Other·February 8, 2018

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 a Recertification Survey. Representing the Department of Public Health: Surveyor I.D. Number : 27787, HFEN Surveyor I.D. Number : 34659, HFEN Surveyor I.D. Number : 38310, HFEN Surveyor I.D. Number : 38469, HFEN Surveyor I.D. Number : 38700, HFEN Trainee Resident Census : 186 Resident Sample : 35 Highest Severity and Scope = G

F557 SS=D Respect, Dignity/Right to have Prsnl Property CFR(s): 483.10(e)(2)

F557 01/18/2018 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain the respect and dignity of one of 35 sampled residents (Resident 181). This had the potential to result 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: Q23J11 Facility ID: CA970000121 If continuation sheet 1 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 in psychological harm. Findings: A review of the Admission Record dated December 18, 2017, indicated Resident 181 was admitted to the facility on November 29, 2017, with the diagnosis of epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and difficulty walking. A review of History and Physical dated November 29, 2017, indicated Resident 181 does not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS-a standardized assessment and care screening tool), dated October 11, 2017, indicated Resident 181's cognitive skills for daily decision making was severely impaired, required limited to extensive assistance by staff for activities of daily living (ADL's), was always incontinent of bladder and frequently incontinent of bowels. On December 19, 2017 04:56 PM during the Initial Tour, Resident 181 was observed sitting in a wheelchair in the hallway with both feet up on the seat of the wheelchair wearing a hospital gown and exposing his brief. During concurrent observation and interview with Licensed Vocational Nurse (LVN) 4, when asked if it was okay for the resident to expose himself, LVN 4 stated it wasn't okay. LVN 4 looked for another nurse to provide additional clothing on Resident 181, such as pants, in order to prevent the resident from exposing himself.

F604 SS=E Right to be Free from Physical Restraints CFR(s): 483.10(e)(1), 483.12(a)(2) FORM CMS-2567(02-99) Previous Versions Obsolete

F604 Event ID: Q23J11 01/18/2018 Facility ID: CA970000121 If continuation sheet 2 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to follow physician's orders for the use of physical restraints for three of 35 sampled residents (Residents 48, 106, and 388). These deficient practices had the potential to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 3 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 result in psychological and physical harm to the residents. Findings: a. A review of the Admission Record indicated Resident 48 was admitted to the facility on June 28, 2017 with the diagnosis of Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and seizure disorder (epilepsy - a disorder in which nerve cell activity in the brain is disturbed). A review of the Order Summary Report dated December 1, 2017, indicated Resident 48 was to have one full side rail up and locked when in bed for safety and positioning due to Parkinson's disease and dementia. The report indicated Informed Consent was obtained from the responsible party after explanation of the risks and benefits, and verified with physician. A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool), dated October 10, 2017, indicated Resident 48's cognitive skills for daily decision making was severely impaired, required limited assistance and one-person physical assistance from staff for activities of daily living and was always continent of bowel and bladder. A review of the Physical Restraint Assessment and Reduction Tool dated June 28, 2017, July 7, 2017 and October 10, 2017, indicated Resident 48 had generalized weakness, was depressed and confused, had seizure disorder and dementia. The less restrictive measures tried and found ineffective for Resident 48 were positioning pillows, anticipate needs, safety reminders and encourage with activities. The assessment indicated the IDT recommended FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 4 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 use of one side rail up as an enabler on June 28, 2017. On July 7, 2017, the IDT determined the use of one full side rail up and locked while Resident 48 was in bed to manage safety and positioning. On October 10, 2017, the assessment recorded the IDT decided to continue one full side rails up and locked while Resident 48 was in bed in order to maintain safety and position because positioning pillows, visual and verbal cues and anticipating needs were determined to be ineffective in managing safety or positioning. A review of the care plan for Physical Restraint in Use dated July 17, 2017, indicated Resident 48 was at risk for decreased mobility, decreased physical functioning, contracture development, behavioral problem, incontinence and pressure sores with one side rail up when in bed for safety, balance and positioning. On December 21, 2017, Resident 48's bed was observed in bed with both full side rails up. b. Resident 106 was admitted to the facility on August 3, 2017, with the diagnosis of cerebrovascular disease (stroke - damage to the brain from interruption of its blood supply), dementia (a group of thinking and social symptoms that interferes with daily functioning), and had dysphagia (difficulty swallowing foods or liquids), and required a gastrostomy tube (GT- a feeding tube, a medical device used to provide nutrition to patients who cannot obtain nutrition by mouth). A review of the History and Physical dated August 9, 2017, indicated Resident 106 did not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS- a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 5 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 standardized assessment and care screening tool)dated November 9, 2017, indicated Resident 106's cognitive skills for daily decision making were severely impaired, required extensive assistance from staff for activities of daily living and was totally dependent from staff for eating. A review of Resident 106's Order Summary Report dated November 23, 2017, indicated the physician ordered bilateral upper side rails up when in bed and had involuntary movement by gravity due to elevated head of the bed for the management and provision of enteral feeding. The report indicated an informed consent was signed by the responsible party. A review of Resident 106's care plan for Physical restraint in use dated November 25, 2017, indicated Resident 106 had bilateral upper side rails due to head of the bed (HOB) elevation with gastrostomy tube use for feeding, in order to prevent or reduce injury or falls. During the initial tour on December 20, 2017 at 3:34 p.m., Resident 106 was observed lying in bed with the HOB elevated, gastrostomy tube feeding infusing and four side rails up. On December 22, 2017 at 10:31 a.m., during observation Resident 106 was in bed with four side rails up. In a concurrent interview with Licensed Vocational Nurse 4 (LVN 4) and LVN 8, and when asked, both LVN 4 and LVN 8 stated there should have only been two side rails up - the upper side rails - instead of four side rails up. c. A review of the Admission indicated Resident 388 was admitted to the facility on August 30, 2017, with the diagnosis of pneumonia (lung FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 6 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 inflammation), dementia (a group of thinking and social symptoms that interferes with daily functioning), ischemic cardiomyopathy (a condition caused by a narrowing of the coronary arteries which supply blood to the heart) and generalized muscle weakness. A review of Order Summary Report dated December 1, 2017, indicated the physician ordered bilateral upper half side rails to be up when resident is in bed for positioning and ease of mobility and as an enabler when in bed. The order indicated an informed consent was obtained from Resident 388's responsible party. A review of the Informed Consent dated August 30, 2017 indicated consent for the use of 1/2 side rails up when in bed was signed by the resident's guardian after the physician gave an informed consent. A review of Physical Restraint Assessment dated August 30, 2017, indicated Resident 388's diagnosis of muscle weakness was the medical symptom that warranted restraint use of bilateral upper ½ side rails up when resident is in bed to prevent falls, to prevent injury, to maintain proper position while in bed and to increase independence with self-positioning. Less restrictive measure were tried and were ineffective. The assessment indicated the IDT recommended the use of bilateral ½ side rails to be up when resident is in bed for positioning and mobility, as an enable when in bed due to diagnosis of muscle weakness. The Physical Restraint Assessment dated December 13, 2017, indicated the use of bilateral ½ side rails up when resident was in bed was appropriate and necessary to manage safety. A review of the care plan dated December 22, 2017, indicated Resident 388 had bilateral ½ FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 7 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 side rails up when in bed for positioning and ease of mobility and as an enabler when in bed, to prevent or reduce incident of injury or falls. A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool), dated December 13, 2017, indicated Resident 388's cognitive skills for daily decision making was severely impaired, and the resident required limited and extensive assistance by staff for activities of daily living, and was always incontinent of bowel and bladder. On December 22, 2017, Resident 388's bed was observed with bilateral full side rails.

