Other·September 12, 2019

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 the investigation of a complaint during an Abbreviated Standard Survey. Complaint number: CA00641635 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 36526 The inspection was limited to the specific complaint investigation and does not represent the findings of a full inspection of the facility. Three deficiencies were issued for complaint CA00641635

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

F550 09/12/2019 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect 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 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: 563X11 Facility ID: CA970000017 If continuation sheet 1 of 16 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: _______________ 555071 (X3) DATE SURVEY COMPLETED 08/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNYVIEW CARE CENTER 2000 W Washington Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow its policy to ensure a resident's and family member's (FM 1) wishes to be discharged were acknowledged and documented in the progress notes for one of three sampled residents (Resident 1). Resident 1 felt she was held against her will for 30 days from the residents' request to go home. This deficient practice resulted in Resident 1's rights being violated by not allowing the resident to go home when she verbalized her wishes to be discharged home. Findings: A review of Resident 1's Admission Record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 563X11 Facility ID: CA970000017 If continuation sheet 2 of 16 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: _______________ 555071 (X3) DATE SURVEY COMPLETED 08/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNYVIEW CARE CENTER 2000 W Washington Blvd Los Angeles, CA 90018 (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 (Face Sheet) indicated the resident was initially admitted to the facility on 12/17/18 and last readmitted on 5/20/19. Resident 1's diagnoses included diabetes (low/high concentrations of sugar in the blood), depression (state of general unhappiness) and obesity (overweight). According to the Face Sheet, Resident 1 was self-responsible and her own decision maker. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/16/19, indicated Resident 1 had a Brief Interview for Mental Status ([BIMS] a mental test) score of 15 (13 to 15 indicates an intact cognition [thought process]). The MDS indicated Resident 1 was totally dependent of a one-person physical assist for ADLs. The MDS indicated there was no discharge plan initiated for Resident 1 to return to the community. A review of Resident 1's undated, Baseline Care Plan indicated that the staff would initiate discharge planning process. A review of the Multidisciplinary Progress Note, dated 5/21/19 and signed by the Social Services Director (SSD), indicated that Resident 1's family wanted to take the resident home. A review of Resident 1's psychologist (study of the human mind and its functions, especially those affecting behavior) consultation notes, dated from 5/23/19 to 6/11/19, indicated Resident 1 expressed frustration and sadness for not being able to go home and her family's separation. On 6/19/19 at 4:09 p.m., during a telephone interview, Resident 1's family member (FM 1) stated that on 5/18/19, he communicated to the facility his wishes to discharge the resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 563X11 Facility ID: CA970000017 If continuation sheet 3 of 16 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: _______________ 555071 (X3) DATE SURVEY COMPLETED 08/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNYVIEW CARE CENTER 2000 W Washington Blvd Los Angeles, CA 90018 (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 home, but was informed that they had to hold Resident 1 in the facility for 24 hours for billing purposes. FM 1 stated that the facility was not acknowledging Resident 1's wishes to go home and was being held hostage by the facility. On 6/19/19 at 4:35 p.m., during an interview, Resident 1 stated that she felt sad and unhappy because she was unaware of why she was not allowed to go home. Resident 1 stated that she had family to take care of her at home and did not want to die in a place that was not her home. At 4:56 p.m. on 6/19/19, during a concurrent interview and record review, the Director of Nursing (DON) stated that Physician 1 was not discharging Resident 1 home because she required total care. On 6/19/19 at 5:20 p.m., during a concurrent interview and record review, the DON stated that there was no documentation of the conversations between Physician 1 and the facility's staff regarding Resident 1's wishes to be discharged home with her family. At 5:31 p.m. on 6/19/19, during a concurrent interview and record review, Licensed Vocational Nurse 1 (LVN 1) stated that there was no documentation of the conversation she had with Physician 1 regarding Resident 1's denial to be discharged home. LVN 1 stated that none of the staff followed-up or acknowledged Resident 1's wishes to be discharged home. LVN 1 stated that she was aware of the decline in Resident 1's emotional state as indicated in the psychologist consultation notes. A review of the facility's undated policy titled, "Resident's Right," indicated that the purpose of the facility was to respect and encourage FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 563X11 Facility ID: CA970000017 If continuation sheet 4 of 16 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: _______________ 555071 (X3) DATE SURVEY COMPLETED 08/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNYVIEW CARE CENTER 2000 W Washington Blvd Los Angeles, CA 90018 (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 patient self-determination and encourage participation in decision making regarding their care through education and inquiry. A review of the facility's undated policy titled, "Licensed Nurse's Notes," indicated that daily notes were to be written for each resident containing specific skills, care provided, and skilled assessment performed as outlined. The policy indicated the notes should include the resident's response and progress toward goals established and summary of the events or changes in condition.

