Other·May 23, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an Annual Recertification Survey. Representing the Department of Public Health. Evaluator ID No. 33638, RN HFEN Evaluator ID No. 40913, RN HFEN Evaluator ID No. 40773, RN HFEN Highest Severity and Scope = F Total Resident Population: 53 Total Resident Sample:18 Total Closed Record Sample:3

F568 SS=D Accounting and Records of Personal Funds CFR(s): 483.10(f)(10)(iii)

F568 06/04/2019 §483.10(f)(10)(iii) Accounting and Records. (A) The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. (B) The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident. (C)The individual financial record must be available to the resident through quarterly statements and upon request. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that Resident 35 received written documentation notifying 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: L2XR11 Facility ID: CA970000125 If continuation sheet 1 of 64 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 04/22/2019 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 35's increase in share of cost. This deficient practice had the potential for Resident 35 to be unaware of their own financial status. Findings: A review of Resident 35's Admissions Record indicated the resident was initially admitted to the facility on 5/3/18, with diagnoses that included hyperkalemia (high potassium), end stage renal failure (loss of kidney function), muscle weakness, and diabetes (high blood sugar). A review of Resident 35's Minimum Data Set (MDS) a care assessment and screening tool, dated 3/4/19, indicated the resident had no cognitive impairment. On 4/17/19, at 3:30 p.m., during an interview, Resident 35 stated that early this month, Resident 35 was accompanied to the bank by the Social Service designee was asked to withdraw $738.00. Resident 35 stated the amount withdrawn for this month was higher by $135.00 and that the resident was not notified of the increase in the share of cost. Resident 35's prior share of cost was $603.00. On 04/17/19, at 10:17 a.m., during an interview, the SSS stated that residents get $35.00 a month after they pay their share of cost. SS stated that on the 3rd of every month, the facility receives the check and gives the check to the resident. The facility maintains a copy for the facility's record. Social Service also stated that there is a form to ensure that the resident has received the check, which the resident has to sign. Social service added that for residents who are not alert, the facility will buy necessities for the resident, such as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 2 of 64 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 04/22/2019 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 clothes, or what the facility may think the resident needs, without the resident's permission. On 4/18/19, between 8:18 a.m., and 8:20 a.m., during an interview, the billing clerk stated that the billing clerk deals with the personal funds for the residents of the facility. The billing clerk stated that for residents who are independent and responsible for themselves, social service will accompany the residents to the bank to withdraw their share of cost for the month. The billing clerk stated that she follows the policy titled, "Policy regarding Resident Trust Funds," which was created by the billing clerk and used as guidelines in carrying out the policy of the facility in dealing with the personal funds of the residents. On 4/18/19 at 9:19 a.m., during an interview with the billing clerk and social service, stated that a Notice of Action is provided to residents to remind residents and make residents aware of their share of cost. However, there was no Notice of Action for Resident 35 for April 2019. On 4/18/19 at 12:07 p.m., during an interview with social service, stated that the facility does not provide any written documentation or statements to residents explaining the increase of share of cost, and that only a verbal explanation is done. The policy did not state verbal or written explanations regarding resident's financial record.

F585 SS=D Grievances CFR(s): 483.10(j)(1)-(4)

F585 06/04/2019 §483.10(j) Grievances. §483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 3 of 64 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 04/22/2019 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 discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay. §483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. §483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident. §483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include: (i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; (ii) Identifying a Grievance Official who is responsible for overseeing the grievance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 4 of 64 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 04/22/2019 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 process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; (iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated; (iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law; (v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns (s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued; (vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and (vii) Maintaining evidence demonstrating the result of all grievances for a period of no less FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 5 of 64 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 04/22/2019 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 than 3 years from the issuance of the grievance decision. This REQUIREMENT is not met as evidenced by: Based on interview, observation and record review, the facility failed to intervene promptly when one of 18 sampled residents (Resident 57) made a complaint about the ongoing screaming from his roommate. This deficient practice made Resident 57 not achieve a sense of well-being for not being able to sleep due to the screaming. Findings: A review of Resident 57's Admission Record indicated the resident was admitted on 3/28/19, with diagnoses that included malignant neoplasm of the larynx (tumor of the larynx), and dysphagia (difficulty swallowing). A review of Resident 57's History and Physical (H&P), dated 2/27/19, indicated the resident had the capacity to understand and make decisions. A review of Resident 57's Minimum Data Set (MDS - a care and assessment screening tool), dated 4/4/19, indicated the resident had no cognitive impairment and required extensive assistance with bed mobility, transfers and activities of daily living. During a concurrent observation and interview on 4/15/19, at 8:46 a.m., Resident 57 was observed using a speech assistive device (a device used to speak by using vibration in the throat to create sound) that he would hold on the front of his throat to speak. The sound created by using the speech assistive device was so low in volume that surveyor 1 had to get FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 6 of 64 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 04/22/2019 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 closer in order to hear. Resident 57 stated the resident next to his bed screams all day that he could not sleep because of the screaming. Resident 57 stated he had stayed with that resident in the same room for two weeks and that he had reported about the screaming to the facility staff. During this observation, Resident 43 was screaming, he was laying down in bed and he was screaming since Surveyor 1 started the observation at 8:21 a.m., while conducting an interview with another resident from another room. During an interview on 4/16/19, at 2:53 p.m., Certified Nursing Assistant 1 (CNA 1) stated that Resident 57 made a complaint about the screaming from the resident next to his bed. CNA 1 stated the resident complained that he felt tired because he could not sleep due to the screaming. CNA 1 stated this complaint was reported to Licensed Vocational Nurse 1 (LVN 1) on 4/1/19, and CNA also reported the same complaint to LVN 2 on 4/5 or 4/6/19. During an interview on 4/16/19, at 3:07 p.m., LVN 1 stated she was informed about the complaint and what she could do as an intervention was to ensure the resident was comfortable. A review of the facility's policy and procedures titled, "Resident Rights, Grievances" indicated prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents.

