Other·November 8, 2019

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health of a Complaint investigation during an Abbreviated Standard Survey. Complaint number: CA00653053 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 34180 The inspection was limited to the specific Complaint investigation and does not represent the findings of a full inspection of the facility. A pattern of the facility's system failure was identified due to failure to implement its policies to ensure residents who were at risk for elopement and required supervision and/or monitoring was not being supervised and had more than two elopement attempts without the staff's knowledge, and unsafe environment, inadequate monitoring and supervision was identified. On 9/3/19 at 5:40 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident) was declared for F689. The facility's administrator (ADM) and the Director of Nursing (DON) were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 9/3/19 at 10:23 p.m., the ADM and DON provided an acceptable plan of action (POA) for correction of the IJ. On 9/5/19 at 5:08 p.m., after the team verified that the Plan of Action (POA) was implemented, both the DON 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: WK1E11 Facility ID: CA970000017 If continuation sheet 1 of 18 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 10/09/2019 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 and the ADM were notified the IJ was lifted.

F689 SS=K Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 11/09/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interviews and record review, the facility failed to implement a resident's plan of care and its policies titled, "Care of the Wandering Resident, Elopement Risk /Prevention and Wanderguard," which indicated that the staff would follow protocol for conducting visual checks, checking residents at risk for elopement (leaving unsupervised, undetected and without authorization or permission) on a regular means, monitor the resident's location and provide one to one (1:1) monitoring as needed, and the facility failed to monitor all doors and ensure alarms were operable on all doors for two of four sampled residents (Residents 1 and 2). Residents 1 and 2, who were assessed as a risk for elopement had a history of wandering into other resident's room and eloping from the facility on multiple occasions, required close supervision but were not being monitored by the facility's staff and the staff did not have any knowledge of Resident 1 and 2's whereabouts. Resident 1, who had eloped three times, was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WK1E11 Facility ID: CA970000017 If continuation sheet 2 of 18 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 10/09/2019 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 not being supervised by the nightshift staff, after attempting to exit from an unalarmed back door of the facility several times within 24 hours prior to him eloping. A review of the facility's surveillance camera video indicated on 9/2/19 at 5:06 a.m., Resident 1 exited from the back door of the facility and entered into a utility van located in the facility's parking lot. Resident 2, who had a history of eloping from the facility three times within 19 days and went missing for over six hours, and once he was located and returned to the facility, resulted in a transfer to the general acute care hospital (GACH) due to elevated blood sugars. These deficient practices resulted in Resident 1, who required close supervision, went missing and was found 36 hours (9/3/19 at 11:30 a.m.) in a utility van located in the facility's parking lot by the facility's staff after they reviewed the video surveillance. The staff discovered Resident 1 was in the van breathless and without movement. The staff determined Resident 1 was deceased. These deficient practices had the potential to result in harm, injury, or death to the other 12 high risk elopement residents. A pattern of the facility's system failure to implement its policies to ensure residents who were at risk for elopement and required supervision and/or monitoring was not being supervised and had more than two elopement attempts without the staff's knowledge, and unsafe environment, inadequate monitoring and supervision was identified. On 9/3/19 at 5:40 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WK1E11 Facility ID: CA970000017 If continuation sheet 3 of 18 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 10/09/2019 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 serious injury, harm, impairment, or death to a resident) was declared for F689. The facility's administrator (ADM) and the Director of Nursing (DON) were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 9/3/19 at 10:23 p.m., the ADM and DON provided an acceptable plan of action (POA) for correction of the IJ. The POA included the following: 1. An alarm installed to emergency exit door, from smoking patio to the west side parking lot on 9/3/19. 2. An alarm installed on the back of the building to the east side emergency exit by the kitchen as of 9/3/19. 3. An alarm installed to exit door employee lunch room to the west side parking lot. 4. The west side parking lot emergency exit had an alarm system installed. 5. The east side parking lot emergency exit had an alarm system installed. 6. The emergency exit alarm system will be loud enough that the staff will respond quickly. 