F604 SS=E Right to be Free from Physical Restraints CFR(s): 483.10(e)(1), 483.12(a)(2)

F604 01/18/2018 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility mustFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 8 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to follow physician's orders for the use of physical restraints for three of 35 sampled residents (Residents 48, 106, and 388). These deficient practices had the potential to result in psychological and physical harm to the residents. Findings: a. A review of the Admission Record indicated Resident 48 was admitted to the facility on June 28, 2017 with the diagnosis of Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and seizure disorder (epilepsy - a disorder in which nerve cell activity in the brain is disturbed). A review of the Order Summary Report dated December 1, 2017, indicated Resident 48 was to have one full side rail up and locked when in bed for safety and positioning due to Parkinson's disease and dementia. The report indicated Informed Consent was obtained from the responsible party after explanation of the risks and benefits, and verified with physician. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 9 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 Set (MDS- a standardized assessment and care screening tool), dated October 10, 2017, indicated Resident 48's cognitive skills for daily decision making was severely impaired, required limited assistance and one-person physical assistance from staff for activities of daily living and was always continent of bowel and bladder. A review of the Physical Restraint Assessment and Reduction Tool dated June 28, 2017, July 7, 2017 and October 10, 2017, indicated Resident 48 had generalized weakness, was depressed and confused, had seizure disorder and dementia. The less restrictive measures tried and found ineffective for Resident 48 were positioning pillows, anticipate needs, safety reminders and encourage with activities. The assessment indicated the IDT recommended use of one side rail up as an enabler on June 28, 2017. On July 7, 2017, the IDT determined the use of one full side rail up and locked while Resident 48 was in bed to manage safety and positioning. On October 10, 2017, the assessment recorded the IDT decided to continue one full side rails up and locked while Resident 48 was in bed in order to maintain safety and position because positioning pillows, visual and verbal cues and anticipating needs were determined to be ineffective in managing safety or positioning. A review of the care plan for Physical Restraint in Use dated July 17, 2017, indicated Resident 48 was at risk for decreased mobility, decreased physical functioning, contracture development, behavioral problem, incontinence and pressure sores with one side rail up when in bed for safety, balance and positioning. On December 21, 2017, Resident 48's bed was observed in bed with both full side rails up. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 10 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 b. Resident 106 was admitted to the facility on August 3, 2017, with the diagnosis of cerebrovascular disease (stroke - damage to the brain from interruption of its blood supply), dementia (a group of thinking and social symptoms that interferes with daily functioning), and had dysphagia (difficulty swallowing foods or liquids), and required a gastrostomy tube (GT- a feeding tube, a medical device used to provide nutrition to patients who cannot obtain nutrition by mouth). A review of the History and Physical dated August 9, 2017, indicated Resident 106 did not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool)dated November 9, 2017, indicated Resident 106's cognitive skills for daily decision making were severely impaired, required extensive assistance from staff for activities of daily living and was totally dependent from staff for eating. A review of Resident 106's Order Summary Report dated November 23, 2017, indicated the physician ordered bilateral upper side rails up when in bed and had involuntary movement by gravity due to elevated head of the bed for the management and provision of enteral feeding. The report indicated an informed consent was signed by the responsible party. A review of Resident 106's care plan for Physical restraint in use dated November 25, 2017, indicated Resident 106 had bilateral upper side rails due to head of the bed (HOB) elevation with gastrostomy tube use for feeding, in order to prevent or reduce injury or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 11 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 falls. During the initial tour on December 20, 2017 at 3:34 p.m., Resident 106 was observed lying in bed with the HOB elevated, gastrostomy tube feeding infusing and four side rails up. On December 22, 2017 at 10:31 a.m., during observation Resident 106 was in bed with four side rails up. In a concurrent interview with Licensed Vocational Nurse 4 (LVN 4) and LVN 8, and when asked, both LVN 4 and LVN 8 stated there should have only been two side rails up - the upper side rails - instead of four side rails up. c. A review of the Admission indicated Resident 388 was admitted to the facility on August 30, 2017, with the diagnosis of pneumonia (lung inflammation), dementia (a group of thinking and social symptoms that interferes with daily functioning), ischemic cardiomyopathy (a condition caused by a narrowing of the coronary arteries which supply blood to the heart) and generalized muscle weakness. A review of Order Summary Report dated December 1, 2017, indicated the physician ordered bilateral upper half side rails to be up when resident is in bed for positioning and ease of mobility and as an enabler when in bed. The order indicated an informed consent was obtained from Resident 388's responsible party. A review of the Informed Consent dated August 30, 2017 indicated consent for the use of 1/2 side rails up when in bed was signed by the resident's guardian after the physician gave an informed consent. A review of Physical Restraint Assessment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 12 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 30, 2017, indicated Resident 388's diagnosis of muscle weakness was the medical symptom that warranted restraint use of bilateral upper ½ side rails up when resident is in bed to prevent falls, to prevent injury, to maintain proper position while in bed and to increase independence with self-positioning. Less restrictive measure were tried and were ineffective. The assessment indicated the IDT recommended the use of bilateral ½ side rails to be up when resident is in bed for positioning and mobility, as an enable when in bed due to diagnosis of muscle weakness. The Physical Restraint Assessment dated December 13, 2017, indicated the use of bilateral ½ side rails up when resident was in bed was appropriate and necessary to manage safety. A review of the care plan dated December 22, 2017, indicated Resident 388 had bilateral ½ side rails up when in bed for positioning and ease of mobility and as an enabler when in bed, to prevent or reduce incident of injury or falls. A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool), dated December 13, 2017, indicated Resident 388's cognitive skills for daily decision making was severely impaired, and the resident required limited and extensive assistance by staff for activities of daily living, and was always incontinent of bowel and bladder. On December 22, 2017, Resident 388's bed was observed with bilateral full side rails.

