Other·January 11, 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 California Department of Public Health during an abbreviated survey for the investigation of one complaint and facility reported incident (FRI). FRI number: CA00606465 Complaint number: CA00608318 Representing the California Department of Public Health: Health Facilities Evaluator Nurse ID: 39739 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for FRI number CA00606465 and complaint number CA00608318.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 12/22/2018 §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 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: 7KNT11 Facility ID: CA970000083 If continuation sheet 1 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056380 (X3) DATE SURVEY COMPLETED 12/14/2018 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 supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) who had been identified as having behaviors of wandering (move about without a definite destination or purpose and can be dangerous when the person goes in areas with unsafe conditions) and identified at risk for elopement (the most dangerous form of wandering is elopement which is when a resident leaves the facility or safe area without authorization or necessary supervision) remained supervised while the assigned certified nursing assistant went on break and free from accidents by leaving an exit door propped open. These deficient practices resulted in Resident 1's elopement from the facility in his wheelchair, which rolled down the parking lot ramp to the street curb, causing Resident 1 to fall out of his wheelchair and hit his head on the street. Resident 1's injuries caused him to be transported to a general acute care hospital (GACH), where he was found to have a facial laceration (deep cut or tear in skin or flesh) that required staples and displaced fractures (break in the bone) of the sixth and seventh right ribs. Findings: A review of Resident 1's Admission Record (Face Sheet), indicated the resident was initially admitted to the facility on June 2, 2013 and readmitted on November 3, 2015 with diagnoses that included Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills), dementia (general term for loss of memory and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7KNT11 Facility ID: CA970000083 If continuation sheet 2 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056380 (X3) DATE SURVEY COMPLETED 12/14/2018 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 other mental abilities severe enough to interfere with daily life) and hemiplegia (inability to move one side of the body) of the left dominant side due to stroke. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool), dated July 29, 2018, indicated the resident had severely impaired cognition (mental process of thinking and understanding). The MDS indicated Resident 1 was totally dependent on staff for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing. A review of the plan of care titled, "Dementia," initiated June 29, 2018, indicated Resident 1 had dementia and Alzheimer's which was manifested by wandering. According to the care plan, the interventions included utilizing diversion, distraction or redirection to limit reoccurrence and providing education to resident, responsible party (RP) and staff regarding special care needs. The goal date for the care plan was September 30, 2018 and there was no indication the care plan had been revised or reviewed since initiation. A review of the plan of care titled, "Wandering/Elopement," dated June 29, 2018, indicated Resident 1 was a risk for wandering or elopement related to cognitive status and the resident not being aware of safety needs. According to the care plan, the interventions included assessing the resident's elopement risk at the following intervals: Admission, Readmission, Quarterly, and Identification of Significant Change of Condition. The goal date for the care plan was September 30, 2018. The care plan was updated after Resident 1's elopement on October 3, 2018. A review of the Psychiatric Progress Notes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7KNT11 Facility ID: CA970000083 If continuation sheet 3 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056380 (X3) DATE SURVEY COMPLETED 12/14/2018 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 dated August 6, 2018, indicated Resident 1 was nonverbal, had impaired long-term and short-term memory, and had a psychiatric condition that was deteriorating. A review of Resident 1's Elopement Risk Assessments indicated the only date for the assessment was October 3, 2018. Resident 1 had a score of eight (8) on 10/3/18. According to the assessment, if the total score is 8 or greater, the resident should be considered at risk for potential elopement from the facility. According to the assessments instructions, the Elopement Risk Assessment is to be done upon admission, readmission, quarterly and identification of significant change. A review of Resident 1's Licensed Personnel Weekly Progress Notes dated October 3, 2018, indicated Resident 1 was observed wheeling by the station's hallway at 12:30 p.m. At 12:35 p.m., the notes indicated the charge nurse received a call about Resident 1 being found outside the facility. The notes further indicated Resident 1 was found on the ground in sitting position beside his wheelchair with a bystander, alert and responding to verbal commands, with a right temporal cut and skin tears to both hands. According to the notes, the 9-1-1 (emergency number) crew arrived at 12:42 p.m., took over the resident's care and transported him to the GACH. A review of Resident 1's GACH Emergency Documentation October 3, 2018, indicated Resident 1 was "brought in by ambulance after rolling down a steep driveway in wheelchair, falling out of wheelchair and striking head." The documentation indicated Resident 1 normally had a Glasgow Coma Scale of 14 (GCS - a neurological scale from 3 to 15, which aims to give a reliable and objective way of recording the conscious state of a person and is useful FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7KNT11 Facility ID: CA970000083 If continuation sheet 4 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056380 (X3) DATE SURVEY COMPLETED 12/14/2018 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 after head injury. A GCS of 8 or less indicates severe injury, one of 9-12 moderate injury, and a GCS score of 13-15 is obtained when the injury is minor.), but upon being brought to the GACH had a GCS of 10. According to the Emergency Documentation, Resident 1 had a five (5) centimeter laceration over