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

F610 06/04/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 7 of 64 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 04/22/2019 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 §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 promptly investigate a fall that was reported before the end of the 11 -7 shift (6:40-6:45 a.m) for Resident 57. This deficient practice had the potential to place Resident 57 at risk for abuse or injury. Findings: A review of Resident 57's Admission Record indicated the resident was admitted on 3/28/19, with diagnoses that included malignant neoplasm of the larynx (tumor of the larynx), dysphagia (difficulty swallowing). A review of Resident 57's History and Physical (H&P), dated 2/27/19, indicated the resident had the capacity to understand and make decisions. A review of Resident 57's Minimum Data Set (MDS - a care and assessment screening tool), dated 4/4/19, indicated resident had no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 8 of 64 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 04/22/2019 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 cognitive impairment and required extensive assistance with bed mobility, transfers and activities of daily living. During a concurrent observation and interview on 4/17/19 at 11:10 a.m., Resident 57 stated that while he was in bed before breakfast, the resident stated, " He punched me and hit me in the chest and I hit him back a couple of times." Resident 57 stated he could not find the call button so he moved his legs hard on the bed to get the staff's attention. Resident 57 stated that a facility staff came 20 minutes later, resident nodded when questioned if he reported the incident but was not able to name the person to whom he reported the incident. Resident 57 did not answer when asked if he reported it to a male or female staff. Observed Resident 57's room, the room had 4 beds; Bed A, closest to the door was occupied by Resident 12, Bed B was occupied by Resident 57, Bed C was occupied by Resident 51 and Bed D, the bed closest to the window was occupied by Resident 15. Resident 12 was sitting on a wheelchair with the privacy curtain closed. Resident 51 was bedbound and Resident 15 was not in the room. Resident 57 shook his head when questioned if Resident 12 was the one who hit him. A few minutes later, Resident 57 was being assisted by staff via wheelchair on the way to the dining room and at this time, Resident 15 was sitting on a wheelchair outside their shared room. Resident 56 and Surveyor were talking 15 feet away from Resident 15. Surveyor 1 pointed at Resident 15 who was sitting in a wheelchair outside the room and asked Resident if Resident 15 was the one who hit him and Resident 57 did not answer. During a subsequent observation and interview on 4/17/19, at 11:35 a.m., observed Licensed Vocational Nurse 1 (LVN 1) wheel Resident 57 out of the dining room. LVN 1 stated that she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 9 of 64 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 04/22/2019 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 had to check the resident for wounds or pain, and to monitor him. LVN 1 stated that the outgoing nurse, LVN 3 informed her verbally on shift to shift handoff report, that the Restorative Nurse Assistant (RNA) witnessed Resident 57 sliding from the bed around 6:45 a.m. LVN 1 did not check the Resident 57 for wounds or injury earlier in the shift. She just started to assess Resident 57 at this time. A subsequent review of the Daily Medicare Notes, dated 3/16/19, indicated the Daily Medicare Notes had no documentation for the 11-7 shift. During an interview on 4/17/19 at 1:33 p.m., the Director of Nursing (DON) stated there was no report of a resident to resident altercation, the facility practice would be to start the investigation and if the incident involved a resident to resident altercation then the residents would be separated immediately. During an interview on 4/17/19 at 1:38 p.m., the RNA stated that the incident happened around 6:40 - 6:45 a.m., he saw Resident 57 was still in bed, and was seen sliding from the bed but the RNA was unable to catch the fall. The RNA also stated the resident's bottom touched the floor. The RNA stated he informed LVN 3 A review of the facility's policy and procedures titled, "Charting and Documentation," undated, indicated that one of the following information is to be documented in the resident's medical record; events, incidents or accidents involving the resident. A review of the facility's policy and procedures titled, "Protection of Residents During Abuse Investigations," undated, indicated the facility will protect residents from harm during FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 10 of 64 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 04/22/2019 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 investigations of abuse allegations.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 06/04/2019 §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). (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 11 of 64 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 04/22/2019 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 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 ensure the care plan for five of 18 sampled residents (Residents 6, 11, 15, 21, 35) were person-centered to meet their needs and preferences. The facility failed to: a. Complete a person centered care plan for four of twelve sampled residents. b. Develop a person-centered care plan when Resident 21 refused the use of a Hoyer lift (mechanical lift used for transfers) for transfers and required placement of a condom catheter (a device attached to the penile area to direct urine to a separate collection chamber). This deficient practice had the potential to not identify the specific needs required to adequately care for Residents 6, 11, 15, 21 and 35. Findings: a. A review of Resident 6's Admission Record indicated the Resident was admitted to the facility on 9/21/18, with diagnoses of hypertension (high blood pressure), bipolar disorder (brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks), depressive disorder, anxiety and schizophrenia (brain disorder that distorts the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). A review of Resident 6's Initial History and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 12 of 64 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 04/22/2019 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 Physical (H&P), dated March 2019, indicated Resident 6 had the capacity to understand and make decisions. A review of Resident 6's Minimum Data Set (MDS, a care screening and assessment tool), dated 1/6/19, indicated that Resident 6 required extensive assistance with bed mobility, transfers, dressing and personal hygiene. The resident also required limited assistance with eating and total dependence with toilet use. A review of Resident 6's Smoking Assessment, dated 4/28/18, did not indicate if Resident 6 was a smoker. The smoking assessment also did not indicate whether Resident 6 required supervision or can smoke independently. A review of the facility's smoking list indicated that Resident 6 was an independent smoker. A review of Resident 6's Care Plan indicated Resident 6 had no care plan regarding smoking. Resident 6's care plan dated 4/20/18 indicated Resident 6 was at risk for increasing confusion and disordered thought secondary to diagnosis of bipolar disorder, schizophrenia with interventions to keep the environment free of hazards. b. A Review of Resident 11's Admission Record indicated the Resident was admitted to the facility on 9/21/18, with diagnoses of kidney failure, muscle weakness, seizures (a sudden, uncontrolled electrical disturbance in the brain), schizophrenia (brain disorder that distorts the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). and anxiety disorder. A review or Resident 11's H&P, dated 2/1/19, indicated the resident had fluctuating capacity to understand and make decisions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 13 of 64 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 04/22/2019 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 Resident 11's MDS, indicated that the resident required supervision with bed mobility and transfers; required limited assistance with eating, dressing, toilet use and personal hygiene. A review of Resident 11's undated Smoking Assessment did not indicate if the resident was a smoker. The Smoking Assessment did not indicate if Resident 11 required supervision or is an independent smoker. A review of the facility's smoking list indicated Resident 11 required supervision during smoking hours. A review of Resident 11's Care Plan, dated 4/10/19, indicated the resident was a high risk for injury related to smoking. The interventions specified were not person-centered and did not indicate that the resident had a history of seizures, the care plan did not indicate the care and services needed to provide Resident 11 safety during smoking. The care plan had no specific accommodations such as the use of a smoking apron for Resident 11 who had a history of seizures. c. A review of Resident 15's Admission Record indicated the resident was initially admitted to the facility 1/8/15, with a diagnoses of epilepsy (seizures), psychosis (mental disorder characterized by loss of touch with reality), depression, and altered mental status. A review of Resident 15's H&P, dated 3/27/18, indicated the resident had the capacity to understand and make decisions. A review of Resident 15's MDS, indicated the resident required supervision for bed mobility, transfers, dressing, eating, toilet use and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 14 of 64 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 04/22/2019 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 personal hygiene. A review of Resident 15's Smoking Assessment did not indicate if Resident 15 was a smoker. The Smoking assessment also did not indicate if Resident 15 required supervision during smoking hours. A review of the facility's smoking list indicated that Resident 15 required supervision during smoking hours. A review of Resident 15's Care Plan did not indicate an initiation of a care plan for smoking, therefore, not addressing the care and needed for Resident 15 to smoke safely. During an interview on 4/16/19 at 9:59 a.m., CNA 1 stated that Resident 15 used to smoke before, had not smoked for two years. CNA 1 stated the resident had a history of seizures and that the last seizure was September 2018. During an interview on 4/16/19 at 9:29 a.m., Resident 15 stated, "I smoke when I get it." d. A review of Resident 21's Admission Record indicated the resident was admitted on 3/15/19, with diagnoses that included quadriplegia (paralysis of the body from the neck down), benign prostatic hyperplasia (BPH - enlarged prostate). A review of Resident 21's History and Physical (H&P), dated 4/15/19, indicated the resident had the capacity to understand and make decisions. A review of Resident 21's Minimum Data Set (MDS - a care and assessment screening tool), dated 2/17/19, indicated resident had no cognitive impairment and required extensive assistance with bed mobility, dressing and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 15 of 64 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 04/22/2019 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 personal hygiene and totally dependent on transfers requiring two-person assistance. A review of Resident 21's Care Plan, dated 3/8/2017, indicated resident was quadriplegic, needed two-person or more assistance for transfers to a wheelchair and back to bed and refused the use of a Hoyer (a mechanical lift) lift for transfers. The interventions included to encourage the use of the Hoyer lift. The care plan did not address other interventions on how to transfer the resident based on his choices and preferences. A review of Resident 21's Care Plan, dated 3/8/2017, indicated the resident was at risk for infection related to the use of condom catheter and desires to use a leg bag during the day and a reusable collection bag at night. The care plan did not address the resident's preference for the use of the condom catheter and to ensure that facility staff were available and competent to put on a condom catheter. During an interview on 4/15/19 at 10:50 a.m., Resident 21 stated he would like to go to church every Sunday but there were only three facility staff who knows how to put on a condom catheter and transfer the resident from the bed to the wheelchair or transfer from the bed to the shower chair. Resident 21 stated that if those three staff were not scheduled on weekends, then the resident would stay in bed. Resident 21 further stated he went to church this Sunday 4/14/19, but not the previous Sunday 4/8/19, and the Sunday prior 4/1/19. Resident 21 stated when he pressed the call light on those weekends, the facility staff would inform Resident 21 that there were no staff to help him, he was informed "Nobody wants to go there". During an observation on 4/17/19, at 9:16 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 16 of 64 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 04/22/2019 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 observed CNA 2 put a condom catheter on for Resident 21. First, CNA 2 sprayed a medical adhesive to the penis prior to putting on the condom catheter, then attached the end of the catheter to a leg bag (a bag used to collect and hold urine) is a long bag with 2 bands that held the bag in place on the resident's leg. On the above date and time, Surveyor 1 also observed two facility staff transfer Resident 21 from the bed to the wheelchair; one facility staff held Resident 21 from the back with arms encircling the chest through the armpit, and CNA 2 supported the resident's lower legs near the knee area, and together, they transferred the resident from the bed to the wheelchair by lifting him off slightly, while moving him towards the wheelchair. During an interview with the Minimum Data Set Nurse (MDS Nurse) on 04/18/19, at 8:36 a.m., the MDS nurse stated that the resident refused the use of the Hoyer lift because it would pull out the condom catheter. The MDS Nurse stated that Resident 21 would visit his family on weekends and there were some weekends that the Certified Nursing Assistants (CNA) were not able to get him up. e. A review of Resident 35's Admission Record indicated the resident was admitted to the facility on 5/3/18, with a diagnoses of end stage renal failure (loss of function of kidneys), muscle weakness, diabetes (high blood sugar) and cancer. A review of Resident 35's H&P, indicated the resident had the capacity to understand and make decisions. A review of Resident 35's MDS, dated 4/4/19, indicated the resident required limited assistance with bed mobility, transfers, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 17 of 64 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 04/22/2019 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 eating. Resident 35 required limited assistance with dressing, toilet use and personal hygiene. A review of Resident 35's Smoking Assessment did not indicate if Resident 35 was a smoker. The Smoking Assessment also did not indicate if Resident 35 required supervision during smoking hours. A review of the facility's Smoking list indicated that Resident 35 was an independent smoker and did not require supervision. A review of Resident 35's Care Plan, dated 4/15/19, indicated the resident was a high risk for injury related to smoking. The interventions specified were not person-centered and did not indicate the care and services for Resident 35 with a diagnosis of dementia. Resident 35's care plan indicated interventions to provide supervision when resident was smoking. The facility's smoking list indicated Resident 35 was an independent smoker. On 4/16/19 at 9 a.m., during an interview, the MDS nurse stated that on admission, a care plan is initiated to focus and guide the staff on how to care for residents in the facility. The MDS nurse stated that all care plans should be specific to each resident. A review of the facility's undated policy and procedures titled, "Using the Care Plan", indicated the Nurse Supervisor uses the care plan to complete the CNA's daily/weekly work assignment sheets or flow sheets. The policy indicated changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made.

