Other·January 31, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of The Department of Public Health during an investigation of two complaints. Complaint numbers: 512158 and 515016 Representing the Department of Public Health: Surveyor ID #: 36331 RN, HFEN The inspection was limited to the specific complaint investigations and does not represent the findings of a full inspection of the facility. A federal deficiency and a State Citation was issued for complaint numbers 512158 and 515016.

F205 SS=D NOTICE OF BED-HOLD POLICY BEFORE/UPON TRANSFR CFR(s): 483.15(d)(1)(i)-(iv)(2)

F205 (d) Notice of bed-hold policy and return(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state 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: 44WY11 Facility ID: CA970000083 If continuation sheet 1 of 4 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: _______________ 056380 (X3) DATE SURVEY COMPLETED 01/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS FELIZ HEALTHCARE & WELLNESS CENTRE, LP 3002 Rowena Ave Los Angeles, CA 90039 (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 plan, under § 447.40 of this chapter, if any; (iii) The nursing facility’s policies regarding bedhold periods, which must be consistent with paragraph (c)(5) of this section, permitting a resident to return; and (iv) The information specified in paragraph (c) (5) of this section. (2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (e)(1) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement the bed hold policy for one of two sampled residents (Resident 1) by failing to allow Resident 1 to return to the facility within the seven day bed hold. On November 14, 2016, Resident 1 was transferred to a general acute care hospital for evaluation and on November 21, 2016, the facility refused to readmit Resident 1. This deficient practice resulted in Resident 1 remaining at the general acute care facility for over one month, until transferred to another skilled nursing facility. Findings: A review of the admission record indicated Resident 1 was readmitted to the facility, on October 29, 2015, with diagnoses which included unspecified dementia (deterioration of memory, changes in behavior, and various other physical and mental problems) with behavioral disturbances and history of falling. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 44WY11 Facility ID: CA970000083 If continuation sheet 2 of 4 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: _______________ 056380 (X3) DATE SURVEY COMPLETED 01/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS FELIZ HEALTHCARE & WELLNESS CENTRE, LP 3002 Rowena Ave Los Angeles, CA 90039 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the Minimum Data Sheet ( MDS an assessment and care screening tool), dated September 9, 2016, indicated Resident 1 had clear speech, the ability to express ideas and wants, and comprehends verbal content. Resident's 1 functional status indicated he used a wheelchair, and moved from seated to standing position requiring staff assistance to stabilize resident. The MDS indicated Resident 1 required extensive assistance with transferring from bed, chair, wheelchair and standing. A review of the Physician's Order sheet, dated November 14, 2016, indicated Resident 1 was to be transferred and the Notice of Proposed Transfer form, same date, indicated to transfer Resident 1 to a general acute care facility. According to the Discharge Chart Monitor form for Resident 1, dated November 21, 2016, the Bed-hold Notice / Bed-hold Order section was documented not applicable (N/A). A review of the general acute care facility's Clinical Notes Report, dated November 28, 2016 indicated the social worker from the GACH called the skilled nursing facility regarding Resident 1's return and the skilled facility reiterated its intention / decision not to accept Resident 1 back. Further record review disclosed no evidence the facility provided a written notice of the bed hold. Upon discharge, there was no physician order indicating to hold the bed for seven days. During an interview, on December 7, 2016, at 2:15 p.m., the Director of Nursing stated a bed hold was not done for Resident 1. During a follow up interview, on December 7, 2016, at 3:40 p.m., regarding the failure to issue a bed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 44WY11 Facility ID: CA970000083 If continuation sheet 3 of 4 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: _______________ 056380 (X3) DATE SURVEY COMPLETED 01/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS FELIZ HEALTHCARE & WELLNESS CENTRE, LP 3002 Rowena Ave Los Angeles, CA 90039 (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 hold, the Administrator stated, "It was something that fell through the cracks." The administrator was asked about notifying Resident 1's family regarding the bed hold and he stated, "The facility refused to let the resident return." The facility policy and procedure titled, "Bed Hold," dated January 1, 2012, indicated the facility notifies the resident and /or representative, in writing, of the bed hold policy, any time the resident was transferred to a general acute care hospital. The Licensed nurse would communicate with the acute care hospital staff to monitor the resident's medical progress and expected date of return to the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 44WY11 Facility ID: CA970000083 If continuation sheet 4 of 4