Other·September 25, 2020

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health (DPH) during an investigation of a complaint. Complaint: CA00694556 Representing the DPH: Health Facilities Evaluator Nurse ID #: 19152 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Three deficiencies were issued for Complaint CA00694556.

F608 SS=D Reporting of Reasonable Suspicion of a Crime F608 CFR(s): 483.12(b)(5)(i)-(iii) 09/08/2020 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual's obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who 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: 7LHS11 Facility ID: CA970000017 If continuation sheet 1 of 10 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 08/28/2020 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 is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. (ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. (iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility's administrative staff failed to Report an allegation of physical abuse to the Department of Public (DPH) for one sampled resident (Resident A). This deficient practice resulted in the inability of the DPH to investigate the allegation of abuse in a timely manner. Findings: A review of Resident A's Admission Records indicated Resident A was initially admitted to the facility on 2/27/15 and last readmitted on 10/29/19. Resident A's diagnoses included dementia (progressive loss of memory) without behavioral disturbance. A review of Resident A's Minimum Data Set (MDS), a care and screening tool, dated 4/20/2020, indicated Resident A had independent, reasonable, consistent cognition (thought process) and exhibited verbal behavioral symptoms directed towards others. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7LHS11 Facility ID: CA970000017 If continuation sheet 2 of 10 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 08/28/2020 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 8/25/2020 at 4:20 p.m., during an interview and on 8/26/2020, at 12:15 p.m. during a subsequent telephone interview, the Director of Nursing (DON) stated Resident A was alert and oriented to name, place, date, and time. The DON stated Resident A had a behavior of refusing care from nurses who she (Resident A) felt had done something she did not like. The DON stated they had to rotate nurses so they would not become burned out with Resident A's behavior and accusations towards them. The DON stated when Resident A reported that a certified nursing assistant (CNA 1) hit her in the shower they considered it a grievance and not an allegation of abuse because Resident A changed her story. The DON stated Resident A did not want to report it to the police and did not want them to pursue it and still wanted CNA 1 to care for her so they did not feel they needed to report it. A review of an Interdisciplinary Team ([IDT] group of different disciplines working together towards a common goal of a resident) Conference Record, dated 11/13/19, indicated Resident A reported CNA 1 hit her while she (Resident A) was receiving a shower. Resident A stated " She hit me on my back, it wasn't hard." Continued review of the IDT record indicated Resident A was given a number to the local police department to file her complaint. Resident A responded, she did not want to press any charges and CNA 1 only hits her on her shower days and she does not mind having CNA 1 except during her showers. The IDT note indicated the IDT team offered Resident A alternative options for placement. Continued review of the IDT note indicated there was no written documentation that the DPH was notified of the allegation of abuse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7LHS11 Facility ID: CA970000017 If continuation sheet 3 of 10 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 08/28/2020 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 review of Resident A's "Concern Record (Theft/Loss and Grievance Report)," dated 11/13/19, indicated Resident A stated, "I don't want (CNA 1) as my nurse on my shower days because she hit me twice, last time when giving me care." A review of the facility's undated policy and procedure (P/P) titled, "Abuse Allegation Investigation," indicated for suspected abuse that does not result in serious bodily injury by a resident with a diagnosis of dementia, the mandated reporter must: Report the incident to the local Ombudsman or the local law enforcement agency by telephone as soon as possible, send a written report within 24 hours to either the local Ombudsman or the local law enforcement agency, the L&C program is not required to receive these reports.

F610 SS=D Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4)