F658 SS=D Services Provided Meet Professional Standards FORM CMS-2567(02-99) Previous Versions Obsolete

F658 Event ID: L2XR11 06/04/2019 Facility ID: CA970000125 If continuation sheet 18 of 64 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 04/22/2019 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 CFR(s): 483.21(b)(3)(i) §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to perform quality control for all glucometers used to test whole blood glucose (sugar) level. This deficient practice had the potential for inaccurate blood sugar result for one (Resident 59) of 15 residents requiring blood glucose testing. Findings: A closed record review of Resident 59's Admission Record indicated the resident was admitted on 10/15/18, with diagnoses that included diabetes (high blood sugar), anemia (low red blood cell count). A review of Resident 59's History and Physical, dated 12/7/18, indicated the resident had the capacity to understand and make decisions. A review of Resident 59's Minimum Data Set (MDS - a care and assessment screening tool), dated 1/9/19, had no assessment on cognition. The MDS indicated the resident required supervision in bed mobility, and ambulation and limited assistance in transfers, dressing, toilet use and personal hygiene. A record review of Resident 59's Medication Administration Record (MAR), dated January 2019, indicated blood sugar testing to be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 19 of 64 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 04/22/2019 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 completed before breakfast and at bedtime. The back page of the MAR indicated that on 1/8/19, at 6:30 a.m, the Licensed Vocational Nurse (LVN) wrote that fingerstick blood sugar (FSBS) was attempted three times and the blood glucose meter showed an error message, the resident declined the fourth attempt to do an FSBS check. During an observation on 4/17/19, at 3:50 p.m., LVN 4 performed quality control testing (QC tests to ensure that the glucometer is working properly) for the glucometer with serial number TPO198494. This glucometer was stored inside the top drawer of a medication cart. The test strips that was used was opened on 4/14/19. LVN used three levels of control solution. Control solution level 1 was opened on 4/6/19, with an expiration date of 10/31/19, or three months after the opened date of the solution. Control solution level 2 was opened on 4/6/19, with an expiration date of 9/30/20, or three months after the opened date of the solution. Control solution level 3 was opened on 4/6/19, with an expiration date of 2/29/20, or three months after the open date of the solution. The quality control testing indicated the glucometer number TP0198494 passed. A record review of the facility's Quality Control Testing Data Form on 4/17/19 at 3:50 p.m., indicated that for the month of April 2019, there were two glucometers with serial numbers TP0198490 and TP0198494. Quality testing was completed from 4/1/19, up to the current date, 4/17/19 for glucometer with serial number TP0198494. During an interview on 4/17/19 at 4:31 p.m., LVN 2 stated there were two glucometers, one for each medication cart. LVN 2 opened the medication cart that he used during the medication administration observation. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 20 of 64 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 04/22/2019 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 glucometer that was kept inside this cart had the serial number TP0198490. LVN 4 stated QC of the glucometers were to be completed by the 3-11 shift charge nurse. A record review of the facility's Quality Control Testing Data Form indicated there was no documented QC for the glucometer with serial number TP0198490. During a record review of the facility's Quality Control Record indicated that for the months of January to March 2019, the record did not identify which glucometer QC was performed on, the portion of the record that states "Serial Number" was left blank. During a record review of the facility's Quality Control Record indicated that for the months of March 2018 to December 2018, the record did not identify which glucometer QC was performed on, the portion of the record that states "Serial Number" was left blank. A review of the "Professional Monitoring Blood Glucose Meter Owner's Manual" that was provided by the facility indicated that "Quality Control Testing - to assure accurate and reliable results ...these tests ensure that the glucometer is working properly and testing technique is good."

F675 SS=F Quality of Life CFR(s): 483.24

F675 06/04/2019 § 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 21 of 64 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 04/22/2019 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 with the resident's comprehensive assessment and plan of care. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to preserve the quality of life for three of 18 sampled residents (Residents 14, 17 and 54), who verbalized disagreement and helplessness with inhaling mainstream (exhaled smoke by smokers) and side stream smoke (smoke from the lighted end of a cigarette) and protect other non-smoking residents residing in the facility from the health dangers of second hand smoke by failing to: 1. Ensure the residents who smoke were separated from residents who were nonsmokers during smoking hours and nonsmoking hours. 2. Ensure that residents who do not smoke had an outdoor area aside from their own rooms and indoor activity/dining rooms to spend quality time with families and friends that was smoke free and be able to breathe fresh air, anytime they want. This deficient practice had the potential to affect all non-smoking residents and expose them to second hand smoke and increase their risks for new respiratory and heart diseases and/or cause an exacerbation of existing respiratory and heart diseases. Findings: On 4/15/19 at 8:16 a.m., during an observation in the facility's courtyard patio, indicated a sign "Designated Smoking Area." The posted smoking hours were as follow: 9:30 a.m. to 10:30 a.m., 12:30 p.m. to 2 p.m., 3:30 p.m. to 4:30 p.m., and 7 p.m. to 8 p.m. The facility's designated smoking area was located in a common courtyard patio in the center of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 22 of 64 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 04/22/2019 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. The courtyard patio was surrounded by five operable patio exit sliding doors, leading into resident's rooms. During the same observation, two of the five sliding doors were left open while residents were smoking in the patio. The facility's common Activity/Dining Room area was directly adjacent to the courtyard patio with an exit through a glass door. A review of an undated smoking list provided by the facility, titled "Residents Who Smoke," indicated there were 12 residents (Residents 11, 23, 15, 40, 18, 12, 55, 35, 6, 20, 39, and 36) who smoke in the facility. The list indicated that the designated smoking location was the "Patio." On 4/15/19 at 12:25 p.m., during an observation of smoking, in the presence of Activity Aide 1 (AA1) there were four residents smoking in the courtyard patio (Residents 11, 23, 40, and 55). During the observation, Resident 17 was sitting in the wheelchair in the center of the courtyard patio. Resident 17 was a non-smoker. During a concurrent interview, Resident 17 stated she likes staying outside the facility. Resident 17 stated that the courtyard patio was the only outdoor area available for all the residents in the facility. Resident 17 stated that the non-smokers were always around smokers most of the time in the courtyard patio. On 04/15/19 at 12:30 p.m., during an observation and interview, the Maintenance Supervisor (MS 1) stated that the total wall to wall measurements of the facility's courtyard patio was 42 feet by 31 feet. During this time, residents were randomly observed smoking in every corner of the courtyard patio. During this observation, on 4/15/19 at 12:30 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 23 of 64 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 04/22/2019 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 p.m., two residents were observed smoking while AA1 was present and five other nonsmoking residents were observed around the two smokers in the facility's courtyard patio. During this observation, the mainstream smoke (the smoke exhaled by a smoker) coming out of the burning cigarettes was noticeable. During a concurrent interview, AA1 stated the facility had only one patio and the facility used it for smoking as well. On 4/15/19 at 3:45 p.m., Resident 55 was observed smoking at the far end corner of the courtyard patio, a few steps to the entrance door leading to the facility hallway and kitchen. Resident 55's cigarette ashes was observed being disposed in the ground. The courtyard patio was observed with four other residents in wheelchairs who were not smoking. On 4/16/19 at 8:16 a.m., during an observation, Resident 18's patio door in his room was open and the resident was observed smoking outside the courtyard patio, sitting approximately four feet outside his room. On 4/16/19 at 8:30 a.m., during an interview, Certified Nurse Assistant 1 (CNA 1) stated that all residents (smokers and non-smokers) and visitors use the courtyard patio as the designated smoking area and other recreational activities. On 4/16/19 at 9:23 a.m., during an interview, Resident 14 stated that the smell of smoke does not bother her anymore because she "had gotten used to the smell." Resident 14 stated she did not like the smell of smoke, but "could not do anything about it." On 4/16/19 at 10:15 a.m., during the resident group meeting held in the facility's common Activity/Dining Room, the exit door to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 24 of 64 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 04/22/2019 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 courtyard patio was closed, however, the smell of cigarette smoke was noted around the whole room from the residents who were smoking outside the courtyard patio. On 4/16/19 at 12:50 p.m., during an interview, Activity Director 1 (AD 1) stated that there is a smoking schedule the facility follows and that all the residents in the facility should be aware of the smoking time. AD 1 stated that during the scheduled smoking hours, the non-smoking residents usually stay in the activity room with their patio doors closed and the Activity/Dining room doors closed. A review of the facility's undated Smoking Policy provided by the facility's Admissions Coordinator 1, indicated that the facility would establish a controlled smoking environment in the facility to reduce the dangers of smoking to residents and staff. The Smoking Policy indicated that smoking is only permitted in designated area which is located outside of the building. During random observations of resident activities in the facility's courtyard patio, from 4/15/19 to 4/17/19, there would always be a resident or residents smoking around other non-smoking residents in the common courtyard patio, within and outside the facility's smoking designated schedule. A review of Resident 14's Admission Record indicated that the resident was admitted to the facility on 3/15/17, with diagnoses that included chronic obstructive pulmonary disease (lung disease making it hard to breath), depression, and hypoxemia (body does not receive adequate oxygen). A review of Resident 14's History and Physical (H&P) dated 1/23/19, indicated that Resident 14 had the capacity to understand and make FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 25 of 64 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 04/22/2019 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 decisions. A review of Resident 14's Minimum Data Set (MDS- a care screening and assessment tool) dated 1/23/19, indicated the resident required total dependence for bed mobility eating, toilet use, and personal hygiene. A review of Resident 14's Physician Orders, dated 4/5/19 indicated an order to administer oxygen at two liters per minute (LPM) via nasal cannula for shortness of breath. A review of Resident 17's Admission Record indicated that the resident was admitted to the facility on 7/28/18, with diagnoses that included chronic kidney disease, hypertension (high blood pressure) and anemia. A review of Resident 17's Initial H&P, dated 7/31/18, indicated that Resident 17 had the capacity to understand and make decisions. A review of Resident 17's MDS dated 1/16/19, indicated that the resident required limited assistance with bed mobility and extensive assistance with dressing, toilet use, and personal hygiene. A review of Resident 54's Admission Record indicated that the resident was admitted to the facility with diagnoses that included stroke with hemiparesis (paralysis) and muscle weakness. A review of Resident 54's H&P, dated 3/27/18, indicated the resident had the capacity to understand and make decisions. A review of Resident 54's Minimum Data Set (MDS - a care and assessment screening tool) dated 3/27/19, indicated the resident had no cognitive impairment and required extensive assistance with bed mobility, transfers and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 26 of 64 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 04/22/2019 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 activities of daily living. During a concurrent observation on 4/17/19 at 10:43 a.m., there were two residents smoking at different areas of the patio. During an interview with Resident 54 at that time, stated that the smoke bothered him and he was at the patio every day. A review of Residents 14, 17, and 54's medical records with the MDS nurse indicated no care plans were developed in regard to exposure to smoke. The MDS nurse verified that Residents 14, 17and 54 have no care plans to address exposure to smoke. On 4/17/19, at 2 p.m., during an interview, the Assistant Director of Nursing (ADON) stated that the smokers should only smoke during scheduled smoking hours with supervision from facility staff. When asked what the facility was doing for residents smoking randomly anytime outside the smoking schedule, the ADON stated that the facility respects the rights of the residents to smoke and accommodates the smokers' requests to smoke outside the schedule from time to time. When asked what the facility was doing for non-smokers who wanted to go outside the courtyard patio during smoking hours, the ADON stated that the residents who were non-smokers should not be allowed outside the courtyard patio when residents were smoking. The ADON stated that non-smokers should stay in the activity/dining area when residents are smoking in the courtyard patio. On 4/18/19 at 10:17a.m., a review of the Smoking Policy with the Director of Nursing (DON) was conducted. The Smoking Policy indicated that residents are not permitted to give smoking articles to other residents and that residents without independent smoking FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 27 of 64 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 04/22/2019 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 privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under supervision. The Smoking Policy indicated that any smokingrelated privileges, restrictions, and concerns shall be noted on the care plan. The DON stated that the facility recognized the fact that the non-smoking residents had been exposed to smokers all the time. The DON stated that the facility would relocate the designated smoking area so that non-smoking resident could enjoy a smoke-free courtyard patio. On 4/18/19 at 2:30 p.m., during an interview, Resident 17 stated that she could smell the smoke inside her room coming from the courtyard patio, when residents were smoking in the courtyard patio. Resident 17 stated that keeping her room's patio door always close helps but does not totally remove the smell of the smoke. A review of an article published by the American Cancer Society website, dated November 20, 2015, "When non-smokers are exposed to secondhand smoke it is called involuntary smoking or passive smoking. Nonsmokers who breathe in secondhand smoke take in nicotine and toxic chemicals the same way smokers do. The more secondhand smoke you breathe, the higher the levels of these harmful chemicals in your body." The article indicated, "Secondhand smoke can be harmful in many ways and causes other diseases. For instance, it affects the heart and blood vessels, increasing the risk of heart attack and stroke in non-smokers. Some studies have linked Secondhand smoke (SHS) to mental and emotional changes, too. For instance, some studies have shown that exposure to secondhand smoke is linked to symptoms of depression." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 28 of 64 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 04/22/2019 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