7. In-service provided by the administrator/designee to all shifts staff and contracted vendors in regards to elopement risk behavior including policy/procedure, intervention and the alarm system. 8. Current residents will be assessed for elopement risk factors to ensure intervention will be implemented based on findings. 9. Residents with risk of elopement will have personal safety alarm device, identification bracelet and pictures on the elopement risk list. 10. The DON/Registered Nurse (RN) Supervisor will monitor residents every two hours, during medication pass and activities of daily living ([ADL] routine activities that people do every day without needing assistance, such as: eating, bathing, dressing, toileting, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WK1E11 Facility ID: CA970000017 If continuation sheet 4 of 18 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 10/09/2019 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 transferring and walking) care for 30 days and findings will be presented to the Quality Assurance (QA) committee in 90 days. 11. The Minimum Data Set (MDS) nurse will ensure physician's orders are in place for residents with elopement risk and an updated elopement risk residents list with a picture. 12. Wanderguard (a device that alarms when residents attempt to elope or wander from a safe environment) checks will be in place on a weekly basis for activity and admission coordinator to ensure the Wanderguard system is effective. 13. A binder per Station, will be placed for elopement risk residents with name and picture. 14. The shift supervisor/charge nurse will discuss with the Certified Nursing Assistant (CNAs), on every shift, re: residents with risk of elopement, monitoring system and supervision. 15. A door person will be assigned by the front door to monitor, redirect and prevent elopement of residents from exiting the building. 16. Reporting within 24 hours of an unusual occurrence/missing resident to the Department of Public Health. On 9/5/19 at 5:08 p.m., after the team verified that the Plan of Action (POA) was implemented, both the DON and the ADM were notified the IJ was lifted. Findings: a. A review of Resident 1's records indicated the following: An "Admission Record," indicated the resident was initially admitted to the facility on 11/7/18 and most recently re-admitted on 8/9/19. Diagnoses included schizoaffective disorder (a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WK1E11 Facility ID: CA970000017 If continuation sheet 5 of 18 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 10/09/2019 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 chronic mental health condition), unspecified psychosis (a mental disorder characterized by a disconnection from reality), cognitive (thought process) communication deficit, delusional (believing things that are not true) disorders, insomnia (difficulty sleeping) and auditory hallucinations (hearing false beliefs). An Admission Assessment, dated 11/7/18, indicated the resident's cognition (ability to think and reason) was marked only as alert. A history and physical (H/P), dated 11/8/19, 1/18/19 and 8/10/19, indicated the resident did not have the capacity to understand and make decisions. A Care Plan, dated 11/8/18, last revised on 8/11/19, and titled "Elopement Risk," resident may sometimes leave the facility without authorization/permission because of diagnosis of schizoaffective disorder. The staff's interventions included for the staff to follow protocol of visual checks. A Care Plan, dated 11/8/18 and titled, "Language Barrier," indicated the resident was at risk for having communication difficulties due to non-English speaking. The staff's interventions included for the staff to use nonverbal ways of communicating, such as gestures, signals/sounds and facial expressions. An Interdisciplinary Team Conference ([IDT] a group of healthcare professionals developing care needs that meets the resident's needs and goals) record, dated 11/13/18, with a note entry dated 12/31/18, by the Social Service Designee (SSD) that indicated the SSD was informed by the Director of Nursing (DON) of Resident 1's attempts to leave out of the back door of the facility leading to the back parking lot. There FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WK1E11 Facility ID: CA970000017 If continuation sheet 6 of 18 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 10/09/2019 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 was no documented evidence in Resident 1's nurses' notes of the resident's attempted elopement on 12/31/18. A physician's order, dated 11/16/18, indicated for the staff to apply a Wanderguard on Resident 1 due to the risk of elopement. A nurses' note, dated 1/7/19 and timed at 8 a.m., indicated Resident 1 was observed walking fast towards the direction of the front lobby, main door of the facility, but was observed and escorted back to his room. The note indicated on the same day at 9 a.m., an hour after the first attempt, Resident 1 attempted to leave the facility again from the main door of the lobby and was escorted back to his room. The nurses' note indicated on the same day at 9:05 a.m., Resident's family member (FM 1) was notified of the resident's two elopement attempts (12/18/18 and 1/7/19) and FM 1 stated Resident 1 displayed the same behavior while at home. According to the nurses' note, FM 1 indicated Resident 1 had escaped from home because he wanted to find his girlfriend and the police was called to search for him. FM 1 asked for the staff to notify Resident 1's physician to transfer the resident to the hospital. A Psychiatric Emergency Teams ([PET] mobile response teams made up of licensed mental health clinicians that evaluate and assess individuals during a psychiatric crisis) note, dated 1/8/19 indicated "According to a charge nurse," the resident (Resident 1) eloped from the facility and walked onto a busy traffic street, for which the cars had to stop to prevent hitting the resident. The note indicated the staff returned Resident 1 to the facility and Resident 1's behavior had been out of control for the past 24 hours. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WK1E11 Facility ID: CA970000017 If continuation sheet 7 of 18 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 10/09/2019 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 A discharge summary indicated the Resident 1 was transferred to the GACH on 1/8/19 for delusions and agitation (feeling or appearing troubled or nervous). A GACH Psychiatrist's (a physician who specializes in the diagnosis and treatment of mental disorders) evaluation, dated 1/9/19, indicated Resident 1 was admitted on a 5150 (an involuntary hold of a person with a mental health disorder who was a danger to themselves and others). The Psychiatrist's evaluation indicated Resident 1 had eloped from the facility and walked onto the busy street in the middle of oncoming traffic, where cars had to stop to prevent Resident 1 from being hit. A re-Admission Assessment, dated 1/16/19, after seven days at the GACH, indicated Resident 1 was reluctant to answer questions, had slow comprehension and was alert, but only oriented to time and place. A "Physical Restraint Assessment," dated 2/13/19, indicated Resident 1 required a Wander guard at all times due to risk of elopement related to disorientation (confusion) and cognitive communication. A review of Resident 1's plan of care, dated 2/13/19 titled, "Wanderguard, resident to wear because of a history of leaving or attempting to leave the facility which compromises his safety due to a diagnosis of schizophrenia." The staff's interventions included for the staff to check placement of Wanderguard bracelet, periodic reassessment of the Wanderguard use, staff to check and ensure the wander guard was functioning properly. A physician's order dated 8/9/19 and timed at 3 p.m., indicated for the staff to apply a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WK1E11 Facility ID: CA970000017 If continuation sheet 8 of 18 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 10/09/2019 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 Wanderguard on Resident 1 due to the risk of elopement. A Re-Admission Assessment, dated 8/9/19, indicated Resident 1 was combative (ready or eager to fight), and disoriented to time, place and person. A nurses' note, dated 9/2/19 and timed at 6:30 a.m., indicated Resident 1 was observed "playing" with the facility's back door, next to the kitchen. According to the nurses' note, Resident 1 was escorted back to his room [Sic]. A nurses' note, dated 9/2/19 and timed at 7 a.m., indicated a Certified Nursing Assistant (CNA 2) reported that Resident 1 was not in his room and was unable to be located. The note indicated the staff began searching for Resident 1. A nurses' notes, dated 9/2/19 and timed at 8 a.m., 8:10 a.m., 8:20 a.m., and 8:30 a.m., indicated FM 1, the physician and the local police department were notified that Resident 1 went missing and had not been located within the facility. The note indicated on 9/2/19 at 8:20 a.m., two local police officers arrived to the facility and took a report. The note indicated at 8:30 a.m., on the same day the Administrator (ADM) and the DON were notified that Resident 1 was missing from the facility. A nurses' note, dated 9/2/19 and timed at 10 a.m., indicated the local police officers arrived to the facility with a sniff and search dog (trained dogs that are sensitive to smells and can identify suspicious objects more easily than humans) attempting to locate Resident 1. A nurses' note, dated 9/2/19 and timed at 10:40 a.m., 4 p.m., and 10:45 p.m. indicated the facility received a telephone call from the local FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WK1E11 Facility ID: CA970000017 If continuation sheet 9 of 18 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 10/09/2019 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 police department inquiring if Resident 1 had been located and they would continue to call for an update about Resident 1. A nurses' note, dated 9/3/19 and timed from 8 a.m. through 11 a.m., indicated various hospitals in the surrounding area were called to check if Resident 1 was possibly admitted, but Resident 1 was not located. A nurses' note, dated 9/3/19 and timed at 11:30 a.m., (over 30 hours after going missing) indicated two nurses and the ADM reviewed the facility's surveillance camera (used for observing an area) and observed Resident 1 leaving out of his room, and walking towards the kitchen door going towards the back parking lot, located on the west side of the facility. The note indicated Resident 1 walked in the corner of the parking lot and opened the door of the utility van and sat in the driver's seat. The note indicated after Resident 1 sat in the van, he was observed getting out of the