F641 SS=E Accuracy of Assessments CFR(s): 483.20(g)

F641 01/18/2018 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 13 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 resident's status. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the nursing staff failed to ensure the residents' Minimum Data Set (MDS comprehensive assessment and care screening tool) accurately reflected the actual oral (mouth) and dental status for two of 35 sampled residents (Resident 72 and Resident 120). This deficient practice resulted to residents not receiving necessary dental care. Cross reference F745, F600, and F684. Findings: a. On December 19, 2017, at 1:58 p.m., during initial tour of the facility, Resident 72 was observed sitting on the bed. Resident 72 stated did not have his bottom teeth. Resident 72 was observed with no bottom teeth. A review of the admission record indicated Resident 72 was admitted on October 5, 2017, with diagnoses that included diabetes mellitus (a group of diseases that result in too much sugar in the blood), and hypertension (high blood pressure). A review of Resident 72's MDS dated October 12, 2017 indicated the resident was cognitively (relating to the process of acquiring knowledge and understanding) intact. The MDS indicated Resident 3 was assessed as having no dental issues. A review of a "Multidisciplinary Progress Record" dated October 10, 2017, indicated Resident 17 was edentulous (lacking teeth). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 14 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 care plan initiated on October 20, 2017, indicated Resident 72 had alteration in oral/dental status secondary to being edentulous on lower part. On December 22, 2017 at 12:34 p.m., during an interview and record review, the MDS Nurse Coordinator confirmed that the MDS under Oral/Dental was not coded correctly, as it indicated the resident had no dental issues. b. A review of the admission record indicated Resident 120 was admitted on May 18, 2015, with diagnoses that included diabetes mellitus (a group of diseases that result in too much sugar in the blood), and hypertension (high blood pressure). A review of Resident 120's Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated November 26, 2017, indicated Resident 120's cognitive status (relating to the process of acquiring knowledge and understanding) moderately impaired. The MDS Oral/Dental Status indicated Resident 120 was assessed as not having any dental issues. A review of Resident 120's physician's order dated July 9, 2017, indicated dental consult and treatment as needed for dental problems. A review of the Admission Assessment dated July 9, 2017 and reassessment dated July 10, 2017, completed by a licensed nurse indicated Resident 120 had missing and broken teeth. A review of Resident 120's "Oral/Dental Assessment" dated July 9, 2017, indicated Resident 120 had missing teeth. On December 22, 2017 at 10:24 a.m., during FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 15 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 interview, the MDS Nurse-Licensed Vocational Nurse 2 (LVN 2) stated he did the coding of Resident 120's MDS. LVN 2 stated the MDS was incorrect as it did not reflect the resident's actual oral and dental status. LVN 2 stated there was "a lack of focus" on his part and that was the reason why the coding was inaccurate. On December 22, 2017 at 10:37 a.m., during an interview the MDS Coordinator/LVN 3 confirmed that the oral and dental section of the MDS was not coded accurately because Resident 120's Oral/Dental Assessment indicated he had missing and broken teeth. A review of the facility's undated policy and procedure titled "Oral/Dental Assessment," indicated that the facility will conduct an initial exam of oral cavity teeth and/or dentures to identify oral conditions. The policy also indicated the Oral/Dental Assessment Form will be utilized for initial oral/dental exam and Section L of the MDS will be completed subsequently.

F656 SS=E Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 01/18/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 16 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to develop an individualized care plan for 2 of 35 sample residents (Resident 120 and Resident 72) who were assessed as having dental problems. These deficient practices resulted to failure in the delivery of necessary care and services. Findings: a. A review of the admission record indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 17 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 Resident 120 was initially admitted to the facility May 18, 2015 and readmitted in July 9, 2017 with diagnoses that included diabetes mellitus (a group of diseases that result in too much sugar in the blood), and hypertension (high blood pressure). On December 19, 2017 at 1:13 p.m. during initial tour of the facility, Resident 120 stated he had a tooth ache and it has been hurting for three months. Resident 120 stated the dentist came but did not remove the tooth. A review of Resident 120's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated November 26, 2017 indicated Resident 120 cognitive (relating to the process of acquiring knowledge and understanding) status was moderately impaired. Resident 120 was assessed as not having any dental issues. A review of Resident 120's care plan initiated in May 28, 2015 and revised on November 26, 2017, indicated Resident 120 had alteration in oral/dental status secondary to resident having some missing natural teeth. However, the care plan did not address Resident 120's chronic moderate peritonitis (a serious gum infection that damages the soft tissue and bone that supports the tooth) and pain. A review of Resident 120's physician's order dated July 9, 2017, indicated dental consult and treatment as needed for dental problems. A review of "Dental Notes" dated February 8, 2017, completed by the facility dentist, indicated Resident 120's tooth #12 (a tooth in the left upper jaw) had sharp edges, bothering resident and he wanted it out. A review of Resident 120's "Dental Notes" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 18 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 May 2, 2017, documented by the facility dentist, indicated Resident 120 had chronic moderate periodontitis. On December 21, 2017 at 10:50 in the presence of CNA 5 and CNA 6, Resident 120 repeated that he had been having tooth ache. A review of Resident 120's "Multidisciplinary Progress Record" dated December 11, 2017, indicated Resident 120 "complained about oral pain," will refer to dentist ASAP (as soon as possible)." On December 21, 2017 at 11:13 a.m. during an interview the SSD stated Resident 120 complained of pain on December 11, 2017. During a follow up interview, SSD stated she did not communicate with licensed staff regarding the pain but just faxed the order for the dentist to see the resident. However, the SSD did not follow up and the resident was not seen until December 22, 2017, after the Evaluator inquired. b. A review of the admission record indicated Resident 72 was initially admitted on October 5, 2017, with diagnoses that included diabetes mellitus (high blood sugar) and hypertension (high blood pressure). On December 19, 2017 at 1:58 p.m., during initial tour of the facility, Resident 72 was observed sitting on the bed. Resident 72 stated he had difficulty eating certain food because he does not have his bottom teeth and was told he could not afford dentures. Resident 72 was observed with no bottom teeth. A review of Resident 72's Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated October 12, 2017 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 19 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 indicated the resident was cognitively (relating to the process of acquiring knowledge and understanding) intact. The MDS indicated Resident 72 was assessed as having no dental issues. A review of a document titled "Multidisciplinary Progress Record" dated October 10, 2017, indicated Resident 17 was edentulous. A review of the care plan initiated on October 20, 2017, indicated Resident 72 had alteration in oral/dental status secondary to being edentulous on lower part and uses dentures or partials. The care plan did not mention a goal or intervention for the missing bottom teeth. On December 22, 2017 at 10:19 a.m., during an interview LVN 2 stated regarding the oral and dental care plans for both Resident 72 and Resident 120, the goal and interventions were not specific to the residents. LVN 2 stated the care plan should be "patient centered" and should reflect the resident's status. A review of the facility's undated policy and procedures titled "The Resident Care Plan" indicated the objective of the care plan is to provide an individualized nursing care and to promote continuity of resident care. The policy indicated the care plan includes identification of medical, nursing and psychosocial needs, goals stated in measurable/observable terms, approaches to meet the goals, and reassessment and changes as needed to reflect current status.