F610 09/08/2020 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7LHS11 Facility ID: CA970000017 If continuation sheet 4 of 10 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 08/28/2020 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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility's administrative staff failed to investigate an allegation of physical abuse for one sampled resident (Resident A). This deficient practice resulted in the inability of the facility and the Department of Public Health (DPH) to determine in a timely manner if physical abuse occurred and had the potential for abuse to continue. Findings: A review of Resident A's Admission Records indicated Resident A was initially admitted to the facility on 2/27/15 and last readmitted on 10/29/19. Resident A's diagnoses included dementia (progressive loss of memory) without behavioral disturbance. A review of Resident A's Minimum Data Set (MDS), a care and screening tool, dated 4/20/2020, indicated Resident A had independent, reasonable, consistent cognition (thought process); and exhibited verbal behavioral symptoms directed towards others. On 8/25/2020 at 4:20 p.m., during an interview and on 8/26/2020, at 12:15 p.m. during a subsequent telephone interview, the Director of Nursing (DON) stated Resident A was alert and oriented to name, place, date, and time. The DON stated Resident A had a behavior of refusing care from nurses who she (Resident A) felt had done something she did not like. The DON stated they had to rotate nurses so they would not become burned out with Resident A's behavior and accusations towards them. The DON stated when Resident A FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7LHS11 Facility ID: CA970000017 If continuation sheet 5 of 10 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 08/28/2020 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 reported a certified nursing assistant (CNA 1) hit her in the shower they considered it a grievance and not an allegation of abuse. The DON stated the Administrator was out of the facility for the next week and after looking through the Administrator's files the DON stated she could not find an investigation of Resident A's grievance. A review of an Interdisciplinary Team ([IDT] a group of different disciplines working together towards a common goal for a resident) Conference Record, dated 11/13/19, indicated Resident A reported CNA 1 hit her while she (Resident A) was receiving a shower. Resident A stated, " She hit me on my back, it wasn't hard." Continued review of the IDT record indicated Resident A was given a number to the local police department to file her complaint. Resident A responded, she did not want to press any charges and CNA 1 only hits her on her shower days and she does not mind having CNA 1 except during her showers. The IDT note indicated the IDT team offered Resident A alternative options for placement. Continued review of the IDT note indicated there was no written documentation that an investigation was conducted. A review of Resident A's Concern Record (Theft/Loss and Grievance Report), dated 11/13/19, Resident A stated, "I don't want (CNA 1) as my nurse on my shower days because she hit me twice, last time when giving me care." A review of the facility's undated policy and procedure (P/P) titled, "Abuse Allegation Investigation," indicated to ensure that a complete and thorough investigation is conducted for all allegations of abuse. The policy indicated the facility shall complete a thorough investigation of all allegations of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7LHS11 Facility ID: CA970000017 If continuation sheet 6 of 10 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 08/28/2020 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 abuse. Upon completion of the investigation all supporting documents shall be placed in a file labeled "Abuse Investigation." The file shall include the name of the resident involved and the date of completion of the investigation.

F842 SS=E Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 09/08/2020 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7LHS11 Facility ID: CA970000017 If continuation sheet 7 of 10 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 08/28/2020 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 with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to track incidents/accidents occurring in the facility on an incident/accident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7LHS11 Facility ID: CA970000017 If continuation sheet 8 of 10 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 08/28/2020 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 log. This deficient practice resulted in the facility's inability to monitor, trend, retrieve incident/accidents as they occurred and had the potential to continue. Finding: On 8/25/2020 at 5:30 p.m., during an interview, the Director of Nursing (DON) stated she did not have an incident/accident log available for review. The DON stated they had been very busy during the COVID (a highly contagious respiratory disease) outbreak and had not had time to track the incident/accidents that occurred in the facility since at least January 2020 on a log. The DON stated she had individual forms of what had occurred in the facility but would need a moment to gather them all. On 8/26/2020 at 3:11 p.m., via an email, the facility's Monthly Incident Report Log was received. A review of the Monthly Incident Report Log indicated the following: January 2020 - Four residents listed with only one indicating what the incident/accident was February 2020 - Five residents listed with only three indicating what the incident/accident was March 2020 - Four residents listed with only two indicating what the incident/accident was April 2020 - Nine residents listed with only only four indicating what the incident/accident was May 2020 - Eight residents listed with none indication what the incident/accident was On 8/27/2020 at 12:15 p.m., during a telephone interview, the DON stated she listed verbal altercations that happened between the residents and if the resident did not make contact with the floor it was left blank. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7LHS11 Facility ID: CA970000017 If continuation sheet 9 of 10 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 08/28/2020 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 review of the facility's undated policy and procedure (P/P) titled, "Reporting Accident/Incidents," indicated the purpose is to provide a reporting system for accidents and incidents. The policy indicated accidents and incidents shall be reported to the charge nurse and documented on the accident/incident log as soon as they occur. Incident/accident reports shall be completed as soon as possible and forwarded to the DNS (DON) for review. The DNS and the DSD shalt review reports and then forward to the facility administrator for further review. Administrator shall log incidents/accident reports. Administrator, DNS, Assistant DNS, DSD and Medical Director shall review reports monthly at CQIC meeting. The Medical Director shall sign off on all incident/accident reports monthly. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7LHS11 Facility ID: CA970000017 If continuation sheet 10 of 10