F660 SS=G Discharge Planning Process CFR(s): 483.21(c)(1)(i)-(ix)

F660 10/23/2019 §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to postdischarge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 563X11 Facility ID: CA970000017 If continuation sheet 5 of 16 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: _______________ 555071 (X3) DATE SURVEY COMPLETED 08/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNYVIEW CARE CENTER 2000 W Washington Blvd Los Angeles, CA 90018 (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 (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a postacute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 563X11 Facility ID: CA970000017 If continuation sheet 6 of 16 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: _______________ 555071 (X3) DATE SURVEY COMPLETED 08/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNYVIEW CARE CENTER 2000 W Washington Blvd Los Angeles, CA 90018 (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 clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to develop and implement a discharge plan that addressed the resident's discharge needs upon resident's readmission to the facility, reduced a resident's and family's anxiety (feeling of unease; excessive worry), and include a post-discharge plan of care with the participation of the resident and/or the resident's family for one of three sampled residents (Resident 1). Resident 1, who was alert and self-responsible, had been requesting upon re-admission on 5/20/19 (30 days after), to be discharged home with family and the facility failed to address her request. These deficient practices resulted in Resident 1 expressing feeling like a hostage (holding someone against their own will), depressed (state of general unhappiness), sad, and not participating in activities of daily living ([ADLs] grooming, tooth/hair brushing, and eating) due to her inability to go home with her family. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the resident was initially FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 563X11 Facility ID: CA970000017 If continuation sheet 7 of 16 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: _______________ 555071 (X3) DATE SURVEY COMPLETED 08/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNYVIEW CARE CENTER 2000 W Washington Blvd Los Angeles, CA 90018 (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 admitted to the facility on 12/17/18 and last readmitted on 5/20/19. Resident 1's diagnoses included diabetes (low/high concentrations of sugar in the blood), depression (state of general unhappiness) and obesity (overweight). According to the Face Sheet, Resident 1 was self-responsible and her own decision maker. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/16/19, indicated Resident 1 had a Brief Interview for Mental Status ([BIMS] a mental test) score of 15 (13 to 15 indicates an intact cognition [thought process]). The MDS indicated Resident 1 was totally dependent of a one-person physical assist for ADLs. The MDS indicated there was no discharge plan initiated for Resident 1 to return to the community. A review of Resident 1's undated Baseline Care Plan indicated that the staff would initiate discharge planning process. The problem indicated an uncertain discharge plan and the goal was for Resident 1 to received ancillary services (wide range of healthcare services provided to support the care of a resident) within the next three (3) months. A review of Resident 1's untimed Multidisciplinary Progress Note, dated 5/21/19 and signed by the Social Services Director (SSD), indicated that Resident 1's family wanted to take the resident home. A review of Resident 1's Interdisciplinary Team's ([IDT] a group of disciplines that work together towards a common goal for a resident) note, dated 5/28/19 and titled, "Resident's Discharge Planning," indicated that Resident 1's family member (FM 1) wanted Resident 1 to be discharged home. The IDT indicated that neither Resident 1 or FM 1 attended the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 563X11 Facility ID: CA970000017 If continuation sheet 8 of 16 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: _______________ 555071 (X3) DATE SURVEY COMPLETED 08/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNYVIEW CARE CENTER 2000 W Washington Blvd Los Angeles, CA 90018 (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 planning meeting. A review of Resident 1's IDT note, dated 6/5/19, indicated that Resident 1 had family to assist with her care at home. The IDT note indicated the SSD informed another family member, FM 2, that