F679 SS=D Activities Meet Interest/Needs Each Resident CFR(s): 483.24(c)(1)

F679 01/18/2018 §483.24(c) Activities. §483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 20 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide on-going activities based on comprehensive assessment and preferences for one of 35 sampled residents (Resident 106). This had the potential to result in a the lack of physical, cognitive, emotional and psychosocial health and well-being. Findings: A review of Resident 106's admission information indicated the resident was admitted to the facility on August 3, 2017, with the diagnosis of cerebrovascular disease (stroke damage to the brain from interruption of its blood supply), dementia (a group of thinking and social symptoms that interferes with daily functioning), and had dysphagia (difficulty swallowing foods or liquids) and required a gastrostomy tube (GT- a feeding tube, a medical device used to provide nutrition to patients who cannot obtain nutrition by mouth). A review of the History and Physical dated August 9, 2017, indicated Resident 106 did not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS- a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 21 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 standardized assessment and care screening tool), dated November 9, 2017, indicated Resident 106's cognitive skills for daily decision making was severely impaired, required extensive assistance from staff for activities of daily living and was totally dependent from staff for eating. On December 20, 2017 at 8:59 a.m. during initial tour, Resident 106 was observed lying in bed wearing a hospital gown with winter holiday music playing at the bedside. The bulletin board was decorated with Resident 106's birthday greeting, and the wall at the head of the bed had a spring season rabbit decoration. On December 22, 2017 at 10:25 a.m., Resident 106 was observed lying in bed with no holiday music playing. During interview Certified Nursing Attendant 7 (CNA 7), was asked when was the last time Resident 106 was taken to the Activities Room. CNA 7 stated she did not know. CNA 7 stated it was difficult to change Resident 106's position in the geriatric chair every two hours during activities. During an interview Licensed Vocational Nurse 4 (LVN 4), stated Resident 106 was on a turning schedule and it is difficult to turn resident on the geriatric chair for activities, that's why he hasn't been taken to activities in a while. On December 22, 2017 at 11:30 a.m., during an interview the Activities Director (AD), when asked who is in charge of the bulletin board in the residents' rooms, stated he was. The AD observed the spring season rabbit decoration hanging on the wall of Resident 106's room. When asked how does he assess the resident's likes, dislikes and preferences of activities, and was Resident 106's family consulted, the AD stated he does a "random assessment" to determine what he thought the resident might FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 22 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 like. The AD stated he did not consult with the family to fully assess.

F684 SS=E Quality of Care CFR(s): 483.25

F684 01/18/2018 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to implement the care plan for one of 35 sampled residents. For Resident 80, the facility failed to continue monitoring for sudden pain, redness or swelling of the right hand and to encourage resident to do mild exercises as tolerated. Findings: On December 19, 2017 at approximately 1:30 p.m., during initial tour of the facility Resident 80 complained about right hand pain. Resident 80 was observed closing his hand but was unable to make a fist and stated he does not do any exercises on his right hand. Resident 80 denied any falls. A review of the admission record indicated Resident 80 was admitted on January 27, 2017, with diagnoses that included muscle weakness, and diabetes (a group of diseases that result in too much sugar in the blood). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 23 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 80's document titled COC (change of condition) Interact Assessment Form -a communication tool, indicated on September 25, 2017 at 8:00 a.m., Resident 80 complained of pain of the right hand. The document also indicated Resident 80 had swelling and was unable to completely "close his fingers". On December 22, 2017 at 11:51 a.m., Resident 80 was observed lying in bed, watching television. In a concurrent interview, Resident 80 stated his right hand was hurting and he is unable to make a fist but nothing was being done. A review of Resident 80's document titled "Radiology Report" indicated an x-ray of the right hand was done on September 26, 2017. The results indicated Resident 80 had soft tissue swelling and osteopenia (a condition that occurs when the body doesn't make new bone as quickly as it reabsorbs old bone). A review of Resident 80's care plan initiated on September 26, 2017. indicated Resident 80 was at risk for sudden acute pain to any upper extremity, swelling and tenderness, and redness The goal was to reduce the risk for pain daily for 90 days. The interventions included monitoring for sudden acute pain, redness, swelling, tenderness and guarded movement, and to encouraging the resident to do mild exercise as tolerated and within joint limitation. A review of Resident 80's Nurses Progress Record from September 25, to 28, 2017, indicated the licensed staff were monitoring the resident right hand. However, there was no documentation to address if the resident's right hand pain, and swelling was resolved. Additionally, there was no evidence indicating FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 24 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 further assessment and monitoring of the hand was done after September 28, 2017 at 2 p.m. On December 22, 2017 at 12:45 p.m., during an interview Licensed Vocational Nurse 10 (LVN 10) stated that she had been caring for Resident 80 for about 8 months, but did not recall any issues with his right hand. On December 22, 2017 at 2:37 p.m., during an interview Registered Nurse Supervisor 2 (RN 2) stated Resident 80 did not complain of any more pain recently. RN 2 stated the licensed staff were supposed to monitor for pain. On December 26, 2017 at 7:42 a.m., during an interview Licensed Vocational Nurse 9 (LVN 9) stated he has been caring for Resident 80 for the past two years. LVN 9 stated Resident 80 had problems with his right hand a long time ago, but did not complain of any pain or swelling recently. On December 26, 2017 at 7:55 a.m., during an interview the Director of Nursing (DON) stated Resident 80 had problems with his right hand a long time ago but had no complaints recently. The DON stated "I have not noticed anything recently". The DON agreed licensed staff would not be able to implement the care plan if they were not even aware that Resident 80 was having a problem with his right hand. A review of the facility's undated policy and procedures titled "The Resident Care Plan" indicated the objective of the care plan is to provide an individualized nursing care and to promote continuity of resident care. The policy indicated the care plan includes identification of medical, nursing and psychosocial needs, goals stated in measurable/observable terms, approaches to meet the goals, and reassessment and changes as needed to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 25 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 reflect current status.

F690 SS=D Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3)