van for three to five seconds, before returning to the driver's seat of the van. The note indicated on the same day, Licensed Vocational Nurse 1 (LVN 1) and the Maintenance Supervisor (MS) approached the van parked in the parking lot and observed Resident 1 sitting in the passenger's seat of the van. The note indicated Resident 1 was pale, not breathing, with no chest movement and appeared to be deceased. The note indicated 911(emergency services) and the local police department was called. A nurses' note, dated 9/3/19 and timed at 3:16 p.m., indicated the coroner (an official who investigates violent, sudden, or suspicious deaths) arrived to the facility for Resident 1. A nurses' note, dated 9/3/19 and timed at 5 p.m., indicated Resident 1's physician was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WK1E11 Facility ID: CA970000017 If continuation sheet 10 of 18 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 10/09/2019 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 called and was notified that Resident 1 was located in a van in the facility's parking lot deceased. On 9/3/19 at 2:37 p.m., upon entrance to the facility, local police officers and detectives, were observed in the ADM's office, when one of the police officers' indicated there was an unfortunate incident. On 9/3/19 at 2:40 p.m., during an interview, the DON stated Resident 1 went out of the back door of the facility, into the parking lot and entered into one of the facility's corporate vans and was found deceased by the staff. On 9/3/19 at 2:50 p.m., during a concurrent observation of the facility's back door and interview with the DON and the MS, they stated the alarm attached to the back door was not working and the MS stated that the door leads to the parking lot. On 9/5/19 at 3:08 p.m., during an interview, CNA 3 started crying and stated, "This really hurts me." CNA 3 stated she worked in the facility on Sunday 9/1/19 and Monday 9/2/19 from 7 a.m. to 3 p.m., and was assigned to Resident 1. CNA 3 stated Resident 1 had a routine of sitting in the non-smoking patio for long hours and would eat his breakfast, lunch and dinner in that patio area. CNA 3 stated Resident 1 would only come inside from the patio to use the bathroom. CNA 3 stated back in December 2018, Resident 1 was not in his room and was not in the facility, and the staff did not know that Resident 1 went missing. CNA 3 stated Resident 1 had eloped from the facility and was found outside of the facility, standing under a tree shivering, because it was very cold that day. CNA 3 stated two weeks prior to Resident 1's December 2018 elopement, Resident 1 was found outside of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WK1E11 Facility ID: CA970000017 If continuation sheet 11 of 18 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 10/09/2019 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 facility in the east parking lot by the large gate. CNA 3 stated on 9/2/19 at 7:14 a.m., and she entered the facility at 7:15 a.m., went to Resident 1's room, but he was not there and she began passing breakfast trays. CNA 3 stated on the same day she did not see Resident 1's breakfast tray and went to the non-smoking patio, but Resident 1 was not there. CNA 3 stated on the same day she asked LVN 3 if Resident 1 was sent out to the hospital or discharged from the facility and LVN 3 replied, "No, the resident was probably in the patio." CNA 3 stated she informed LVN 3 that Resident 1 was not in the patio, CNA 3 stated the facility then began searching for Resident 1. CNA 3 stated Resident 1 wore an alarm bracelet on his ankle. CNA 3 stated on 9/2/19, the same day, she asked LVN 1 to review the facility's surveillance video and camera, but LVN 1 stated the surveillance camera and video were locked in the Administrator's office and the staff does not have a key. On 9/3/19 at 3:05 p.m., during a concurrent observation of the facility's back door and the east parking lot and an interview, LVN 1 stated Resident 1 was alert and oriented, but a quiet person and cognition (thought process) was impaired and did not communicate well due to a language barrier. LVN 1 stated Resident 1 was at risk for eloping and attempted to elope from the front door of the facility six months prior. LVN 1 stated Resident 1 made an attempt to elope, but never got out of the building and was re-directed [sic]. LVN 1 stated on 9/2/19 at approximately at 7:15 a.m., CNA 3 indicated Resident 1 was unable to be located within the facility. LVN 1 stated she searched the middle patio (non-smoking patio) for Resident 1 because he loved sitting in that patio and the bathrooms, but Resident 1 was not located. LVN 1 stated a "Code Green" (an emergency code used denote the activation of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WK1E11 Facility ID: CA970000017 If continuation sheet 12 of 18 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 10/09/2019 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 an emergency plan; missing resident) was announced and initiated between the time of 7:15 a.m. to 7:30 a.m. On 9/3/19 at 3:25 p.m., during a subsequent interview, LVN 1 stated on 9/2/19 at 7:30 a.m., LVN 1 stated she and the staff drove around the surrounding area in an attempt to locate Resident 1. LVN 1 stated on 9/2/19, the same day at 8 a.m., she placed a telephone call to the Adm. and the DON and informed them that Resident 1 was missing. LVN 1 stated she was