F684 Quality of Care CFR(s): 483.25

F684 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 06/04/2019 § 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 to follow the facility's policy and plan of care to ensure one of 18 sampled resident (Resident 43), who was on hospice (a type of medical treatment to take care of people who are very sick and have an illness that they not heal from) for palliative care and who was screaming was accurately assessed. This deficient practice caused Resident 43 to experience pain and discomfort. Findings: a. During a concurrent observation and interview on 4/15/19, at 8:21, while Surveyor 1 was in another room conducting an interview with Resident 53, an on and off screaming was heard, coming from the room across the hallway. Resident 53 stated Resident 43 "screams 24/7." A review of Resident 53's Admission Record indicated resident was admitted on 3/24/19 with diagnosis of senile degeneration of the brain (dementia - a decline in mental ability severe enough to interfere with daily life.) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 29 of 64 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 04/22/2019 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 Resident 53's H&P, dated 7/8/18, indicated resident had the capacity to understand and make decisions. b. During a concurrent observation and interview on 4/15/19, at 8:40 a.m., Surveyor 1 was in another room conducting an interview with Resident 4. Resident 43 continued to scream from across the hallway. Resident 4 stated that Resident 43 screams day and night. A review of Resident 4's Admission Record indicated the resident was admitted on 3/25/18. A review of Resident 4's H&P, dated 4/15/19 indicated resident did not have the capacity to understand and make decisions. c. During a concurrent observation and interview on 4/15/19, at 8:46 a.m., Surveyor 1 was conducting an interview with Resident 57, who was staying in the same room next to Resident 43s bed. Resident 43 continued to scream. Resident 57 stated he could not sleep because of the screaming, " He screams all day, I've stayed with that guy for two weeks already." A review of Resident 57's Admission Record indicated the resident was admitted on 3/28/19, with diagnoses that included malignant neoplasm of the larynx (tumor of the larynx), and dysphagia (difficulty swallowing). A review of Resident 57's History and Physical (H&P), dated 2/27/19, indicated the resident had the capacity to understand and make decisions. During an interview on 4/15/19 at 8:57 a.m., Certified Nursing Assistant 1 (CNA 1) stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 30 of 64 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 04/22/2019 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 43 would scream when he is in pain, because of his contractures (a permanent shortening of muscles, tendons or ligaments causing rigidity and loss of movement) CNA 1 stated she would notify the nurse. During a concurrent observation and interview on 4/15/19 at 9:10 AM, observed Licensed Vocational Nurse 1 (LVN1) gave medication to Resident 43. During this observation, LVN 1 did not ask the patient regarding the reason for screaming, LVN 1 did not assess the resident regarding the presence of pain, location of pain or the pain level. During an interview with LVN 1, she stated "I just gave him morphine." LVN 1 stated that she asked CNA 1 about the pain level and the presence of pain. During a concurrent observation and interview on 4/16/19, at 1:05 p.m., Resident 43 was laying on his right side, and was screaming on and off. When interviewed, Resident 43 stated he had pain on his head, but he was unable to state a pain level. A review of Resident 43's Admission Record indicated the resident was admitted on 3/5/19. A review of Resident 43's Physician's Certification for Hospice Benefit dated 3/5/19, indicated the resident was admitted to a Hospice Palliative Care Service under routine level of care, for palliative care management, pain and symptom management with a primary diagnosis of End Stage Cerebrovascular Accident (ES CVA - Stroke). A review of Resident 43's History and Physical (H&P), dated 5/2/18, indicated the resident had diagnoses that included ischemic stroke (poor blood flow to the brain resulting in brain injury), hemiplegia (paralysis on one side of the body). The H&P indicated resident had the capacity to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 31 of 64 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 04/22/2019 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 understand and make decisions. A review of Resident 43's Minimum Data Set (MDS - a care and assessment screening tool), dated 3/18/19, indicated the resident had severe cognitive impairment, and was totally dependent with bed mobility, transfers and activities of daily living. A review of Resident 43's Plan of Care, dated 3/6/19, indicated actual alteration in comfort with interventions that included: to assess pain site, intensity based on pain scale, verbal/nonverbal, frequency and predisposing factor; to position for comfort; to medicate as ordered; to encourage activity attendance to keep busy. A review of Resident 43's Medication Administration Record (MAR) for April 2019, indicated resident was on routine tramadol (pain medication) 50 milligrams (mg) for 9 a.m, 1 p.m., and 5 p.m., gabapentin (pain medication) 100 mg for 9 a.m., 1 p.m., and 5 p.m., norco (opiod pain medication) 5/325, 1 tablet every 8 hours as needed, morphine (opiod pain medication) 5 mg every 4 hours as needed for severe pain. The MAR indicated Resident 43 was given pain medication on 4/5/19, 4/11/19, at 11:55 p.m, 4/12/19 at 6:57 p.m., 4/13/19, at 8 pm and 2:50 a.m, and on 4/14/19, at 7:15 p.m. A review of Resident 43's Pain Assessment Record for the month of April 2019 indicated that on 4/5/19 on all shifts, pain was assessed as "0" or no pain on a scale of 1-10. On 4/11/19 on all shifts, pain was assessed as "0" or no pain on a scale of 0-10. On 4/12/19 at 3-11 shift, pain was assessed as "6" on a scale of 010 and on 4/14/19 at 3-11 shift, pain was assessed as "6" on a scale of 0-10. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 32 of 64 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 04/22/2019 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 facility's policy and procedures titled, "Pain - Clinical Protocol", undated, indicated that staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The policy indicated the staff and the physician will also evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life.

