegation Reporting", indicated: Policy: All allegations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident's property will be reported immediately to the Administrator/Abuse Coordinator. Procedure: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1QZ11 Facility ID: CA950000003 If continuation sheet 7 of 8 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: _______________ 055181 (X3) DATE SURVEY COMPLETED 05/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN GABRIEL CONVALESCENT CENTER 8035 Hill Dr Rosemead, CA 91770 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. All allegations involving abuse of any type will be reported by the Charge Nurse and/or supervisor immediately to the Director of Nursing. 2. Please note that as a mandated reporter, an employee who identifies suspected abuse committed against an individual who is a resident must also report the incident to one local law enforcement entity by phone within 24 hours and provide a written report to the local ombudsman, L & C (licensing and certification) program and local law enforcement within 24 hours for non-serious bodily injury. For serious bodily injury, the requirement requires a phone report within 2 hours to local law enforcement, Ombudsman and the L & C program. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1QZ11 Facility ID: CA950000003 If continuation sheet 8 of 8