instructed by the ADM to follow the facility's protocol for a missing resident. LVN 1 stated on 9/3/19 between the hour of 7 a.m. and 8 a.m., she began calling the hospitals in search of Resident 1. LVN 1 stated when the ADM arrived to the facility, they were able to view the facility's surveillance video and she and the ADM observed Resident 1 exiting the facility, entering into a van parked in the facility's parking lot and did not make an exit from the van. LVN 1 stated on 9/3/19, the same day at 12 p.m., she and the MS went out to the east parking lot, opened the door of the van and observed Resident 1 sitting upright and slightly slumped over, with his head down and eyes closed. LVN 1 stated Resident 1 appeared to be deceased and 911 was called. On 9/3/19 at 6 p.m., during an observation of the facility's surveillance video with the ADM and the DON of the day of the incident, Resident 1 was observed walking rapidly in the facility's east parking lot, towards a large gate on 9/2/19 at 5:06 a.m., towards two large white vans parked in the parking lot. At 5:09 a.m., Resident 1 was observed standing between both vans and opened the driver's side door and entered the van closest to the large gate. Resident 1 was observed sitting in the van with the door ajar (slightly open) until 5:12 a.m., then exited the van, at 5:13 a.m., and at 5:14 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WK1E11 Facility ID: CA970000017 If continuation sheet 13 of 18 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 10/09/2019 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 a.m., Resident 1 returned to the van, closed the door and did not exit the van again. On 9/3/19 at 7:24 p.m., during an interview, CNA 1 stated he was assigned to Resident 1 on 8/28/19 and 8/29/19. CNA 1 stated Resident 1 did not talk much and always sat in the middle patio across from his room. During the interview, CNA 1 was unaware why Resident 1 wore an alarm bracelet and was unaware Resident 1 was a high elopement risk. On 9/3/19 at 8:33 p.m., during a concurrent interview and a review of Resident 1's medical records assessments, the DON stated Resident 1 did not have an elopement risk assessment completed on 1/16/19 and 8/9/19, during two separate re-admissions to the facility. The DON stated she could not provide a reason and the facility just missed completing the elopement risk assessment on Resident 1. On 9/3/19 at 8:49 p.m., during a telephone interview, LVN 3 stated she worked in the facility on Sunday 9/1/19 and Monday 9/2/19 from 11 p.m. to 7 a.m. LVN 3 stated on Sunday, 9/2/19 at 6:30 a.m., she observed Resident 1 at the facility's back door. [Sic] LVN 3 stated the back door did not open and it was locked, however, LVN3 stated she did not check to ensure that the back door was locked. LVN 3 stated she observed Resident 1 pushing on the door handles attempting to open the door and she escorted the resident back to his room. LVN 3 stated approximately three months' prior, Resident 1 attempted to elope from the facility by exiting from the front door. b. A review of Resident 2's records indicated the following: An Admission Record indicated Resident 2 was admitted to the facility on 6/7/19 and last reFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WK1E11 Facility ID: CA970000017 If continuation sheet 14 of 18 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 10/09/2019 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 on 7/6/19. Resident 2's diagnoses included paranoid schizophrenia (false beliefs that some individuals are plotting against self or members of family), Alzheimer's disease (memory loss including the loss of intellectual and social abilities that interfere with daily functioning), abnormalities of the gait (walking) and mobility, and muscle weakness. An H/P, dated 7/11/19, indicated Resident 2 did not have the capacity to understand and make decisions. An "Elopement Risk Assessment," dated 7/6/19, indicated the resident had a score of 10. According to the Elopement Risk Assessment, a score of eight (8) or more indicated a risk for elopement. A physician's orders, dated 7/6/19, indicated for the staff to apply an alarm bracelet to the resident's right upper extremity (arms and/or legs) to reduce the risk of elopement. A Care Plan, dated 7/6/19 and titled, "Wander guard, Resident 2 was at risk for Elopement," indicated for the staff to frequently conduct visual supervision. A Care Plan, dated 7/25/19 and titled, "Elopement Risk," Resident 2 was at risk for leaving safe area without authorization, indicated the interventions included for the staff to monitor the resident at frequent intervals, redirect and other alternatives such as, 1:1 monitoring if indicated to redirect the behavior. A nurses' notes, dated 8/2/19 and timed from 3 p.m. through 11:30 p.m., indicated Resident 2 was wandering around the facility, searching for an exit door and had to be redirected to return to his room. The note indicated on 8/2/19 at 5 p.m., Resident 2 made three attempts to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WK1E11 Facility ID: CA970000017 If continuation sheet 15 of 18 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 10/09/2019 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 exit the facility through the front door and was redirected to return to his room, but continued to wander around the facility. The note indicated on the same day, at 6:15 p.m., Resident 2 