Other·July 23, 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 California Department of Public Health for the investigation of one complaint during an Abbreviated survey. Complaint Number: CA00580177 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 38487 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Five deficiencies were issued for complaint CA00580177.

F607 SS=D Develop/Implement Abuse/Neglect Policies CFR(s): 483.12(b)(1)-(3)

F607 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced 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: GV6H11 Facility ID: CA970000125 If continuation sheet 1 of 17 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: _______________ 055538 (X3) DATE SURVEY COMPLETED 06/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BONNIE BRAE SKILLED NURSING 420 S Bonnie Brae St Los Angeles, CA 90057 (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 by: Based on observation, interview and record review, the facility failed to ensure a certified nurse assistant 1 (CNA 1) and the social services director (SSD) were able to verbalize all types of abuse, for two of four sampled staff members. This deficient practice had the potential for the misidentification of the signs of abuse and perpetuate ongoing abuse. Cross reference F580, F609, F610, F656, and

F842. Findings: On 4/6/18, an unannounced visit was made to the facility to investigate a complaint regarding injury of unknown origin. A review of the Admission Record, dated 4/6/18, indicated Resident 1 was originally admitted on 5/9/12 and readmitted on 4/6/18, with the diagnoses which included dementia (decline in mental ability severe enough to interfere with daily life), muscle weakness, and Parkinson's disease (deterioration in motor function). A review of the Minimum Data Set, an assessment tool, dated 3/26/18, indicated Resident 1 cognitive skills for daily decisionmaking was severely impaired. Resident 1 required total dependence from staff on bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of the physician orders, dated 3/16/18, indicated Resident 1 had left lateral chest multiple discoloration, monitor every shift, call medical doctor for signs and symptoms of infection or unusual change of condition for 30 days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GV6H11 Facility ID: CA970000125 If continuation sheet 2 of 17 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: _______________ 055538 (X3) DATE SURVEY COMPLETED 06/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BONNIE BRAE SKILLED NURSING 420 S Bonnie Brae St Los Angeles, CA 90057 (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 4/6/18, at 8:40 a.m., Resident 1 was assessed with a licensed vocational nurse (LVN 1). Resident 1 was observed to be in his bed with his eyes closed. Resident 1 makes eye contact when touched, but did not verbalize. Resident 1 had no movement. LVN 1 confirmed Resident 1's left flank (area below the ribs and above the hip) had an area of dark purple discoloration surrounded by a yellowish edge approximately 11 centimeters (cm) by seven (7) cm in size. LVN 1 could not confirm whether the area of discoloration was a healing bruise. On 4/6/18, at 10:00 a.m., the social services director (SSD) was interviewed. The SSD stated the types of abuse are mental, verbal, physical, financial, and isolation (involuntary seclusion). On 4/6/18, at 10:02 a.m., a certified nurse assistant (CNA 1) was interviewed. CNA 1 stated the types of abuse are physical, verbal, sexual, mental, isolation (involuntary seclusion), and financial. On 4/6/18, at 11:15 a.m., the administrator (Administrator), also the abuse coordinator, was interviewed. The Administrator acknowledged Resident 1's left flank discoloration is an injury of unknown origin, a sign of abuse. The Administrator stated she did not believe Resident 1's left flank discoloration was from abuse, but was unable to conclude the injury of unknown origin was not the result of abuse. A review of the undated policy, titled Abuse, indicated the facility shall uphold resident's rights to be free from mental, verbal, physical, sexual, and financial, abuse, corporal punishment, neglect, and involuntary seclusion. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GV6H11 Facility ID: CA970000125 If continuation sheet 3 of 17 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: _______________ 055538 (X3) DATE SURVEY COMPLETED 06/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BONNIE BRAE SKILLED NURSING 420 S Bonnie Brae St Los Angeles, CA 90057 (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 Facility staff and employees shall receive, through orientation and continuing education sessions, training on issues related to abuse prohibition practices such as what constitutes abuse, neglect, and misappropriation of resident funds and property.