F698 SS=D Dialysis CFR(s): 483.25(l)

F698 06/04/2019 §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive 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 interview and record review, the facility failed to ensure that an ongoing communication from the dialysis center and the facility was consistent for one of two sampled residents (Resident 35) on dialysis. 1. There was no documentation after resident came back from the dialysis center. 2. The one page communication sheet when Resident 35 goes to dialysis was not present in the communication log book. This deficient practice had the potential for information to be missed and could affect the care of Resident 35. Findings: A review of Resident 35's Admissions Record indicated that the resident was initially admitted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 33 of 64 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 04/22/2019 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 to the facility on 5/3/18, with diagnoses that included hyperkalemia (high potassium), end stage renal failure (loss of kidney function), muscle weakness, and diabetes (high blood sugar). A review of Resident 35's Minimum Data Set (MDS), a care assessment and screening tool, dated 3/4/19, indicated the resident had no cognitive impairment and required supervision for transfers and eating. Resident 35 required limited assistance with dressing, toilet use and personal hygiene. A review of Resident 35's Physician's Orders, dated 3/30/19, indicated the resident was scheduled for dialysis (a treatment that filters and purifies the blood using a machine) on Tuesdays and Saturdays. The Physician's Orders further indicated an order to monitor for bleeding of the arteriovenous (AV) shunt (a connection between an artery and a vein that allows blood to flow between the two) every shift, to check the AV shunt on the left arm for bruit and thrill every shift, and to monitor AV shunt every shift for redness, swelling, drainage and pain. A review of Resident 35's Medication Administration Record (MAR) did not have any documentation on 4/18/19, for the 7-3p.m., and 3-11p.m. shift about the AV shunt being monitored for bleeding, swelling and assessment of the bruit and thrill by the facility. A review of the Resident 35's Nurses Dialysis Communication Record indicated a record dated 4/13/19. A Nurses Dialysis Communication Record dated 4/16/19, was not provided for Resident 35's most recent dialysis. On 4/18/19, during an interview, Licensed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 34 of 64 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 04/22/2019 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 Vocational Nurse 2 (LVN 2) stated that the Nurses Dialysis Communication Record is a communication sheet between the dialysis center and the facility. LVN 2 stated that the communication record is filled out before and after dialysis, and while Resident 35 is at the dialysis center it is filled out by the dialysis center. LVN 2 stated that the Communication Record is done to make sure Resident 35 is "OK to go to dialysis." LVN 2 further stated that the facility monitors the vital signs (VS) before and after dialysis. LVN 2 stated that the facility does not document VS anywhere else other than the communication sheet before or after Resident 35 comes back to the facility from the dialysis center. On 4/18/19 at 2:15p.m., during an interview, the Director of Nursing (DON) stated that the facility did not have or could not find a policy for dialysis. A review of the facility's undated policy and procedures titled, " Dialysis Care" indicated that all documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident's medical record.

F726 SS=D Competent Nursing Staff CFR(s): 483.35(a)(3)(4)(c)

F726 06/04/2019 §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 35 of 64 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 04/22/2019 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 §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that licensed nurses and certified nursing assistants were validated for specific competencies and skills sets necessary to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial wellbeing. This deficient practice had the potential for residents to not receive appropriate care needs and had the potential for injury. Findings: During a review of the In-service Meeting Minutes, dated 5/10/18 to 4/18/19, indicated that lectures and training were provided to the facility staff. There were no records found to indicate an assessment of facility staff's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 36 of 64 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 04/22/2019 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 competencies and skills sets. During an interview on 4/18/19 at 11:05 a.m., the Director of Staff Development (DSD) was asked to provide proof of competency skills validation conducted for the licensed nurses and certified nursing assistants (CNA). The DSD did not have any records of competency skills validation. The DSD stated competency training was only completed upon hire. Upon hiring, the facility provides 4 days of orientation that covered education on emergency preparedness, facility set up orientation, facility schedule and workload assignments, hours of work, organizational set-up of the facility, abuse protocol including video and commitment to safety. During the interview, the DSD stated the Director of Nursing provided a form about staff competency checklist to be implemented starting April 2019 annually for CNA's and licensed nurses. During the interview, the DSD Stated that she was on leave of absence for 2018 and recently came back on 2/2019 A review of the facility's policy and procedures titled, "Competency Evaluations," undated, did not indicate assessment of facility staff's competencies and skills sets.

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 06/04/2019 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 37 of 64 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 04/22/2019 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 drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that medications were available for the residents in a timely manner when ordered by the physician. This deficient practice resulted in the unavailability of the medication for one of six residents (Resident 8) observed for medication administration. Findings: A review of Resident 8's Admission Record indicated the resident was readmitted to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 38 of 64 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 04/22/2019 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 on 11/24/17, with diagnoses that included dementia (a decline in mental ability severe enough to interfere with daily life) and epilepsy (seizures). A review of Resident 8's History and Physical, dated 3/27/18, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 8's Minimum Data Set (MDS - a care and assessment screening tool), dated 1/8/19, indicated the resident required extensive assistance with bed mobility, transfers and personal hygiene, and was totally dependent with toileting. During an observation on medication administration on 4/17/19 at 8:51 a.m., Licensed Vocational Nurse 2 (LVN 2) stated he will not administer phenytoin (anti-seizure medication) and handed the medication pack for phenytoin and stated he will call pharmacy because the newly ordered medication was not delivered. The medication pack indicated an order for phenytoin 100 milligrams (mg.), take 3 capsules (300 mg) by mouth every Monday, Wednesday, Friday and Sunday and to take 4 capsules (400 mg) by mouth every Tuesday, Thursday, Saturday for seizure disorder. The delivery date written on this medication pack was 3/26/19. A review of Resident 8's Physician Orders indicated a physician's order, dated 4/12/19, to discontinue the previous order of Dilantin (brand name of phenytoin) and a new order of Dilantin 100 mg capsule, give two capsules (200 mg) by mouth twice a day for seizure disorder. During an interview on 4/18/19 at 2:33 p.m., LVN 2 stated he did not administer the dose for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 39 of 64 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 04/22/2019 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 today, 4/18/19, because the medication pack that was delivered by pharmacy on 4/17/19 was not the correct dose. A review of the medication pack that was delivered by pharmacy on 4/17/19 indicated an order for phenytoin 100 mg, to take four capsules (400 mg) by mouth on Monday, Tuesday, Thursday, Saturday and Sunday and to take three capsules on Wednesday and Friday for seizure. A review of Resident 8's Physician Orders indicated a physician's order for phenytoin, dated 3/5/19, to take four capsules (400 mg) by mouth on Monday, Tuesday, Thursday, Saturday and Sunday and to take three capsules (300 mg) on Wednesday and Friday. This was the dose delivered on 4/17/19. During an interview on 4/18/19 at 4:54 p.m., LVN 2 stated that he did not call the pharmacy on 4/13/19, when he discovered that the new medication pack for the new order did not arrive. LVN 2 stated he used the old medication pack that was delivered 3/26/19 and gave 2 capsules and wasted the two other capsules. LVN 2 was unable to show documentation that he only gave 2 capsules and was unable to show documentation that the other 2 capsules were wasted. During an interview on 4/18 19 at 4:54 p.m., the Director of Nursing (DON) stated LVN 2 should have called the pharmacy the next day, on 4/13/19, when the medication pack for the new order was not delivered. The DON stated that the facility practice for new medication orders, the order would be faxed to pharmacy, the pharmacy staff who received the new order would verify the order either by calling the physician or call the facility to verify the new medication order. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 40 of 64 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 04/22/2019 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 facility's policy and procedures titled, "Discontinued Medications," undated, indicated that discontinued medication must be destroyed or returned to the issuing pharmacy in accordance with established policies. A review of the facility's policy and procedures titled, "Drug Ordering and Receipt," undated, indicated that medications and related products will be ordered by authorized personnel of the center accurately and promptly, and received from the pharmacy in a timely fashion. The center will maintain accurate records of order and receipt.