Resident 1's physician (Physician 1) refused to discharge Resident 1 home because she is a total care and its unsafe. The IDT indicated that Resident 1 required reinforcement to participate in rehabilitation. The IDT indicated that FM 2 stated having sufficient help at home or have Resident 1 move to a facility closer to them. A review of the Resident 1's psychologist ([Physician 2] a physician dedicated to the study of the human behavior) consultation notes indicated the following: On 5/23/19 and timed at 12:52 p.m., Resident 1 demonstrated improved alertness and conversation. The psychologist's consult indicated that Resident 1 reported wanting to go home to reunite with her family. On 5/30/19 and timed at 11:27 a.m., Resident 1 expressed her desire to be discharged from the facility and asked the family to assist in the process of discharge planning. On 6/4/19 and timed at 10:46 a.m., Resident 1 reported being frustrated due to being separated from her family. On 6/11/19, and timed at 12:34 p.m., Physician 2 informed the facility's staff of Resident 1's decline in health because of her depression and adjustment to the nursing home. On 6/19/19 at 4:09 p.m., during a telephone interview, FM 1 stated that on 5/18/19 he communicated to the facility SSD his wishes to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 563X11 Facility ID: CA970000017 If continuation sheet 9 of 16 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: _______________ 555071 (X3) DATE SURVEY COMPLETED 08/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNYVIEW CARE CENTER 2000 W Washington Blvd Los Angeles, CA 90018 (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 Resident 1 home, but was informed that they had to hold Resident 1 in the facility for 24 hours for billing purposes. FM 1 stated that the facility was not acknowledging Resident 1's wishes to go home and "She (Resident 1) was being held hostage by the facility." On 6/19/19 at 4:35 p.m., during a concurrent observation and interview, Resident 1 was observed in her wheelchair with her head down looking towards the floor. Resident 1's eyes were observed watery and stated that she felt sad and unhappy because she was unaware why she was not allowed to go home to be with her family. Resident 1 stated that she had family to take care of her at home and she did not want to die in a place it was not her home. On 6/19/19 at 4:56 p.m., during a concurrent interview and record review, the Director of Nursing (DON) stated that Physician 1 was not discharging Resident 1 home because she required total assistance from staff in her ADLs. The DON was not able to provide documentation of the phone conversation with Physician 1. On 6/19/19 at 5:05 p.m., during an interview, FM 2 stated that the facility staff was notified of Resident 1's strong family support and that Resident 1 had someone at home to care for her. On 6/19/19 at 5:20 p.m., during a concurrent interview and record review (Nursing notes 5/2019 through 6/2019), the DON stated that according to the facility's policy (Resident's Rights), Resident 1 had the right to go home, but the physician (Physician 1) was not approving Resident 1's discharge. The DON stated that there was no documentation of the conversations between Physician 1 and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 563X11 Facility ID: CA970000017 If continuation sheet 10 of 16 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: _______________ 555071 (X3) DATE SURVEY COMPLETED 08/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNYVIEW CARE CENTER 2000 W Washington Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility's staff regarding Resident 1's wishes to be discharged home with her family. On 6/19/19 at 5:25 p.m., during a telephone interview, the SSD stated that Resident 1 was self-responsible and able to make decisions. The SSD stated that she initiated Resident 1's discharge in 5/2019 (didn't remember the date) but discontinued it when the doctor (Physician 1) indicated that a discharge was unsafe. The SSD stated that she did not speak with Physician 1 regarding the resident's wishes to be discharged home. The SSD stated that the resident had the right to be discharged and not held against her will. On 6/19/19 at 5:31 p.m., during a concurrent interview and record review (Nursing notes 5/2019 through 6/2019), Licensed Vocational Nurse 1 (LVN 1) stated there was no documentation of the conversation she had with Physician 1 regarding Resident 1's wishes to be discharged home. LVN 1 stated that none of the staff followed-up or acknowledged the residents' wishes to be discharged home. LVN 1 stated