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GV6H11 Facility ID: CA970000125 If continuation sheet 4 of 17 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: _______________ 055538 (X3) DATE SURVEY COMPLETED 06/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BONNIE BRAE SKILLED NURSING 420 S Bonnie Brae St Los Angeles, CA 90057 (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 report injury of unknown origin to the Department of Public Health within 24 hours for one of two sampled residents (Resident 1). Resident 1 was found with multiple discoloration (bruise) to his left lateral chest. This deficient practice had the potential for ongoing abuse. Cross reference F607, F610, F656, and F842. Findings: On 4/6/18, an unannounced visit was made to the facility to investigate a complaint regarding injury of unknown origin. A review of the Admission Record, dated 4/6/18, indicated Resident 1 was originally admitted on 5/9/12 and readmitted on 4/6/18, with the diagnoses which included dementia (decline in mental ability severe enough to interfere with daily life), muscle weakness, and Parkinson's disease (deterioration in motor function). A review of the Minimum Data Set, an assessment tool, dated 3/26/18, indicated Resident 1 cognitive skills for daily decisionmaking was severely impaired. Resident 1 required total dependence from staff on bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of the physician orders, dated 3/16/18, indicated Resident 1 had left lateral chest multiple discoloration, monitor every shift, call medical doctor for signs and symptoms of infection or unusual change of condition for 30 days. On 4/6/18, at 8:40 a.m., Resident 1 was assessed with a licensed vocational nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GV6H11 Facility ID: CA970000125 If continuation sheet 5 of 17 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: _______________ 055538 (X3) DATE SURVEY COMPLETED 06/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BONNIE BRAE SKILLED NURSING 420 S Bonnie Brae St Los Angeles, CA 90057 (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 (LVN 1). Resident 1 was observed to be in his bed with his eyes closed. Resident 1 makes eye contact when touched, but did not verbalize. Resident 1 had no movement. LVN 1 confirmed Resident 1's left flank (area below the ribs and above the hip) had an area of dark purple discoloration surrounded by a yellowish edge approximately 11 centimeters (cm) by seven (7) cm in size. LVN 1 could not confirm whether the area of discoloration was a healing bruise. On 4/6/18, at 11:15 a.m., the administrator (Administrator), also the abuse coordinator, was interviewed. The Administrator acknowledged Resident 1's left flank discoloration is an injury of unknown origin, a sign of abuse. The Administrator stated the facilities process for abuse prohibition and injuries of unknown origin include: Reporting of the alleged incident to the administrator; investigation of the alleged incident; and reporting to the Department of Public Health, ombudsman, and law enforcement as needed, within two hours. The Administrator confirmed the injury of unknown origin was not reported to the Department of Public Health within two hours, the time she believed was the timeframe for reporting. The Administrator stated, LVN 2 "dropped the ball, she should have called me." A review of the undated policy, titled Abuse, indicated the facility shall institute procedures of identifying unusual occurrences and events, such as suspicious bruising of residents, unexplained skin tears, fractures, etc. that may constitute abuse. Such procedural guidelines shall also provide for directions of necessary reporting and investigative efforts. Any incidences or occurrences that may constitute abuse shall be reported to the local ombudsman and/or the local law enforcement and shall be recorded on the Incident Report FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GV6H11 Facility ID: CA970000125 If continuation sheet 6 of 17 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: _______________ 055538 (X3) DATE SURVEY COMPLETED 06/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BONNIE BRAE SKILLED NURSING 420 S Bonnie Brae St Los Angeles, CA 90057 (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 Form and reported to the Administrator and Director of Nurses immediately after and no later than 24 hours after the identification of the unusual occurrence or events constituting abuse or probable abuse. (Please note that facilities are required to report to the Department of Health Services any incident of unknown origin. It is therefore, very vital to take extra caution in documenting that the incident is of unknown origin, unless proven otherwise). Extensive efforts shall be carried out in the investigation and determination of unusual occurrences and/or events that may constitute abuse, including those injuries uncured by the residents for which origin of such injury is "unknown."