F812 SS=D Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 06/04/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 41 of 64 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 04/22/2019 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 staff failed to change gloves in between tasks while preparing food. This deficient practice had the potential to contaminate food and spread food borne illnesses. Findings: On 4/16/19 at 11:21a.m., during an observation of the tray line, Cook 1 was observed serving food with gloved hands and continuing to open the stove and resume the tray line with the same gloves. On 4/16/19 at 11:25a.m., the Dietary Supervisor (DS) was assisting in the tray line. The DS put on gloves and opened the refrigerator to take out the oranges and lemons. The DS did not change gloves after touching the handle of the kitchen refrigerator. The DS continued assisting in tray line, handling the oranges and lemons and placing them on each plate. On 4/16/19 at 11:29a.m., during an observation, Cook 1 put on oven mitten, over gloved hands, removing a pan for the oven. Cook 1 did not change gloves after the removal of the oven mitten, and continued with the tray line. On 4/16/19 at 11:52a.m., during an interview with Cook 1, stated that gloves should be changed all the time. Cook 1 stated that it was not appropriate to touch the refrigerator's handles or place oven mittens on, and continue with the tray line with the same gloves. Cook 1 stated that it was important to change gloves because "it can cause contamination." On 4/16/19 at 12p.m., during an interview with the DS, stated that hand-washing in-services FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 42 of 64 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 04/22/2019 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 were done often. The DS stated that it was not appropriate to go to the refrigerators with gloves, and then resume serving food. The Dietary Supervisor stated gloves need to be changed. A review of the facility's In- Service Meeting Minutes, dated 4/9/19, on handwashing, indicated that "as much as possible, after each task, before starting each new task, and before changing gloves, use appropriate gloves for each task." A review of the facility's In-Service Meeting Minutes, dated 2/5/19 on handwashing, indicated that, "if you open the door, you have to wash your hands ..." A review of the facility's undated policy titled, "Handwashing: Safety and Sanitation," indicated, "Hands will be washed at the following times: between working with different food, after working with or cleaning dirty equipment ..."

F838 SS=E Facility Assessment CFR(s): 483.70(e)(1)-(3)

F838 06/04/2019 §483.70(e) Facility assessment. The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 43 of 64 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 04/22/2019 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 §483.70(e)(1) The facility's resident population, including, but not limited to, (i) Both the number of residents and the facility's resident capacity; (ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; (iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population; (iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and (v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. §483.70(e)(2) The facility's resources, including but not limited to, (i) All buildings and/or other physical structures and vehicles; (ii) Equipment (medical and non- medical); (iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies; (iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; (v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and (vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 44 of 64 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 04/22/2019 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 §483.70(e)(3) A facility-based and communitybased risk assessment, utilizing an all-hazards approach. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to evaluate and provide specific services and care needed for 12 sampled residents (Resident 6, 11, 12, 15, 18, 20, 23, 35, 36, 39, 40 and 55) out of 53 residents in the facility who smoked. This deficient practice had the potential for Residents 6, 11, 12, 15, 18, 20, 23, 35, 36, 39, 40 and 55 to not receive specific resources needed. (Cross reference to F0926) Findings: On 4/22/19 at 10:16a.m., in the presence of the Administrator in Training (AIT), during an interview with the Director of Nursing (DON), the DON stated that within the Facility Assessment, the facility identified the smoking population and provided an area for the smoking residents to smoke and implemented a smoking schedule. The DON stated that the Facility Assessment was updated by the Administrator in March 2019. The facility was unable to provide the 2018 Facility Assessment. A review of the Comprehensive Facility Assessment indicated that the facility identified that it was not a smoke-free facility. There was no evaluation or documentation of the resources needed to provide and accommodate the specific necessities for Residents 6, 11, 12, 15, 18, 20, 23, 35, 36, 39, 40 and 55, who smoked. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 45 of 64 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 04/22/2019 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 facility's Emergency Preparedness, did not indicate the identification of the smoking population.

F912 SS=B Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) 06/04/2019 §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure seven of 25 residents' rooms (Rooms # 1, 3, 5, 12, 15, 23 and 24) met the 80 square feet (sq. ft.) per resident in multiple resident bedrooms. The room size for these rooms had the potential to have inadequate space for resident care and mobility. Findings: During the Resident Council Meeting on 4/16/19 at 10:30 a.m., there were no concerns brought up regarding small room size. During the recertification survey from 4/15/10 to 4/22/19, a general observation of the facility and residents' rooms, it was observed that the residents residing in the rooms with an application for variance had sufficient amount of space for residents to move freely inside the rooms. Each room had resident's beds, side tables with drawers. There was adequate room for the operation and use of wheelchairs, walkers, or canes. Observed the nursing staff provide care to these residents, the room variance did not affect the care and services provided to the residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 46 of 64 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 04/22/2019 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 4/15/19, the administrator submitted the application for the Room Variance Waiver for 7 resident rooms. The room variance letter indicated that these rooms did not meet the 80 square feet per resident requirements per federal regulation. The letter indicated that the rooms were in accordance with the special needs of residents and would not have an adverse effect on the residents' health and safety or impede the ability of any resident in the room to attain his/her highest practicable well-being. The room waiver request showed the following: Room # Room Size Number of Beds 1 149.64 square feet 2 3 152.1 square feet 2 5 150.8 square feet 2 12 221.95 square feet 3 15 223.1 square feet 3 23 143.28 square feet 2 24 152.76 square feet 2

F926 SS=F Smoking Policies CFR(s): 483.90(i)(5)