his right brow that required four (4) staples. A review of Resident 1's computed tomography (CT, an imaging procedure that uses special xray equipment to create detailed pictures, or scans, of areas inside the body) result from the GACH dated October 3, 2018 indicated Resident 1 had mildly displaced fractures of the lateral 6th and 7th right rib. A review of Resident 1's GACH Discharge Summary indicated Resident 1 had a hospital stay of eight (8) days, from October 3, 2018 to October 11, 2018. During the course of hospitalization, Resident 1 needed to be intubated (placement of a flexible plastic tube into the trachea [windpipe] to maintain an open airway) while in the emergency department and was sent to the intensive care unit (ICU, a department of a hospital in which resident who are dangerously ill are kept under constant observation for monitoring) from October 3, 2018 to October 4, 2018. According to the discharge documentation, Resident 1 needed continued hospitalization from October 4, 2018 to October 11, 2018, on the medical floor for acute encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition) and decreased mental alertness likely secondary to concussion (an injury to the brain that results in temporary loss of normal brain function). During an interview with Certified Nursing Assistant 1 (CNA 1) on October 30, 2018 at 9:20 a.m., CNA 1 stated that in order to prevent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7KNT11 Facility ID: CA970000083 If continuation sheet 5 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056380 (X3) DATE SURVEY COMPLETED 12/14/2018 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 accident, injury or elopement, he makes rounds and checks residents frequently. CNA 1 stated that he was assigned to Resident 1 on the day of his elopement. CNA 1 stated before he went on his break, he got Resident 1 up to his wheelchair and brought him in front of the door and somebody was supposed to pick him up to bring him to the dining room. CNA 1 stated that when he goes on break, he tells the charge nurse and another staff covers his residents. CNA 1 stated that when he came back from break, he was informed that Resident 1 got out of the building and had an accident in the parking lot. During an interview with Licensed Vocational Nurse 1 (LVN 1) on October 30, 2018 at 9:40 a.m., LVN 1 stated that he was the one to find Resident 1 outside the facility. LVN 1 stated around 12:30 p.m., he was leaving the facility to pick up his food that he had ordered and was driving his car through the exit way of the facility parking lot. LVN 1 stated he saw someone on the floor next to a wheelchair at the exit way close to the sidewalk. LVN 1 stated he stopped to check the person and found that it was one of their residents, Resident 1. LVN 1 stated there was a bystander beside Resident 1 who had already called 9-1-1. LVN 1 stated Resident 1 was in sitting position, bleeding on the right temporal side. LVN 1 stated he called the facility right away and staff came out immediately. According to LVN 1, at baseline, Resident 1was non-verbal, with left sided weakness due to a stroke, alert but confused, his both arms with contractures, but was able to wheel himself using his feet. During an interview with the Administrator (ADM) on November 19, 2018 at 12:15 p.m., the ADM stated "there was nothing we could do to prevent that fall." The ADM stated he was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7KNT11 Facility ID: CA970000083 If continuation sheet 6 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056380 (X3) DATE SURVEY COMPLETED 12/14/2018 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 not sure how Resident 1 got outside. When asked if Resident 1 had a wander guard in place, the ADM stated that he did not have a wander guard because the facility did not feel like he needed one at that time. During an interview and concurrent tour of the facility with the Director of Nursing (DON) on November 19, 2018 at 3:35 p.m., the DON stated Resident 1 had wandering behavior but had never made an attempt to leave the facility before. The DON stated Resident 1 just wheels around the stations and hallways near his room. When asked why Resident 1 did not have a wander guard, the DON stated wander guards are only used on residents who have attempted to elope, so upon readmission, a wander guard would be applied on Resident 1. When asked about the interventions for his wandering behavior, the DON stated Resident 1 was always under close supervision of staff. During the tour of the facility, the DON pointed out all the exits; the main entrance which leads to the parking lot, the emergency exit in the Activities Room, the back exit which leads to the employee patio and an emergency exit located between the kitchen and rehabilitation room which leads to the steep parking lot driveway. The DON stated that since Resident 1 was found at the end of the driveway, the staff believe the resident eloped using the exit that was between the kitchen and the rehabilitation room. During the observation of the exit between the kitchen and the rehabilitation room, the exit door was found to be propped open with a piece of wood. The DON confirmed the door was propped open. The sign on the exit door stated to keep door closed at all times. During an interview with the Administrator (ADM) on November 19, 2018 at 12:15 p.m., when asked about the propped exit door, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7KNT11 Facility ID: CA970000083 If continuation sheet 7 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056380 (X3) DATE SURVEY COMPLETED 12/14/2018 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 ADM stated that after the incident with Resident, 1 he made sure all staff was inserviced about the importance of making sure all exit doors are secured and closed properly. The ADM stated that he made it very clear to all staff that all doors are to remain locked. The ADM stated that after the incident with Resident 1, he installed cameras at the exits. The ADM stated that he will look into the video footage and will have to let go of the staff member who propped the door open because "that disregard for safety, will not be tolerated in the facility." A review of the facility's policy titled, "Elopement Risk Reduction Approaches," revised November 2012, indicated the facility will ensure that residents are monitored and remain safe. The policy also indicated the facility staff need to know the protocols to follow to minimize successful exiting. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7KNT11 Facility ID: CA970000083 If continuation sheet 8 of 8