F690 01/18/2018 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 26 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infection (UTI) for one of 35 sample residents (Resident 85) including: 1. Failure to implement the care plan on Incontinence by not assisting Resident 85 with toilet use prior to breakfast, not changing the brief promptly when soiled, not observing good perineal care, and not encouraging adequate fluid intake. 2. Failure to implement the facility's policy on Perineal (around the genitals) Care when Certified Nursing Assistant 3 (CNA 3) used a soiled towel to wipe the vaginal area and urinary meatus (the external opening where urine is ejected from the body). 3. Failure to implement the facility's policy on UTI Preventive Measures, by not ensuring Resident 85 drank sufficient fluids. 4. Failure to implement the care plan on Altered Behavior Patterns (yelling, crying and cursing at staff) by not reducing/eliminating the triggers of the behavior when Resident 85 was requesting to have her brief changed. As a result, Resident 85 was placed at risk of recurring UTI. Findings: According to the Admission Record, Resident 85 was re-admitted on June 1, 2016, with diagnoses including paranoid schizophrenia (a mental illness, delusions make someone with it unreasonably suspicious of other people), anxiety disorder (nervousness and fear about what might happen), and diabetes (high blood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 27 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 sugar). A review of the Nursing Admission Assessment dated June 1, 2016, indicated Resident 85 was incontinent (unable to control) of bowel and bladder function. A review of Resident 85's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated November 14, 2017, indicated the resident's cognitive patterns were severely impaired, had no mood and behavioral signs and symptoms, required extensive assistance from staff for bed mobility, transfer, toilet use, personal hygiene, and bathing with one person physical assistance. Resident 85 required assistance with eating and was always incontinent of bowel and bladder. A review of the ongoing Care Plan, dated December 17, 2014, developed for Resident 85's incontinence, included in the interventions monitoring incontinent episodes; assisting with toilet use prior to bedtime, upon awakening, before and after meals, and as needed while awake; changing brief promptly when soiled/soaked; good incontinent care with each episode; keeping clean, dry and odor free, observing good perineal care; encouraging adequate fluid intakes (amount not indicated); assessing ability to participate with bladder/bowel program; and monitoring for signs and symptoms of UTI. Notify the physician as indicated. A review of the ongoing Care Plan, dated May 22, 2016, developed for Resident 85's need of assistance with toilet use, personal hygiene and eating, included in the interventions assisting Resident 85 with daily needs and providing adequate hydration (amount not indicated) and nutrition. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 28 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 Nutritional Assessment Screening dated June 2, 2016, indicated Resident 85's daily fluid requirement ranged from 1,100 cubic centimeters (cc) to 1,375 cc. A review of the nursing notes for the month of November 2017 indicated Resident 85 was refusing to eat and on November 7, 2017, was transferred to a GACH due to failure to thrive (a state of decline that includes weight loss, decreased appetite, poor nutrition, and inactivity). Resident 85 returned on the same day with diagnoses of UTI and the Discharge Instructions included drinking enough fluid to keep urine clear or pale yellow and wipe from front to back after a bowel movement. A review of the Care Plan dated November 14, 2017, developed for Resident 85's altered behavior patterns related to anxiety manifested by yelling, crying and cursing at staff, included in the interventions to encourage verbalization of feelings and concerns and address appropriately, assess what may cause and trigger behavior, and attempt to reduce/eliminate those triggers if possible. On December 22, 2017, at 8:05 a.m., Resident 85 was heard screaming and yelling, in a foreign language, to staff in her room. Upon arrival to the room, Resident 85 was screaming, spitting and throwing objects at Certified Nursing Assistant 1 (CNA 1), who did not attend to Resident 85. At 8:11 a.m., Restorative Nursing Assistant 1 (RNA 1) was in Resident 85's room and when asked what Resident 85 wanted, RNA 1 stated the resident wanted her incontinent brief to be changed. At 8:20 a.m., CNAs 1 and 9 changed Resident 85's soiled brief and Resident 85 calmed down. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 29 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 December 22, 2017, at 8:25 a.m., during an interview, Registered Nurse 1 (RN 1) stated Resident 85 was explained the CNAs were passing (breakfast) trays and would change her later. On December 22, 2017, at 9:30 a.m., during an interview, CNA 1 stated she did not change Resident 85's incontinent brief because she was passing trays. CNA 1 stated Resident 85 asked to be changed since 7:30 a.m. and after eating her breakfast started screaming and yelling. On December 22, 2017, at 5:27 p.m., during an interview and record review with the Director of Nursing (DON), she stated there was no documentation to determine if the amount of fluids Resident 85 consumed met the assessed needs (1,100 cc to 1,375 cc) before the resident was transferred to the GACH on November 7, 2017 or after returning from the GACH with diagnosis of UTI and recommendation to increase fluid intake. On December 26, 2017, at 3:15 p.m., during an observation of Resident 85's perineal care provided by CNAs 3 was done and CNA 3 wiped the area with a towel with soap and water from the front to the anal and buttocks areas and then wiped dry the vaginal area with the same soiled towel. CNA 3 did not rinse the perineal area. On December 26, 2017, at 3:35 p.m., during an interview, CNA 3, she stated she should have cleaned Resident 85 thoroughly and should have not used the same towel. The facility's undated policy and procedure titled "Perineal Care," indicated the purpose of the policy was to ensure that residents are clean and prevent odors and infection. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 30 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 procedure included wash hands, wipe from pubic area towards rectal area, and dry perineal and anal area. The facility's undated policy and procedure titled "UTI - Preventive Measures," indicated the facility would utilize measures in order to help prevent UTI. All residents will benefit from the following: drink liberal amounts of water to lower bacterial concentrations in the urine, offer cranberry juice or cranberry pill to high risk residents as indicated/ordered.

F692 SS=G Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 01/18/2018 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure a resident, who is at risk of dehydration (lack of sufficient fluids in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 31 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 body) and malnutrition, is offered sufficient food and fluid intake to prevent dehydration and urinary tract infection (UTI) for one of 35 sample residents (Resident 85) including: 1. Failure to implement the facility's policy on Dehydration by not utilizing measures to identify the causes of, that may include decreased food or fluid intake as well as signs and symptoms of dehydration (depletion of water) and manage dehydration with hydration measures such as provision of oral fluids and monitoring oral fluid intake. 2. Failure to implement the care plan on Incontinence by not encouraging adequate fluid intake as indicated in the Nutritional Assessment Screening. 3. Failure to implement the care plan on Resident 85's needing assistance with eating by not providing adequate hydration and nutrition in the amount required as per the the Nutritional Assessment Screening. 4. Failure to implement the facility's policy on UTI Preventive Measures, by not ensuring Resident 85 drank sufficient fluids as indicated in the Nutritional Assessment Screening of daily fluid requirement of 1,100 cubic centimeters (cc) to 1,375 cc. 5. Failure to implement the Discharge Instructions from the General Acute Care Hospital (GACH) of November 7, 2017, to drink enough fluid to keep the urine clear or pale after Resident 85 was diagnosed with dehydration. As a result, Resident 85 was transferred to a GACH on November 7, 2017, where she was diagnosed with dehydration and UTI. After returning to the facility on the same day, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 32 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 through December 22, 2017, the facility did not monitor Resident 85's fluid intake, placing Resident 85 at further risk of dehydration. Findings: According to the Admission Record, Resident 85 was re-admitted on June 1, 2016, with diagnoses including paranoid schizophrenia (a mental illness, delusions make someone with it unreasonably suspicious of other people), anxiety disorder (nervousness and fear about what might happen), and diabetes (high blood sugar). A review of Resident 85's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated November 14, 2017, indicated the resident's cognitive (reasoning) patterns were severely impaired, required extensive assistance from staff for activities of daily living (ADLs) transfer, toilet use, personal hygiene with one-person physical assistance. Resident 85 required limited assistance with one-person assist with eating and was incontinent of bowel and bladder. A review of the ongoing Care Plan, dated December 17, 2014, and revised on November 15, 2017, developed for Resident 85's incontinence, included in the interventions monitoring incontinent episodes and encouraging adequate fluid intakes (amount not indicated). A review of the ongoing Care Plan, dated May 22, 2016, and revised on November 15, 2017, developed for Resident 85's need of assistance with toilet use, personal hygiene and eating, included in the interventions assisting Resident 85 with daily needs and providing adequate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 33 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 hydration (amount not indicated) and nutrition. A review of the Nutritional Assessment Screening dated June 2, 2016, signed by the Dietitian indicated Resident 85's daily fluid requirement ranged from 1,100 cubic centimeters (cc) to 1,375 cc and required 1,100 calories to 1,375 calories each day. A review of the meal chart percentage documented on the Certified Nursing Assistant ADL Sheet dated October 2017, indicated Resident 85 refused breakfast, 17 days, refused lunch 21 days, and refused dinner 14 days. For snacks, during the 3 p.m. to 11 p.m. shift, Resident 85 refused three days. There was lack of documentation for the month of October through November 5, 2017, to indicate meal substitutes, additional snacks and sufficient fluids were offered or provided to Resident 85 to ensure adequate hydration and nutrition. There was no documented evidence Resident 85 was provided or offered the amount of fluids assessed by the Registered Dietitian on June 2, 2016. A review of Certified Nursing Assistant ADL Sheet dated November 1 to 6, 2017, indicated Resident 85 refused 9 of 17 meals and three of five snacks offered during the 3 p.m. to 11 p.m. shift. A review of the Change of Condition (COC)/Situation, Background, Assessment, Recommendation (SBAR) form dated November 5, 2017, timed at 8 a.m., indicated Resident 85 refused the breakfast meal and orders to continue monitoring and encouraging food and fluid intake. On November 7, 2017, Resident 85 was transferred to a GACH due to failure to thrive (a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 34 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 state of decline that includes weight loss, decreased appetite, poor nutrition, and inactivity). Resident 85 returned on the same day with diagnoses of UTI. The Discharge Instructions included drinking enough fluid to keep urine clear or pale. After Resident 85 was re-admitted from the GACH on November 7, 2017, with diagnoses of dehydration and UTI, the record of the food intake from November 7, to 30, 2017, indicated the resident refused 36 of 68 meals. There was no documentation of the amount of fluid Resident 85 consumed. On December 22, 2017, at 5:27 p.m., during an interview and record review with the Director of Nursing (DON), she stated there was no documentation to determine if the amount of fluids Resident 85 consumed met the assessed needs (1,100 cc to 1,375 cc) before the resident was transferred to the GACH on November 7, 2017, or after returning from the GACH with diagnosis of dehydration and UTI. The facility's undated policy and procedure titled "Meal Consumption Documentation," indicated the purpose of the policy was to ensure accuracy and consistency of documentation for resident's meal consumption. Using the guide, for each meal tray, subtract the amount of food, items left on the tray from 100 percent to get the percentage of consumption by the resident. The facility's undated policy and procedure titled, "Dehydration - Measures to Identify and Manage", indicated the facility would utilize measures to identify and manage dehydration. Nursing assessment will include the identification of causes, as well as signs and symptoms of dehydration (depletion of water) that may include decreased food or fluid intake, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 35 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 diabetes mellitus, abnormal laboratory values, decreased skin turgor, dry mucous membranes, tachycardia (increased heart rate), delirium (acute onset confusion) manifested by anxiety, agitation, decreased skin turgor, increased motor activity: restlessness. ..Notification of attending physician ... order to monitor hydration status ... hydration measures that may include oral fluids ... documentation of findings ... development of plan of care that includes monitoring hydration status. The facility's undated policy and procedure titled, "Perineal Care," indicated the purpose of the policy was to ensure that residents are clean and prevent odors and infection. The procedure included wash hands, wipe from pubic area towards rectal area, and dry perineal and anal area. The facility's undated policy and procedure titled "UTI - Preventive Measures," indicated the facility would utilize measures in order to help prevent UTI. All residents will benefit from the following: drink liberal amounts of water to lower bacterial concentrations in the urine, offer cranberry juice or cranberry pill to high risk residents as indicated/order.