F926 06/04/2019 §483.90(i)(5) Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement the existing smoking policy for 12 sampled residents (Residents 6, 11, 12, 15, 18, 20, 23, 35, 36, 39, 40 and 55) out of 53 residents in the facility, who used the designated smoking area for smoking and other recreational activities. 1. The facility's assessments for each resident that smoke (Residents 6, 11, 12, 15, 18, 20, 23, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 47 of 64 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 04/22/2019 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 35, 36, 39, 40 and 55) did not indicate how the residents' capabilities and deficits were determined whether or not supervision were required during smoking. This deficient practice had the potential for accidents and injuries. 2. The facility failed to follow its policy to establish a controlled smoking environment to reduce the health dangers of second-hand smoke to other residents and staff. The facility's designated smoking area (a common courtyard patio) was directly adjacent to the residents' rooms' patio exit doors and allowed non-smoking residents to be around smoking residents. This deficient practice had the potential to cause second hand smoke on all non-smokers (residents and visitors) occupying the facility's only courtyard patio (designated smoking area). 3. The facility did not provide a fire extinguisher in close proximity to the designated smoking area that is readily accessible in the event of a fire. This deficient practice had the potential to affect the response time and could play a critical role in getting a fire under control or extinguished in the facility's designated smoking area. 4. During multiple observations of residents smoking, the facility staff did not implement consistently the facility's smoking policy such as allowing residents to smoke outside of the smoking schedule and allowing residents to have access to lighters and cigarettes. This deficient practice present a fire hazard to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 48 of 64 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 04/22/2019 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 the rest of the residents, visitors, and staff in the facility. Findings: On 4/15/19 at 8:16a.m., during an inspection of the facility's courtyard patio, a sign indicated "Designated Smoking Area" was observed. The posted smoking hours indicated: 9:30 a.m.10:30 a.m., 12:30 a.m.-2 p.m., 3:30 p.m.-4:30 p.m. and 7 p.m.-8 p.m. The facility's designated smoking area was located in a common courtyard patio in the center of the facility, surrounded by five operable patio exit sliding doors, leading into residents' rooms. Two of the five sliding doors were left open while residents were smoking in the patio. There were three long neck ashtrays scattered throughout the patio. There was no portable fire extinguisher and fire blanket observed in the courtyard patio. On 4/15/19 at 9:30a.m., an interview was conducted with the Activity Director (AD), who stated that the fire extinguisher for the designated smoking area was located inside the facility. Staff had to enter the entrance door to the activity/dining room and exit to the facility's hallway and across the nursing station. During the observation, a staff had to walk past several residents in wheelchairs and tables in the activity/dining room to locate the nearest fire extinguisher. On 4/15/19 at 10:30 a.m., the facility's Admission Coordinator (AC1) handed over an undated policy and procedures titled, "Smoking Policy" (Smoking Policy 1). A review of the Smoking Policy 1 indicated the facility would establish a controlled smoking environment in the facility to reduce the dangers of smoking to residents and staff. The policy indicated residents, visitors, and staff should smoke only FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 49 of 64 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 04/22/2019 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 in the facility's designated areas "Outside Patio and Dining Room." The policy indicated nursing staff should be notified of any smoking materials brought into the facility. On 4/15/19 at 11:43 a.m., during an interview, Resident 55 stated that she carries her own lighter. Resident 55 stated the lighter was given to her by a facility staff. On 4/15/19 at 12:25p.m., during a smoking observation and interview, Activity Aide 1 (AA1) was observed in the courtyard patio. AA1 stated that during smoking hours, a staff of the facility should supervise the residents who smoke. There were four residents smoking in the courtyard patio (Residents 11, 23, 40, and 55). During the observation, Resident 17 was sitting in the wheelchair in the courtyard patio. Resident 17 was a non-smoker. On 04/15/19 at 12:30 p.m., during an observation and interview, the Maintenance Supervisor (MS 1) stated that the total wall to wall measurements of the facility's courtyard patio was 42 feet by 31 feet. MS 1 stated the distance of the nearest fire extinguisher to the courtyard patio was between 46.6 feet to 70.3 feet from the patio. During this observation, on 4/15/19 at 12:30 p.m., two residents were observed smoking while AA1 was present. Five other residents were observed around the smokers in the facility's courtyard patio. During this observation, the smell of the mainstream smoke (the smoke exhaled by a smoker) coming out of the burning cigarettes was noticeable. During a concurrent interview, AA1 stated the facility had only one patio and the facility used the patio also as a smoking area. On 4/15/19 at 3:45p.m., Resident 55 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 50 of 64 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 04/22/2019 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 observed smoking in the far end corner of the courtyard patio, a few steps to the entrance door leading to the facility hallway and kitchen. Resident 55's cigarette ashes was observed being disposed in the ground. AA2 was observed sitting at the other end of the courtyard patio, approximately 30 feet away from Resident 55. The courtyard patio was observed with four other residents in wheelchairs who were not smoking. On 4/15/19, at 1 p.m., the AC1 handed over a second undated facility policy for smoking (Smoking Policy 2). The policy indicated that the facility will "accommodate residents who desire to smoke by providing a safe environment to them and protect the nonsmoking residents. It is the facility policy that residents are not allowed to have matches, lighters and any flammable liquid in their possessions." The policy had the Smoking Assessment tool attached to it. On 4/16/19 at 8:16 a.m., during an observation, Resident 18's patio door was open and the resident was observed smoking in the courtyard patio and was sitting approximately four feet outside his room. Resident 18 had in his possession a cigarette and a lighter. Resident 18 was using a clear four-ounce plastic cup filled with approximately 2 ounces of water. Resident 18 was observed using the plastic cup as an ashtray. There was no staff present supervising Resident 18. On 4/16/19 at 8:30 a.m., during an interview, Certified Nurse Assistant 1 (CNA 1) stated residents who are alert and oriented could keep their own cigarettes and lighters. CNA 1 stated that the licensed nurse would store the lighter for residents who needed supervised smoking. CNA 1 stated that all residents (smokers and non-smokers) and visitors used the courtyard FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 51 of 64 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 04/22/2019 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 patio as the designated smoking area and for other recreational activities. CNA 1 stated that during smoking hours, a facility staff should always be in the courtyard patio to supervise. A review of the facility's blank smoking assessment tool titled, "Smoking Assessment," attached to Smoking Policy 2, indicated a resident smoking agreement. At the bottom of the tool was a space for the resident's and witness' signatures. The Smoking Assessment form indicated a question if the resident smokes or not and if the answer was "Yes," the form indicated a blank space each for "Independently" or "Needs Supervision." The Smoking Assessment tool did not indicate specific indicators that the facility staff used to adequately assessed a smoker between independent and needing supervision. On 4/16/19 at 8:50 a.m., during an interview, the Social Services Designee (SSD) stated that she was responsible in the completion of the smoking assessment of all residents who wanted to smoke in the facility. The SSD could not identify how she assessed the smokers' capabilities, using the facility's smoking assessment tool to determine whether the resident could be an independent smoker or needed supervision. The SSD stated that when she is not in the facility, she does not know who completes the smoking assessments for new residents. A review of the facility's smoking list provided by the facility, titled "Residents Who Smoke," indicated nine residents (Residents 40, 18, 12, 55, 35, 6, 20, 39, 36) listed as independent smokers and three residents (Residents 11, 23, 15) listed as needing supervision. The list indicated that the designated smoking location was the "Patio." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 52 of 64 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 04/22/2019 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 4/16/19 at 10:23 a.m., during an observation and interview, Resident 36 was observed with an electronic cigarette in her possession. Resident 36 stated the electronic cigarette was given by a family member. Resident 36 stated she would use the electronic cigarette to try to quit smoking. Resident 36 stated she did not know if the facility staff was notified of her electronic cigarette. On 4/16/19 at 12:30p.m., during another smoking observation, non- smoking residents were scattered on different patio tables around the courtyard patio. Resident 18 was observed smoking right outside an opened patio exit sliding door of one of the resident's rooms. There was no facility staff facility observed in the courtyard patio. A review of the facility's admission packet provided by the facility during the survey's entrance conference did not include the residents' smoking assessment forms. 1. A review of Resident 6's Admission Record indicated the resident was admitted to the facility on 9/21/18, with diagnoses of bipolar disorder (a manic-depressive mental illness), anxiety, and schizophrenia (a chronic [long standing] and severe mental disorder that affects how a person thinks, feels, and behaves). A review of Resident 6's Initial History and Physical (H&P), dated March 2019, indicated the resident had the capacity to understand and make decisions. A review of Resident 6's Minimum Data Set (MDS, a care screening and assessment tool), dated 1/6/19, indicated that Resident 6 required extensive assistance (staff had to provide FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 53 of 64 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 04/22/2019 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 weight bearing support to perform the activity) with bed mobility, transfers, dressing, and personal hygiene. Resident 6 required limited assistance (staff provided guided maneuvering of limbs during performance of the activity) with eating and total dependence with toilet use. A review of a Smoking Assessment, dated 4/28/18, found in Resident 6's medical record with the resident's name at the bottom. The Smoking Assessment was not completed. The form did not indicate whether Resident 6 was a smoker and required supervision or not. The facility's smoking list indicated that Resident 6 was an independent smoker. A review of Resident 6's medical records did not indicate a care plan to address the resident's safety during smoking. 2. A Review of Resident 11's Admission Record indicated that the resident was admitted to the facility on 9/21/18, with diagnoses of muscle weakness, seizures, schizophrenia and anxiety disorder. A review or Resident 11's H&P, dated 2/1/19, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 11's MDS, dated 1/7/19, indicated that the resident required supervision with bed mobility and transfers. The MDS indicated Resident 11 required limited assistance with eating, dressing, toilet use and personal hygiene. A review of a Smoking Assessment, dated 4/15/19, found in Resident 11's medical records with the resident's name at the bottom. The Smoking Assessment was not completed. The form did not indicate whether Resident 11 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 54 of 64 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 04/22/2019 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 was a smoker and required supervision or not. The facility's smoking list indicated that Resident 11 required supervision during smoking. A review of Resident 11's Care Plan, dated 4/10/19, indicated that the resident was high risk for injury related to smoking. The nursing interventions included to provide supervision while smoking. 3. A review of Resident 12's Admission Record indicated that the resident was admitted to the facility on 8/22/1997, with diagnoses of chronic obstructive pulmonary disease (COPDcollection of lung diseases), schizophrenia, psychosis (mental condition, loss of touch with reality), anxiety, and asthma (disorder of the lungs airways). A review of Resident 12's initial History and Physical (H&P), dated 9/22/18, indicated that Resident 12 had fluctuating capacity to understand and make decisions due to Resident 12's mental illness. A review of Resident 12's MDS, dated 1/18/19, indicated that Resident 12 required extensive assistance with dressing and personal hygiene, limited assistance with toilet use and transfers, and supervision with bed mobility and eating. A review of Resident 12's Smoking Assessment, dated 7/3/12, indicated that the resident was a non-smoker and did not have a completed assessment form. A review of the facility's smoking list indicated that Resident 12 was an independent smoker. A review of Resident 12's Care Plan dated 2/28/17, indicated that the resident was at risk FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 55 of 64 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 04/22/2019 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 for injury related to smoking due to noncompliance of the facility's smoking policy. The Care Plan did not indicate an individualized nursing approach to Resident 12's noncompliance with smoking. The nursing interventions included to provide supervision while smoking. A review of Resident 12's Care plan dated 2/13/17, indicated that the resident was at risk for increasing confusion and disordered thoughts. This specific mental issues of Resident 12 were not addressed in Resident 12's care plan for smoking risks for injury. 