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

F610 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to investigate one of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GV6H11 Facility ID: CA970000125 If continuation sheet 7 of 17 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: _______________ 055538 (X3) DATE SURVEY COMPLETED 06/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BONNIE BRAE SKILLED NURSING 420 S Bonnie Brae St Los Angeles, CA 90057 (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 two sampled residents (Resident 1) who was found with multiple discoloration (bruise) on his left lateral chest, an injury of unknown origin. This deficient practice had the potential for ongoing abuse. Cross reference F607, F609, F656, and F842. Findings: On 4/6/18, an unannounced visit was made to the facility to investigate a complaint regarding injury of unknown origin. A review of the Admission Record, dated 4/6/18, indicated Resident 1 was originally admitted on 5/9/12 and readmitted on 4/6/18, with the diagnoses which included dementia (decline in mental ability severe enough to interfere with daily life), muscle weakness, and Parkinson's disease (deterioration in motor function). A review of the Minimum Data Set, an assessment tool, dated 3/26/18, indicated Resident 1 cognitive skills for daily decisionmaking was severely impaired. Resident 1 required total dependence from staff on bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of the physician orders, dated 3/16/18, indicated Resident 1 had left lateral chest multiple discoloration, monitor every shift, call medical doctor for signs and symptoms of infection or unusual change of condition for 30 days. On 4/6/18, at 8:40 a.m., Resident 1 was assessed with a licensed vocational nurse (LVN 1). Resident 1 was observed to be in his bed with his eyes closed. Resident 1 makes eye contact when touched, but did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GV6H11 Facility ID: CA970000125 If continuation sheet 8 of 17 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: _______________ 055538 (X3) DATE SURVEY COMPLETED 06/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BONNIE BRAE SKILLED NURSING 420 S Bonnie Brae St Los Angeles, CA 90057 (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 verbalize. Resident 1 had no movement. LVN 1 confirmed Resident 1's left flank (area below the ribs and above the hip) had an area of dark purple discoloration surrounded by a yellowish edge approximately 11 centimeters (cm) by seven (7) cm in size. LVN 1 could not confirm whether the area of discoloration was a healing bruise. On 4/6/18, at 10:45 a.m., the director of nursing (DON) was interviewed. The DON stated she believes Resident 1 is "safe," but cannot conclude the injury of unknown origin was not from abuse because the incident was not investigated. On 4/6/18, at 11:15 a.m., the administrator (Administrator), also the abuse coordinator, was interviewed. The Administrator acknowledged Resident 1's left flank discoloration is an injury of unknown origin, a sign of abuse. The Administrator stated the facilities process for abuse prohibition and injuries of unknown origin include: Reporting of the alleged incident to the administrator; Investigation of the alleged incident; and reporting to the Department of Public Health, ombudsman, and law enforcement as needed within two hours. The Administrator confirmed the injury of unknown origin was not investigated because LVN 2 did not report the injury of unknown origin, but should have. The Administrator stated, LVN 2 "dropped the ball, she should have called me." The Administrator stated she did not believe Resident 1's left flank discoloration was from abuse, but was unable to conclude the injury of unknown origin was not the result of abuse. A review of the undated policy, titled Abuse, indicated the facility shall ensure thorough and extensive investigation of different types of incidents including but not limited to those that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GV6H11 Facility ID: CA970000125 If continuation sheet 9 of 17 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: _______________ 055538 (X3) DATE SURVEY COMPLETED 06/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BONNIE BRAE SKILLED NURSING 420 S Bonnie Brae St Los Angeles, CA 90057 (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 may constitute abuse; and identification of every staff member who is a mandated reported, reporting of alleged or suspected abuse and investigation shall be immediately reported to the local ombudsman and/or local law enforcement as well as the facility administrator and director of nurses. All employees are mandated reporters. Initial results of investigations shall be submitted to facility Administrator within 24 hours for determination of further investigative actions and/or corrective measures. The Facility Administrator and/or facility abuse coordinator and/or designees shall be responsible for ensuring thorough investigation, utilizing such measures as interview staff, visitors, residents or other individuals who may have knowledge of alleged violations.