Other·March 22, 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 a complaint investigation. Complaint Number: CA00617471 Representing the Department: HFEN # 36202 The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of the complaint number: CA00617471

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

F660 03/01/2019 §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to postdischarge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. 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: AFNO11 Facility ID: CA970000117 If continuation sheet 1 of 7 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: _______________ 555165 (X3) DATE SURVEY COMPLETED 02/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND PARK SKILLED NURSING & WELLNESS CENTRE 5125 Monte Vista St Los Angeles, CA 90042 (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 (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a postacute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AFNO11 Facility ID: CA970000117 If continuation sheet 2 of 7 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: _______________ 555165 (X3) DATE SURVEY COMPLETED 02/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND PARK SKILLED NURSING & WELLNESS CENTRE 5125 Monte Vista St Los Angeles, CA 90042 (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 must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to plan for a safe discharge that met the health and safety needs for one of two sampled residents (Resident 1), including: 1. Failure to ensure Resident 1's was trained to take care of himself and will be safe to be discharge to an independent living. 2. Failure to ensure Resident 1 has the capacity and capability to perform self-care including blood sugar check, insulin selfadministration, right heel wound treatment, and dressing change. 3. Failure to ensure that Resident 1's dialysis schedule and transportation was arranged. These deficient practices placed Resident 1 at risk for not receiving the necessary care and treatment after the resident was discharged to an independent living. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AFNO11 Facility ID: CA970000117 If continuation sheet 3 of 7 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: _______________ 555165 (X3) DATE SURVEY COMPLETED 02/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND PARK SKILLED NURSING & WELLNESS CENTRE 5125 Monte Vista St Los Angeles, CA 90042 (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 Findings: A review of the Face Sheet (admission record) indicated Resident 1 was admitted to the facility on 8/25/17 and was readmitted on 6/15/18 with diagnoses including muscle weakness, end stage renal disease (loss of kidney function that filter wastes and excess fluids from the blood, which are then excreted in urine), osteomyelitis foot (an infection of the bone) of right ankle, and and diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). A review of the Discharge Planning Assessment, dated 6/18/18, indicated Resident 1 would like to be discharge to an independent living; however, Resident 1's family member (FM) anticipated to take Resident 1 back home. The assessment indicated Resident 1 will be discharge when medically stable. The notes did not indicated Resident 1's request to be discharge to an independent living was followed up by social service staff. A review of the Minimum Data Set (MDS, standardized assessment and care planning tool), dated 10/4/18, indicated Resident 1 has no impairment with cognition (ability to think and process information). The MDS indicated Resident 1 required extensive assistance from staff including bed mobility, transfer locomotion on unit, locomotion off unit, dressing, toilet use and personal hygiene. The MDS indicated Resident 1 was not steady and was able to stabilize with staff assistance on moving on and off toilet and with surface to surface transfer including transfer between bed and chair or wheelchair. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AFNO11 Facility ID: CA970000117 If continuation sheet 4 of 7 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: _______________ 555165 (X3) DATE SURVEY COMPLETED 02/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND PARK SKILLED NURSING & WELLNESS CENTRE 5125 Monte Vista St Los Angeles, CA 90042 (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 1's Intervention Notes from Social Service staff, dated 11/27/18, indicated Resident 1 requested to be discharge or transfer from facility to better place. The notes did not indicate Resident 1 was assisted to find a place of the resident choice. A review of the Discharge Summary/Comprehensive Assessment, dated 12/4/18, indicated Resident 1 was incontinent with bowel and bladder. Resident 1's functional status required assistance with bathing, dressing, personal hygiene, and bed mobility. The assessment indicated Resident 1 was dependent with transfer, toilet use and ambulation. A review of Resident 1's Post Discharge Plan of Care, dated 12/4/18, indicated the physician ordered for Humalog (insulin, A natural hormone helps keeps the blood sugar level from getting too high [hyperglycemia] or too low [hypoglycemia]) 100 units/milliliter injection, subcutaneous per sliding scale (refers to the progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges) before lunch and dinner on Monday-Wednesday-Friday, 1 pen - 300 units. A review of the Licensed Personnel Progress Notes, dated 12/4/18, indicated Resident 1's medication was placed in a bag and dispensed, and Resident 1 was educated on when to take the medication. The notes did not indicate on how Resident 1 was instructed to check his own blood sugar and to self-administer Humalog. The notes did not indicate Resident 1 understood the instruction and was able to demonstrate self-administration of Humalog. On 2/20/19 at 4:20 p.m., during an interview, the Social Services Director (SSD) stated she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AFNO11 Facility ID: CA970000117 If continuation sheet 5 of 7 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: _______________ 555165 (X3) DATE SURVEY COMPLETED 02/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND PARK SKILLED NURSING & WELLNESS CENTRE 5125 Monte Vista St Los Angeles, CA 90042 (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 did not assisted Resident 1 to look for an independent living facility until prior to discharge. The SSD stated she did not inquire on the independent living prior to Resident 1's discharge on 12/4/18. The SSD stated she talked to an agent who was marketing the independent living facility and asked for a place for Resident 1. The SSD stated the independent living only provided room and board. On 2/21/19 at 3:30 p.m., during a telephone interview, the SSD stated she called Resident 1's health insurance to inform Resident 1 will have a different address for transportation pick up for dialysis. The SSD stated she called the dialysis center at the time of discharge that Resident 1 has a new address. The SSD stated she could not remember the name of the staff from the dialysis center due to she did not document any information on Resident 1's medical record. On 2/21/19 at 3:40 p.m., during a telephone interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was given an instructions on medications administration. LVN 1 stated she did not know if Resident 1 was able to check his blood sugar and self - administer Humalog. LVN 1 stated Resident 1 was not asked to for return demo on the Humalog administration to ensure Resident 1 was able to self - administer Humalog. On 2/21/19 at 3:51 p.m., during a telephone interview, LVN 2 stated Resident 1 has non healing wound on the right heel with a slight drainage upon discharge. LVN 2 stated Resident 1 was regularly seen by a wound specialist on Monday and Friday for right heel non healing wound. LVN 2 stated she did not know if Resident 1 was able to change the dressing on the right heel wound as needed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AFNO11 Facility ID: CA970000117 If continuation sheet 6 of 7 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: _______________ 555165 (X3) DATE SURVEY COMPLETED 02/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND PARK SKILLED NURSING & WELLNESS CENTRE 5125 Monte Vista St Los Angeles, CA 90042 (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 due to treatment was always done by the licensed nurse while the resident was in the facility. On 2/21/19 at 4:10 p.m., during a telephone interview, the Director of Nurses (DON) stated Resident 1 had a history of non-complaint with care. The DON stated Resident 1 wanted to go against medical advice (AMA), and facility's staff discharged the resident to an independent living facility. A review of the facility's policy and procedure titled "Transfer and Discharge," with a revision date of 10/2017, indicated to ensure that adequate preparation and assistance is provided to residents prior to transfer or discharge from the facility, social service staff will participate in assisting the resident with transfers and discharges and preparing the Discharge Summary and post discharge plan of care/discharge instructions. Referrals made to local contact agencies will be documented in the medical record. Preparation for and assistance with discharge planning will be documented in the medical record as well. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AFNO11 Facility ID: CA970000117 If continuation sheet 7 of 7