made another attempt to leave out of the facility and was placed at the nurses' station for 1:1 monitoring. The note indicated at 7:30 p.m., the licensed nurse reported that she was not able to locate Resident 2 and the staff began searching for Resident 2 and 911 was called. The note indicated on the same day, at 8:30 p.m., two police officers arrived to the facility. The note indicated on 10 p.m., on 8/2/19, the local police officers, including a helicopter searched the surrounding area was conducted for Resident 2, but the resident was not located. The note indicated at 11:30 p.m., on 8/2/19, the facility was waiting for the police officers with the blood hounds (a dog with the ability to detect human scent over great distances, even days later) to arrive at the facility. A Change of Condition (COC) Assessment, dated 8/3/19, indicated at 1:30 a.m., Resident 2 was escorted by local police officers back to the facility. The note indicated Resident 2 was found 1.4 miles (an estimated 34-minute walk, equivalent to over 3,000 steps) from the facility. The note indicated upon Resident 2's return to the facility, the resident had an elevated blood glucose (sugar) level of 472 milligrams per deciliter ([mg/dL; unit of measurement] the normal reference range [NRR] is 70 and 130 mg/dL), 911 was called and Resident 2 was sent to the GACH for evaluation and treatment. A COC Assessment, dated 8/10/19, indicated at 7:30 a.m., on 8/10/19, Resident 2 was found outside of the facility and had exited from the Physical Therapy (PT) room. The note indicated security should be put in place, because this was the second time Resident 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WK1E11 Facility ID: CA970000017 If continuation sheet 16 of 18 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 10/09/2019 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 had eloped from the facility from the PT room, four CNAs had to run after him and the staff and resident was locked out of the facility due to no access to open the door or the gate at 2 a.m. A COC Assessment, dated 8/22/19, indicated at 1:30 p.m., the nursing staff made rounds when the front door alarmed and observed Resident 2 walking towards the east direction of the facility. The note indicated the nursing staff yelled and ran towards Resident 2 and returned the resident back to the facility. On 9/3/19 at 4:11 p.m., during an interview, LVN 2 stated Resident 1 was known for wandering and going into other residents' rooms. LVN 2 stated she was told that Resident 1 made an attempt to elope from the facility and would normally sit in the nonsmoking patio. LVN 2 stated Resident 2 made an attempt to elope from the facility, however, Resident 2 is no longer in the facility. LVN 2 stated Resident 2 attempted to exit from the west parking lot gate. On 9/3/19 at 4:24 p.m., during a concurrent observation of the smoking patio emergency exit door leading to the west parking lot of the facility and interview, the emergency exit door was opened with no sound of an alarm ringing, the DON stated there was no alarm at this door and the front door was the only door in the facility with a sensor alarm to activate the alarm bracelets. The DON was asked for a log of residents in the facility who were an elopement risk and residents who required the use of alarm bracelets, which was 14 residents. On 9/3/19 at 4:45 p.m., a review of the facility's list of residents at risk for elopement with alarm bracelets from 8/1/19 to 9/2/19, indicated Residents 1 and 2 were on the list. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WK1E11 Facility ID: CA970000017 If continuation sheet 17 of 18 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 10/09/2019 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 9/3/19 at 5 p.m., during an interview, the DON was asked how did the facility ensure residents who were at risk for eloping from leaving out the facility's back door when there was no alarm on the exit doors. The DON stated the residents could not get out of the facility's parking lot without a remote control to open the gate. The DON was asked when visitors and staff are entering and exiting the facility, how did the facility ensure a resident who was already in the parking lot awaiting for the gate to open since there was no alarm on the back door, the DON could not provide an answer. The DON was asked how did the facility ensure residents with alarm bracelets were being monitored. The DON stated the residents with alarm bracelets cannot go out the front door of the facility without the alarm sounding off. A review of the facility's undated policy titled, "Elopement," indicated the facility will monitor and manage residents at risk for elopement to minimize the risk of residents leaving a safe area without authorization. A review of the facility's undated policy titled, "Care of Wandering Residents," indicated the purpose was to protect wandering residents from injury. The policy indicated residents who wander shall have their picture taken and placed in the medical record and a plan of care should address the wandering. The policy indicated all staff must continuously reorient wandering residents to their room and belongings. The policy indicated the nursing staff must monitor the wandering resident's location with visual checks as needed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WK1E11 Facility ID: CA970000017 If continuation sheet 18 of 18