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) §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 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). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GV6H11 Facility ID: CA970000125 If continuation sheet 10 of 17 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: _______________ 055538 (X3) DATE SURVEY COMPLETED 06/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BONNIE BRAE SKILLED NURSING 420 S Bonnie Brae St Los Angeles, CA 90057 (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 (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 and implement a resident-centered care plan with the coordination of the interdisciplinary team after Resident 1 was found with multiple discoloration (bruise) to left lateral chest, an injury of unknown origin, for one of two sampled residents (Resident 1). This deficient practice had the potential for the misidentification of resident-specific interventions causing on-going abuse. Cross reference F607, F609, F610, and F842. Findings: On 4/6/18, an unannounced visit was made to the facility to investigate a complaint regarding injury of unknown origin. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GV6H11 Facility ID: CA970000125 If continuation sheet 11 of 17 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: _______________ 055538 (X3) DATE SURVEY COMPLETED 06/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BONNIE BRAE SKILLED NURSING 420 S Bonnie Brae St Los Angeles, CA 90057 (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 Admission Record, dated 4/6/18, indicated Resident 1 was originally admitted on 5/9/12 and readmitted on 4/6/18, with the diagnoses which included dementia (decline in mental ability severe enough to interfere with daily life), muscle weakness, and Parkinson's disease (deterioration in motor function). A review of the Minimum Data Set, an assessment tool, dated 3/26/18, indicated Resident 1 cognitive skills for daily decisionmaking was severely impaired. Resident 1 was totally dependent from staff on bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of the physician orders, dated 3/16/18, indicated Resident 1 had left lateral chest multiple discoloration, monitor every shift, call medical doctor for signs and symptoms of infection or unusual change of condition for 30 days. On 4/6/18, at 8:40 a.m., Resident 1 was assessed with a licensed vocational nurse (LVN 1). Resident 1 was observed to be in his bed with his eyes closed. Resident 1 makes eye contact when touched, but did not verbalize. Resident 1 had no movement. LVN 1 confirmed Resident 1's left flank (area below the ribs and above the hip) had an area of dark purple discoloration surrounded by a yellowish edge approximately 11 centimeters (cm) by seven (7) cm in size. LVN 1 could not confirm whether the area of discoloration was a healing bruise. On 4/6/18, at 10:45 a.m., the director of nursing (DON) was interviewed. The DON stated Resident 1's left flank discoloration is an injury of unknown origin, a sign of abuse. The DON stated resident-centered care plans are FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GV6H11 Facility ID: CA970000125 If continuation sheet 12 of 17 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: _______________ 055538 (X3) DATE SURVEY COMPLETED 06/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BONNIE BRAE SKILLED NURSING 420 S Bonnie Brae St Los Angeles, CA 90057 (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 generated in coordination with the IDT. The DON admitted there was no documented evidence of care plan specific to Resident 1's injury of unknown origin, but should have. The DON acknowledged, without a resident-specific are plan, staff members may not be able to identify and implement resident-specific interventions to prevent on-going abuse. A review of the policy, titled Care Planning Interdisciplinary Team, revised September 2013, indicated the facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. A review of the policy, titled Care Plans Comprehensive, revised September 2010, indicated the facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.