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 01/18/2018 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 36 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 Based on interview, observation, and record review, the facility failed to ensure physician's orders were followed for monitoring of oxygen saturation (is the fraction of oxygen-saturated hemoglobin-a red protein responsible for transporting oxygen in the blood, relative to total hemoglobin in the blood)every shift for one of 35 sampled residents (Resident 29). This deficient practice had the potential to result in inability to recognize if oxygen used by Resident 29 is effective. Findings: A review of Resident 29's admission record indicated Resident 29 was initially admitted to the facility on October 2, 2012, with the most recent re-admission on October 17, 2017. Resident 29's diagnoses included but were not limited to, diabetes (high blood sugar), dysphagia (difficulty swallowing), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), and dementia (a general term for loss of memory and other mental abilities severe enough to interfere with daily life) without behavioral disturbance. A review of Resident 29's Minimum Data Set (MDS - a standardized care planning tool)dated October 5, 2017, indicated Resident 29 rarely understands others and rarely makes self understood and required extensive physical assistance with transfer, dressing, toilet use and personal hygiene. A review of Resident 29's physician's order dated August 26, 2017, indicated to administer oxygen at 2 liters per minute (LPM) via nasal cannula (a thin tube). The order did not specify if administration is continuous or as needed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 37 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 to monitor oxygen saturation every shift. The most current physician's order dated October 17, 2017, indicated to administer oxygen at 2 LPM as needed, via nasal cannula and to monitor oxygen saturation every shift. During an observation on December 26, 2017 at 8:28 a.m., accompanied by Licensed Vocational Nurse 8 (LVN 8), Resident 29 was lying in bed while receiving formula through the gastrostomy tube (GT- a tube inserted through the abdomen that delivers nutrition directly to the stomach). The head of the resident's bed was elevated to 35 degrees. In a concurrent interview at the time of observation, LVN 8 confirmed after reviewing the Physician's order dated November 27, 2017, the current order is for oxygen to be administered at 2 LPM via nasal cannula as needed and to monitor oxygen saturation every shift. LVN 8 acknowledged there was no oxygen saturation monitoring equipment available at Resident 29 's bedside at the time of observation. A review of the Medication Administration Record, indicated and confirmed by LVN 8, there was no monitoring of oxygen saturation done from August 26, 2017 to November 30, 2017, as the physician ordered. A review of the facility's undated policy titled, "Oxygen Administration", indicated to "check oxygen saturation, if ordered, to ensure that oxygen use is effective; for example, for a COPD resident, the attending physician should determine the specific parameter".

F697 SS=E Pain Management CFR(s): 483.25(k)