that she was aware of Resident 1's decline in her emotional state, as was indicated in Physician 2's consultation notes. LVN 1 indicated that Physician 2 informed the staff of Resident 1's frustration of not being able to be discharged home to her family. On 6/19/19 at 6:13 p.m., during a telephone interview, Physician 1 stated he mentioned to the staff to start planning Resident 1's discharge (did not remember the fate) with the appropriate home health assistance. Physician 1 stated that Resident 1 was declining ad becoming depressed and sad because she wanted to go home, but couldn't discharge her until the facility provided the resident and family with teach back education regarding her care at home. Physician 1 stated he was aware he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 563X11 Facility ID: CA970000017 If continuation sheet 11 of 16 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: _______________ 555071 (X3) DATE SURVEY COMPLETED 08/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNYVIEW CARE CENTER 2000 W Washington Blvd Los Angeles, CA 90018 (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 could not hold Resident 1 against her will and he would write a discharge order to go home when education and medical equipment was provided by the facility. On 6/19/19 at 6:35 p.m., during a concurrent observation and interview, Resident 1 was observed to be excited and smiling after she was notified that Physician 1 would write a discharge order after discharge education and medical equipment was provided. FM 1 stated that the reason why Resident 1 did not leave Against Medical Advice (AMA) was because they were informed by the staff that no home equipment was going to be provided if she (Resident 1) left AMA (such as a wheelchair, hospital bed and transfer lift). On 6/27/19 at 2:30 p.m., during a telephone interview, Physician 2 stated that Resident 1 was emotionally distressed due to her separation from her family. Physician 2 stated that the facility's staff was made aware over a month prior of Resident 1's wishes to go home with her family. A review of the facility's undated policy, "Resident's Right," indicated that the purpose of the facility was to respect and encourage patient self-determination and encourage participation in decision making regarding their care through education and inquiry. A review of the undated policy, "Transfer and Discharge Policy & Procedure," indicated that the transfer and discharge is ideally planned event. The facility's staff should handle the transfer/discharge of the residents in a way that minimizes the resident's and family's anxiety. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 563X11 Facility ID: CA970000017 If continuation sheet 12 of 16 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: _______________ 555071 (X3) DATE SURVEY COMPLETED 08/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNYVIEW CARE CENTER 2000 W Washington Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F711 Physician Visits - Review Care/Notes/Order CFR(s): 483.30(b)(1)-(3)

F711 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10/23/2019 §483.30(b) Physician Visits The physician must§483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; §483.30(b)(2) Write, sign, and date progress notes at each visit; and §483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure physician's visits with a written summary were completed and documented in the resident's clinical chart for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1's inadequate discharge planning. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the resident was initially admitted to the facility on 12/17/18 and last readmitted on 5/20/19. Resident 1's diagnoses included diabetes (low/high concentrations of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 563X11 Facility ID: CA970000017 If continuation sheet 13 of 16 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: _______________ 555071 (X3) DATE SURVEY COMPLETED 08/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNYVIEW CARE CENTER 2000 W Washington Blvd Los Angeles, CA 90018 (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 sugar in the blood), depression (state of general unhappiness) and obesity (overweight). According to the Face Sheet, Resident 1 was self-responsible and her own decision maker. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/16/19, indicated Resident 1 had a Brief Interview for Mental Status ([BIMS] a mental test) score of 15 (13 to 15 indicates an intact cognition [thought process]). The MDS indicated Resident 1 was totally dependent of a one-person physical assist for ADLs. The MDS indicated there was no discharge plan initiated for Resident 1 to return to the community. A review of Resident 1's undated Baseline Care Plan indicated that the staff would initiate the resident's discharge planning process. A review of the Multidisciplinary Progress Note, dated 5/21/19 and signed by the Social Services Director (SSD), indicated that Resident 1's family wanted to take the resident home. A review of the Interdisciplinary Team's ([IDT] a group of disciplines that work together towards a common goal for a resident) document titled, "Resident's Discharge Planning," dated 5/28/19, indicated that Resident 1's family member (FM 1) wanted the resident to be discharged home. The IDT document indicated that Resident 1 nor FM 1 attended the discharge planning meeting. A review of the a IDT note, dated 6/5/19, indicated that Resident 1 had family to assist with her care at home. The IDT note indicated that the SSD informed FM 2 that the resident's physician (Physician 1) refused to discharge Resident 1 home. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 563X11 Facility ID: CA970000017 If continuation sheet 14 of 16 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: _______________ 555071 (X3) DATE SURVEY COMPLETED 08/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNYVIEW CARE CENTER 2000 W Washington Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 6/19/19 at 4:09 p.m., during a telephone interview, FM 1 stated that on 5/18/19, he communicated to the facility his wishes to discharge Resident 1 home, but was informed that they had to hold the resident in the facility for 24 hours for billing purposes. FM 1 stated that the facility was not acknowledging Resident 1's wishes to go home and was being held hostage by the facility. On 6/19/19 at 4:35 p.m., during a concurrent observation and interview, Resident 1 was noted in her wheelchair with her head down looking towards the floor. Resident 1's eyes were noted watery and stated that she felt sad and unhappy because she was unaware why she was not allowed to go home. Resident 1 stated that she had family to take care of her at home and did not want to die in a place that was not her home. At 4:56 p.m. on 6/19/19, during a concurrent interview and record review, the Director of Nursing (DON) stated that Physician 1 was not discharging Resident 1 home because she required total care. On 6/19/19 at 5:20 p.m., during a concurrent interview and record review, the DON stated that according to their facility's policy, Resident 1 had the right to go home, but Physician 1 was not approving Resident 1's discharge. The DON stated that there was no documentation of the conversations between Physician 1 and the facility's staff regarding Resident 1's wishes to be discharged home with her family. At 5:31 p.m. on 6/19/19, during a concurrent interview and record review, Licensed Vocational Nurse 1 (LVN 1) stated that there was no documentation of the conversation she had with Physician 1 regarding Resident 1's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 563X11 Facility ID: CA970000017 If continuation sheet 15 of 16 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: _______________ 555071 (X3) DATE SURVEY COMPLETED 08/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNYVIEW CARE CENTER 2000 W Washington Blvd Los Angeles, CA 90018 (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 denial to be discharged home. LVN 1 stated that none of the staff followed-up or acknowledged Resident 1's wishes to be discharged home. LVN 1 stated that she was aware of the decline in Resident 1's emotional state that as indicated in the psychologist consultation notes. LVN 1 indicated that the psychologist stated to the staff Resident 1's frustration for not being able to be discharged home to her family. On 6/19/19 at 6:13 p.m., during a telephone interview, Physician 1 stated that he mentioned to the staff to start planning Resident 1's discharge with the appropriate home health assistance. Physician 1 stated that he failed to document Resident 1's assessments and plan of care and the communication with the facility regarding his denial for the resident's discharge. Physician 1 stated that he was aware that he needed to document in the resident's clinical record, but he forgot. On 6/28/19 at 1:30 p.m., the DON stated that the facility did not have a Physician Job description guideline to ensure that the physicians were following the facility's expectations for residents' care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 563X11 Facility ID: CA970000017 If continuation sheet 16 of 16