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

F842 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GV6H11 Facility ID: CA970000125 If continuation sheet 13 of 17 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: _______________ 055538 (X3) DATE SURVEY COMPLETED 06/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BONNIE BRAE SKILLED NURSING 420 S Bonnie Brae St Los Angeles, CA 90057 (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 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 reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GV6H11 Facility ID: CA970000125 If continuation sheet 14 of 17 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: _______________ 055538 (X3) DATE SURVEY COMPLETED 06/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BONNIE BRAE SKILLED NURSING 420 S Bonnie Brae St Los Angeles, CA 90057 (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) 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 observation, interview and record review, the facility failed to ensure Resident 1's injury of unknown origin was documented accurately in regards to location and type of skin condition and failed to document that the physician was notified of left lateral chest multiple discoloration for one of two sampled residents (Resident 1). This deficient practice had the potential for a break in continuity of care leading to a decline in skin status. Cross-reference F607, F609, F610, and F656. Findings: a. On 4/6/18, an unannounced visit was made to the facility to investigate a complaint regarding injury of unknown origin. A review of the Admission Record, dated 4/6/18, indicated Resident 1 was originally admitted on 5/9/12 and readmitted on 4/6/18, with the diagnoses which included dementia (decline in mental ability severe enough to interfere with daily life), muscle weakness, and Parkinson's disease (deterioration in motor function). A review of the Minimum Data Set, an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GV6H11 Facility ID: CA970000125 If continuation sheet 15 of 17 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: _______________ 055538 (X3) DATE SURVEY COMPLETED 06/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BONNIE BRAE SKILLED NURSING 420 S Bonnie Brae St Los Angeles, CA 90057 (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 assessment tool, dated 3/26/18, indicated Resident 1 cognitive skills for daily decisionmaking was severely impaired. Resident 1 required total dependence on bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of the physician orders, dated 3/16/18, indicated Resident 1 had left lateral chest multiple discoloration, monitor every shift, call medical doctor for signs and symptoms of infection or unusual change of condition for 30 days. On 4/6/18, at 8:40 a.m., Resident 1 was assessed with a licensed vocational nurse (LVN 1). Resident 1 was observed to be in his bed with his eyes closed. Resident 1 makes eye contact when touched, but did not verbalize. Resident 1 had no movement. LVN 1 confirmed Resident 1's left flank (area below the ribs and above the hip) had an area of dark purple discoloration surrounded by a yellowish edge approximately 11 centimeters (cm) by seven (7) cm in size. LVN 1 could not confirm whether the area of discoloration was a healing bruise. On 4/6/18, at 10:57 a.m., Resident 1's skin was assessed with the director of nursing (DON). The DON confirmed Resident 1 had "discoloration to the left lateral (side) and posterior (back) chest and left flank. On 4/6/18, at 11:00 a.m., Resident 1's progress note, dated 3/18/18, was reviewed with the DON. The DON confirmed for the section, labeled condition of skin, an anterior (front) and posterior diagram of a person is provided. The documentation specifically instructs, indicate new bruises, rashes, tears, pressure sores, et cetera. For the anterior diagram, the left lateral chest is circled. The DON acknowledged the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GV6H11 Facility ID: CA970000125 If continuation sheet 16 of 17 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: _______________ 055538 (X3) DATE SURVEY COMPLETED 06/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BONNIE BRAE SKILLED NURSING 420 S Bonnie Brae St Los Angeles, CA 90057 (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 circled left lateral chest did not indicate the type of skin condition, as instructed by the progress note, but should have. The DON admitted the left flank should also be circled and indicated with the skin condition, but was not. A review of the policy, titled Charting and Documentation, revised April 2018, indicated, all observations, medications administered, services performed, etc., must be documented in the resident's clinical record. b. On 4/6/18, at 11:00 a.m., the director of nursing (DON) was interviewed. The DON acknowledged Resident 1's injury of unknown origin is COC. The facility believes the change of condition occurred on 3/16/18 because there was a physician order for the monitoring of left lateral chest multiple discoloration for this day. The DON admitted LVN 2 should have documented the COC with a narrative surrounding the circumstances upon assessment of the injury of unknown origin. The DON acknowledged there was a late entry on 3/19/18 regarding a large red bruise, but no documented evidence of a COC for 3/16/18. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GV6H11 Facility ID: CA970000125 If continuation sheet 17 of 17