F697 02/12/2018 §483.25(k) Pain Management. The facility must ensure that pain management FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 38 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure a resident's pain was managed as indicated in the facility's Pain Management policy for one of 35 sampled residents (Resident 123). This had the potential to result in unnecessary pain experienced during physical therapy exercises and throughout daily activities and can lead to a decline in the quality of the resident's life. Findings: A review of the Admission Record dated November 2, 2017, indicated Resident 123 was admitted to the facility on October 31, 2017, with the diagnosis of generalized muscle weakness, dementia (a group of thinking and social symptoms that interferes with daily functioning), and seizure disorder (epilepsy - a disorder in which nerve cell activity in the brain is disturbed). A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool)dated December 4, 2017, indicated Resident 123's cognitive skills for daily decision making were severely impaired, required extensive assistance by staff for activities of daily living, and was always incontinent of bowel and bladder. A review of the physician Order Summary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 39 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 Report dated November 23, 2017, indicated Resident 123 has physical therapy daily five times a week for four weeks and Resident 123's pain assessment is to be done every shift. The Order Summary Report indicates to give the resident Tylenol tablet 325 milligrams (mg)- 2 tablets by mouth every 4 hours for mild pain (for pain rating level of 1-4). During observation of Resident 123 and concurrent interview with Physical Therapy Staff 1, (PT 1)on December 20, 2017 at 9:50 a.m., Resident 123 was taken to the Rehabilitation Room for physical therapy exercises. The resident was observed during physical therapy exercises. Resident 123 was observed grimacing with eyebrows furrowed during passive range of motion exercises (therapist or equipment moves the joint through the range of motion with no effort from the patient)provided by PT 1 of the resident's ankles, knees and both hips. On December 20, 2017 at 9:55 a.m., in an interview , eventhough Resident 123 was observed grimacing during exercises, Physical Therapy Staff 1 stated Resident 123 was not given pain medicine prior to physical therapy and normally does not receive pain medication prior to physical therapy. A review of Resident 123's Medication Administration Record (MAR)pain assessment section indicated the resident had no pain or pain medication on December 20, 2017, during the day shift. However, the Nurses' PRN Notes/Medication Notes indicated the resident was given Tylenol 325 mg tablets 2 tablets prior to rehabilitation on December 21, 2017 at 9 a.m., after PT 1 was asked about the resident's pain medication. The PRN Notes/Medication Notes indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 40 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 resident's Tylenol was effective after 30 minutes. There were no entries on the MAR or pain assessment section to indicate Resident 123 was offered Tylenol prior to rehabilitation exercises until December 21, 2017, in order to provide comfort to the resident during exercises. A review of the facility's undated Pain Management policy, indicates the purpose of the policy is to provide guidelines for the consistent assessment, and management of pain of the resident in order to maximize comfort and quality of life. The Pain Management policy indicated the health professionals are to respond quickly to a resident's report of pain.

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 01/18/2018 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 41 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure that two multi-dose vials of Novolin-R Regular Human Insulin Injection (medication used to control blood sugar levels) were marked with the dates opened in accordance with the facility's general guidelines for safe and accurate medication administration for two out of 35 residents (Resident 29 and 79), and failed to label the glucometer test strip (a material used for testing for blood sugar level) bottles in accordance with professional standards, including an expiration date, after first use, for two of four medication carts and ensure the glucometers were quality controlled. These deficient practices had the potential to result in an inaccurate blood sugar monitoring test results and can lead to uncontrolled blood glucose levels for the residents. Findings: a. On December 21, 2017 at 4:38 p.m., during medication pass observation at Station 2 with Licensed Vocational Nurse 5 (LVN)5, the two glucometers (a medical device for determining the approximate concentration of glucose in the blood) quality control (QC - a system of maintaining standards in manufactured products by testing a sample of the output against the specification) were not done. The glucose test strip bottle was not dated when it was first opened. LVN 5 confirmed that the two glucometer machine QC was not done last FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 42 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 night and it has to be done every night. LVN 5 also stated that the glucose test strip has to be dated when it's first opened. On December 21, 2017 at 5:01 p.m., during observation of Station 1 medication cart with LVN 5, two glucometers machine QC was not done. LVN 5 stated that the glucometer machine QC should have been done last night. Also, the QC test solution bottle did not have a date when it was first opened. A review of the facility policy and procedure titled "Blood Glucose Monitoring System Quality Control, test strips," indicated the QC bottles are to be labeled with the opening date when it was first opened to determine the expiration date, within 3 months of first opening the bottle. Quality Control of each glucometer is to be done daily using the dose quality control solution with the results documented in the glucometer monitoring log. Control solution for Quality Control should be dated upon first use of the bottle to determine expiration date of the solutions, which is within 90 days from first opening of the bottle. A review of the manufacturer's instructions, Assure Platinum Test Strips, when the test strip bottle is first opened, write the date on the bottle label and use test strips within 3 months of first opening the bottle. Also, when a new bottle of test strips is opened, staff is to check the Quality Control using the Assure Dose Control Solutions. A review of the manufacturer's instructions, Assure Dose Control Solution, it is recommended that the date of the first opening on the control solution bottle label be written as a reminder to dispose of the opened solution after 90 days of opening. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 43 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 b. A review of Resident 29's admission record indicated the resident was initially admitted to the facility on October 2, 2012, with the most recent re-admission on October 17, 2017. Resident 29's diagnoses included but were not limited to, diabetes (high blood sugar), dysphagia (difficulty swallowing), chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), and dementia (a general term for loss of memory and other mental abilities severe enough to interfere with daily life) without behavioral disturbance. A review of Resident 29's Minimum Data Set (MDS - a standardized care planning tool) dated October 5, 2017, indicated Resident 29 rarely understand others and rarely makes self understood and required extensive physical assistance with transfer, dressing, toilet use and personal hygiene. A physician's order dated November 19, 2017, 2017 indicated an order for blood sugar monitoring every 6 hours for diabetes mellitus, with sliding scale coverage of Novolin R 100 Unit per milliliter (ml)10 ml vial, inject subcutaneously (applied under the skin). c. A review of Resident 79's admission record indicated Resident 79 was admitted to the facility on January 24, 2017, with diagnoses that included but were not limited to, diabetes (high blood sugar), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), and hypertension (high blood pressure). A review of Resident 79's Minimum Data Set (MDS - a standardized care planning tool)dated November 5, 2017, indicated Resident 79 is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 44 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 cognitively impaired and required extensive physical assistance with transfer, dressing, toilet use and personal hygiene. A review of Resident 79's physician's order dated November 13, 2017, indicated an order for blood sugar monitoring before breakfast for diagnosis of diabetes mellitus, with sliding scale coverage of Novolin R 100 Unit per milliliter 10 ml vial, inject subcutaneously. On December 19, 2017, at 3:27 p.m., during a random medication cart inspection, accompanied by Licensed Vocational Nurse 8(LVN 8), of Medication Cart 1 (Station 1) contained two opened multi-dose vials of Novolin- R in a plastic medication container, with sticker each indicating R 29 and R 79's name. Both vials did not have a date indicating when these vials were opened. During the concurrent observation and interview LVN 7 (Medication Nurse for Station 1), stated "We should always put a date, it should be discarded after 42 days and we follow the sticker indicating 42 days". LVN 8 and stated "it should be discarded after 28 days". A review of the facility's undated General Guidelines for Safe and Accurate Medication Administration, indicated that open insulin vials are only good for 30 days.