4. A review of Resident 15's Admission Record indicated that the resident was initially admitted to the facility on 1/8/15, with diagnoses of epilepsy (seizures), psychosis, and altered mental status. A review of Resident 15's H&P, dated 3/27/18, indicated that the resident had the capacity to understand and make decisions. A review of Resident 15's MDS, dated 1/24/19, indicated that the resident required supervision for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. A review of Resident 15's Smoking Assessment did not indicate if Resident 15 was a smoker. The Smoking Assessment did not indicate if Resident 15 required supervision during smoking hours. A review of the facility's smoking list indicated that Resident 15 required supervision during smoking. A review of Resident 15's medical records did not indicate a care plan to address the resident's need for supervision during smoking. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 56 of 64 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 04/22/2019 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 5. A Review of Resident 18's Admission record indicated that the resident was admitted to the facility on 10/16/17, with a diagnoses of COPD, bronchitis (inflammation of the lining of the bronchial tubes, which carry air to and from the lungs), emphysema (disease of the lungs), and hypoxemia (a state when the body does not have enough oxygen). A review of Resident 18's initial H&P, dated 1/13/18, indicated that Resident 18 had the capacity to understand and make decisions. A review of Resident 18's MDS, dated 1/20/19, indicated that Resident 18 required supervision with bed mobility, transfers, and eating. The MDS indicated that Resident 18 required limited assistance with dressing, toilet use, and personal hygiene. A review of Resident 18's Smoking Assessment, dated 10/17/17, indicated that Resident 18 was a smoker. The smoking assessment did not indicate whether Resident 18 required supervision or independent. A Review of the facility's smoking list indicated that Resident 18 was an independent smoker. A review of Resident 18's Physician Orders, dated 4/5/19, indicated a physician order to administer oxygen at two liters per minute (LPM) via nasal cannula as needed. A review of Resident 18's medical records did not indicate a care plan that addressed Resident 18's smoking safety in the facility and was allowed to store his own lighters or cigarettes. On 4/16/19 at 9:06 a.m., during an interview, Resident 18 stated that "usually" the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 57 of 64 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 04/22/2019 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 allows him to store and keep his own lighter. 6. A review of Resident 20's Admission Record indicated that the resident was admitted to the facility on 7/24/18, with diagnoses of syncope (loss of consciousness such as fainting), repeated falls, and altered mental status. A review of Resident 20's Initial H&P, dated 7/31/19, indicated that the resident had fluctuating capacity to understand and make decisions. A review of Resident 20's MDS, dated 2/6/19, indicated that the resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated Resident 20 required limited assistance with eating. A review of Resident 20's Smoking Assessment, dated 7/30/18, indicated that the resident was a non-smoker and did not have a completed assessment form. A review of the facility's smoking list indicated that Resident 20 was an independent smoker. A review of Resident 20's Care Plan, dated 7/25/18, indicated that Resident 20 was high risk for injury related to smoking. The nursing interventions indicated to provide supervision during smoking. 7. A review of Resident 23's Admission record indicated that the resident was admitted to the facility on 10/29/18, with a diagnoses of muscle weakness, hearing loss, asthma, depression, dementia and psychosis. A review of Resident 23's H&P, dated 12/7/18, indicated that Resident 23 had fluctuating capacity to understand and make decisions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 58 of 64 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 04/22/2019 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 Resident 23's MDS, dated 2/11/19, indicated Resident 23 required extensive assistance with transfers, dressing, toilet use and personal hygiene. Resident 23 required limited assistance with bed mobility and supervision with eating. A review of Resident 23's Smoking Assessment, dated 11/2/18, indicated that Resident 23 was a smoker. The Smoking assessment did not indicate if Resident 23 was independent or required supervision. A review of the facility's smoking list, indicated that Resident 23 required supervision during smoking. A review of Resident 23's Care Plan, dated 10/31/18, indicated that Resident 23 was high risk for injury related to smoking due to noncompliance of the facility's smoking policy. The nursing interventions indicated to provide supervision during smoking. 8. A review of Resident 35's Admission Record indicated that the resident was admitted to the facility on 5/3/18, with diagnoses of muscle weakness and cancer. A review of Resident 35's Initial H&P, dated 5/3/18, indicated that the resident had the capacity to understand and make decisions. A review of Resident 35's MDS, dated 3/4/19, indicated that the resident required supervision with bed mobility, transfers, and eating. The MDS indicated Resident 35 required limited assistance with dressing, toilet use and personal hygiene. A review of Resident 35's Smoking Assessment, dated 5/7/18, did not indicate if FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 59 of 64 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 04/22/2019 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 35 was a smoker. The Smoking Assessment did not indicate if Resident 35 required supervision during smoking. A review of the facility's smoking list indicated that Resident 35 was an independent smoker. A review of Resident 35's Care Plan, dated 4/15/19, indicated that the resident is high risk for injury related to smoking. The nursing interventions indicated to provide supervision during smoking. 9. A review of Resident 36's Admission Record, indicated that Resident 36 was admitted to the facility on 1/8/19, with diagnoses of muscle weakness, COPD, and schizophrenia. A review of Resident 36's MDS, dated 3/8/19, indicated that the resident was cognitively intact. The MDS indicated that Resident 36 required limited assistance with bed mobility and transfers. The MDS indicated that Resident 26 required supervision with eating and extensive assistance with dressing, toilet use and personal hygiene. A review of Resident 36's Smoking Assessment, dated 1/18/19, indicated that Resident 36 was an independent smoker and does not require supervision when smoking. A review of the facility's smoking list indicated that Resident 36 was an independent smoker. A review of Resident 36's Care Plan dated 1/9/19, indicated that Resident 36 was high risk for injury related to smoking. The nursing interventions indicated to provide supervision during smoking. A review of Resident 36's Care Plan, dated 1/21/19, indicated that Resident 36 was at risk FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 60 of 64 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 04/22/2019 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 for confusion and disordered thoughts. This mental issues were not included in Resident 36's smoking care plan. 10. A review of Resident 39's Admission Record indicated that Resident 39 was admitted to the facility on 1/15/19, with a diagnoses of encephalopathy (brain disease, damage, or malfunction) and muscle weakness. A review of Resident 39's MDS, dated 3/15/19, indicated that the resident required supervision with eating. The MDS indicated that the resident required limited assistance with bed mobility and transfers, extensive assistance for dressing, toilet use and personal hygiene. A review of Resident 39's Smoking Assessment, dated 1/15/19, indicated that Resident 39 was a smoker. The smoking assessment did not indicate if Resident 39 was an independent smoker or required supervision. A review of the facility's smoking list indicated that Resident 39 was an independent smoker. A review of the Resident's 39's Care Plan, dated 1/16/19, indicated that the resident was high risk for injury related to smoking. The nursing interventions indicated to provide supervision during smoking. 11. A review of Resident 40's Admission Record, indicated that resident was admitted to the facility on 5/20/17, with diagnoses that included muscle weakness and anxiety disorder. A Review of Resident 40's Initial H&P, dated 6/22/18, indicated that the resident had the capacity to understand and make decisions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 61 of 64 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 04/22/2019 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 Resident 40's MDS, dated 3/16/19, indicated that the resident required supervision during bed mobility, transfers, eating and toilet use. The MDS indicated that Resident 40 required limited assistance with dressing and personal hygiene. A review of Resident 40's Smoking Assessment, dated 6/9/17, indicated that the resident was a smoker. The Smoking Assessment did not indicate if Resident 40 was an independent smoker, or required supervision during smoking. A review of the facility's smoking list indicated that Resident 40 was an independent smoker, and did not require supervision. A review of Resident 40's Care Plan, revised on 1/27/18, indicated that Resident 40 was high risk for injury related to smoking. The nursing interventions indicated to provide supervision during smoking. 12. A review of Resident 55's Admissions Record indicated that Resident 55 was admitted to the facility 3/4/17, with a diagnoses of heart failure, epilepsy (seizures), and COPD. A review of Resident 55's H&P, dated 5/1/18, indicated that Resident 55 had the capacity to understand and make decisions. A review of Resident 55's MDS, dated 3/28/19, indicated that the resident required supervision with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. A review of Resident 55's Smoking Assessment, dated 3/9/17, did not indicate whether Resident 55 was a smoker. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 62 of 64 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 04/22/2019 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 smoking Assessment did not indicate if smoking was independent or required supervision. A review of the facility's smoking list, indicated that Resident 55 was an independent smoker. A review of Resident 55's Care Plan, with a revised on 3/7/17, indicated that Resident 55 was high risk for injury related to smoking. The nursing interventions indicated to provide supervision during smoking. The care plan did not indicate safety precautions for resident's potential for seizures while smoking. On 4/15/19 at 11:43a.m., during an interview, Resident 55 stated that he keeps his own lighter. Resident 55 stated it was given to him by the facility staff. On 4/16/19 at 9a.m., during an interview, the Minimum Data Set (MDS) Nurse stated that on admission, a care plan is initiated to focus and guide the staff on how to care for residents in the facility. The MDS nurse stated that all care plans should be specific to each resident. On 4/17/19, at 2p.m., during an interview, the Assistant Director of Nursing (ADON) stated that the facility did not have documented evidence to show how each resident's safety with smoking was adequately assessed. The ADON stated that the facility should have addressed in the Smoking Assessment for the resident's diagnoses, physical impairments, mental illness, hand dexterity, and visual impairments. The ADON stated that the facility does not reassess the resident's smoking assessments during change of condition and readmissions. The ADON stated that the facility should at least assess the resident smoking safety quarterly. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 63 of 64 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 04/22/2019 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 4/18/19 at 10:17a.m., during an interview, the Director of Nursing (DON) stated that a smoking assessment should be included in the facility's admission packets. The DON stated that the SSD perform the smoking assessments on all new residents. The DON stated that if the SSD was not in the facility, it was the responsibility of nursing to complete the smoking assessment. The DON stated she was not aware that some of the residents' smoking assessments and care plans were not completed. The DON stated she was not aware of the existence of Smoking Policy 1 and 2 provided by the Admissions Coordinator on 4/15/19. A review of the National Fire Protection Association Fire Code 1 (NFPUAP 1) Section 13.6 under Chapter 13, Fire Protection Systems, the fire extinguisher should be visible and located where they are readily accessible and available in the event of a fire. These are typically located along normal paths of travel so that a person could grab one with ease in the event of a fire. (https://www.nfpa.org/codesand-standards/all-codes) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L2XR11 Facility ID: CA970000125 If continuation sheet 64 of 64