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

F842 01/18/2018 §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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 45 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 §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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 46 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 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 ensure for three of 35 sampled residents (Residents 72, 102 and 120) Physician Orders for Life Sustaining Treatment (POLST- a form that has a medical order for the specific medical treatments during a medical emergency) were complete with signatures of resident's responsible party. This deficient practice had the potential to result in confusion on the delivery of care and services during a medical emergency. Findings: a. A review of the admission record indicated Resident 72 was admitted on October 5, 2017 with diagnoses including diabetes mellitus (a group of diseases that result in too much sugar in the blood), and hypertension (high blood pressure). A review of Resident 72's Minimum Data Set FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 47 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 (MDS - a comprehensive assessment and care screening tool), dated October 12, 2017 indicated the resident's cognitive status (relating to the process of acquiring knowledge and understanding) and daily decision making skills were intact. A review of the POLST dated October 5, 2017 indicated Resident 72 had a conservator (a guardian appointed by a judge to protect and manage the financial affairs and the person's daily life due to mental limitations) who was responsible for signing the POLST. However the signature section of the POLST was blank. b. A review of the admission record indicated Resident 102 was admitted on September 19, 2017 with diagnoses that included muscle weakness and dementia (a decline in mental ability severe enough to interfere with daily life). A review of Resident 102's Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated September 25, 2017 indicated the resident's cognitive (relating to the process of acquiring knowledge and understanding) status and decision making skills were severely impaired. A review of Resident 102's POLST dated September 19, 2017 indicated Resident 102's daughter was the legally recognized decision maker and responsible for signing the POLST. However, the signature section for the decision maker was blank. c. A review of the admission record indicated Resident 120 was admitted on May 18, 2015 with diagnoses that included diabetes mellitus (high blood sugar) and hypertension (high blood pressure). A review of Resident 120's Minimum Data Set FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 48 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 (MDS - a comprehensive assessment and screening tool),dated November 26, 2017, indicated the resident's cognitive (relating to the process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired. A review of Resident 120's POLST dated July 9, 2017 indicated Resident 120 had a conservator (a guardian appointed by a judge to protect and manage the financial affairs and the person's daily life due to mental limitations) who was responsible for signing the POLST. However the signature section for the decision maker was blank. On December 26, 2017 at 11:48 a.m., during an interview, the Administrator (ADM) stated the conservators told the facility they do not sign the POLST. The ADM stated the conservators did not give an explanation why they do not sign the POLST. On December 22, 2016 at 1:00 p.m., during an interview Social Service Director (SSD) confirmed that Resident 102's POLST was not signed by the legal decision maker. On December 26, 2017 at 1:00 p.m., during an interview, the SSD stated the conservators told her they do not sign the POLST. The SSD was unable to explain why the POLST was not completed. The SSD stated for family members, the facility was supposed to follow up and ask them to sign the document.

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

F842 01/18/2018 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 49 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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) 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 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 50 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 §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 ensure for three of 35 sampled residents (Residents 72, 102 and 120) Physician Orders for Life Sustaining Treatment (POLST- a form that has a medical order for the specific medical treatments during a medical emergency) were complete with signatures of resident's responsible party. This deficient practice had the potential to result in confusion on the delivery of care and services during a medical emergency. Findings: a. A review of the admission record indicated Resident 72 was admitted on October 5, 2017 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 51 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 diagnoses including diabetes mellitus (a group of diseases that result in too much sugar in the blood), and hypertension (high blood pressure). A review of Resident 72's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated October 12, 2017 indicated the resident's cognitive status (relating to the process of acquiring knowledge and understanding) and daily decision making skills were intact. A review of the POLST dated October 5, 2017 indicated Resident 72 had a conservator (a guardian appointed by a judge to protect and manage the financial affairs and the person's daily life due to mental limitations) who was responsible for signing the POLST. However the signature section of the POLST was blank. b. A review of the admission record indicated Resident 102 was admitted on September 19, 2017 with diagnoses that included muscle weakness and dementia (a decline in mental ability severe enough to interfere with daily life). A review of Resident 102's Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated September 25, 2017 indicated the resident's cognitive (relating to the process of acquiring knowledge and understanding) status and decision making skills were severely impaired. A review of Resident 102's POLST dated September 19, 2017 indicated Resident 102's daughter was the legally recognized decision maker and responsible for signing the POLST. However, the signature section for the decision maker was blank. c. A review of the admission record indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 52 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 Resident 120 was admitted on May 18, 2015 with diagnoses that included diabetes mellitus (high blood sugar) and hypertension (high blood pressure). A review of Resident 120's Minimum Data Set (MDS - a comprehensive assessment and screening tool),dated November 26, 2017, indicated the resident's cognitive (relating to the process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired. A review of Resident 120's POLST dated July 9, 2017 indicated Resident 120 had a conservator (a guardian appointed by a judge to protect and manage the financial affairs and the person's daily life due to mental limitations) who was responsible for signing the POLST. However the signature section for the decision maker was blank. On December 26, 2017 at 11:48 a.m., during an interview, the Administrator (ADM) stated the conservators told the facility they do not sign the POLST. The ADM stated the conservators did not give an explanation why they do not sign the POLST. On December 22, 2016 at 1:00 p.m., during an interview Social Service Director (SSD) confirmed that Resident 102's POLST was not signed by the legal decision maker. On December 26, 2017 at 1:00 p.m., during an interview, the SSD stated the conservators told her they do not sign the POLST. The SSD was unable to explain why the POLST was not completed. The SSD stated for family members, the facility was supposed to follow up and ask them to sign the document. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 53 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F850 Qualifications of Social Worker >120 Beds CFR(s): 483.70(p)(1)(2)

F850 SS=F PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 01/18/2018 §483.70(p) Social worker. Any facility with more than 120 beds must employ a qualified social worker on a full-time basis. A qualified social worker is: §483.70(p)(1) An individual with a minimum of a bachelor's degree in social work or a bachelor's degree in a human services field including, but not limited to, sociology, gerontology, special education, rehabilitation counseling, and psychology; and §483.70(p)(2) One year of supervised social work experience in a health care setting working directly with individuals. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to employ a qualified social worker on a full time basis that met the qualifications specified in the regulation. This deficient practice had a potential for 186 of 186 residents residing in the facility not being assisted and receiving medically related necessary care to attain highest practicable well-being. Cross reference F684 , F745, F600 Findings: On December 22, 2017 at 12.05 p.m., during an interview the Social Services Designee (SSD) stated she was the social service person in charge of all the residents in the facility since April 2017. The SSD stated she learned on the job and had no prior experience as a social FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 54 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 worker. The SSD stated she did not have any certification in social services here in the United States. The SSD was unsure if she had a social worker consultant because she had not met the consultant. On December 22, 2017 at 12:21 p.m., during an interview the SSD stated she felt it was impossible to care for all the residents in the facility. The SSD further explained she informed the Administrator that she was unable to care for all the residents. On December 22, 2017 at 1:05 p.m., during an interview the Administrator (ADM) stated she knew the SSD has a college degree from another country but was unsure if she had an equivalency of the degree in the United States. The ADM stated she was working on hiring a social worker and agreed the current SSD was not able to care for all the residents in the facility. A review of SSD's Employee file indicated the SSD has a master's degree of education in another country and was verified by approved academic credential agency. However, there was no evidence that the SSD had certification in social services and/or Bachelor's degree in psychology. On December 26, 2017 at 9:25 a.m., during an interview the Administrator and SSD stated they were in agreement that the SSD does not meet the qualification as she did not have prior supervised social work experience in a clinical setting nor certifications in social services. A review of the Social Services Designee job description dated March 12, 2014, indicated the Designee competencies should include completion of 36 hours of certificate in Social Services. The job description also stated a high FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 55 of 56 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: _______________ 056237 (X3) DATE SURVEY COMPLETED 12/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALDEN TERRACE CONVALESCENT HOSPITAL 1240 S Hoover St Los Angeles, CA 90006 (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 school or General Equivalency Diploma (GED) are required, Associate Degree of Art or Bachelors of Science beneficial. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q23J11 Facility ID: CA970000121 If continuation sheet 56 of 56