Other·September 19, 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 the investigation of one complaint. Complaint number: CA00634365 Representing the Department of Public Health: Health Facilities Evaluator Nurse: 33638 Health Facilities Evaluator Nurse: 40913 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Three deficiencies were written as a result of complaint CA00634365. Highest Severity and Scope: G

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 09/19/2019 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or 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: N3QM11 Facility ID: CA970000125 If continuation sheet 1 of 15 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 08/20/2019 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 (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that the physician was promptly notified of the resident's change of condition, for one of two sampled residents (Resident 1) by not following up with the physician promptly, after Resident 1 complained of dizziness and low blood pressure (BP) on 1/29/19, during the 3 p.m. to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N3QM11 Facility ID: CA970000125 If continuation sheet 2 of 15 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 08/20/2019 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 11 p.m. shift. This deficient practice resulted in a delay in or lack of delivery of care and services. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on 10/15/18, and readmitted on 1/14/19 from General Acute Care Hospital (GACH) with diagnoses that included diabetes (high blood sugar), anemia (lack of blood cells to carry oxygen to tissues) and congestive heart failure (CHF - a condition in which the heart's function as a pump is not enough to meet the body's needs.) A review of Resident 1's History and Physical (H&P) dated 12/7/18, indicated the resident had the capacity to understand and make decisions. The H&P indicated that Resident 1 had a diagnosis of congestive heart failure and peripheral vascular disease. A review of Resident 1's Minimum Data Set (MDS - a care and assessment screening tool) dated 1/9/19, indicated the resident had no cognitive impairment. The MDS indicated that Resident 1 required supervision in bed mobility and limited assistance during walking, transfers, dressing, toilet use, and personal hygiene. A review of Resident 1's licensed nurses progress notes indicated the following electronic entry on 1/29/19 timed at 5:38 p.m., LVN 4 documented that Resident 1 complained of "feeling dizzy" when he stood up. LVN 4 documented Resident 1's vital signs included a blood pressure (BP) of 98/50 millimeters of mercury (mm/Hg), pulse rate of 60, respiration of 18, and temperature of 97.9 degrees FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N3QM11 Facility ID: CA970000125 If continuation sheet 3 of 15 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 08/20/2019 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 Fahrenheit and fingerstick blood sugar (FSBSmeasuring the amount of sugar in the blood via a puncture in a finger) of 130 milligrams per deciliter (mg/dL). At 8:34 p.m., LVN 4 documented that Resident 1's blood pressure of 95/45 mm/Hg. LVN 4 documented calling NP 1 and indicated "there was no answer." The note indicated that LVN 4 left a message to NP 1. During an interview, on 4/19/19 at 12:50 p.m., LVN 1 stated that on 1/29/19 during the 11 p.m. to 7 a.m. shift, LVN 4 reported that Resident 1 had a change of condition of low BP and feeling dizzy. LVN 1 stated Resident 1 was placed on "72-hour observation" according the facility's practice. LVN 1 stated that she "peeked in" on Resident 1 around midnight and observed that Resident 1's chest was rising. LVN 1 stated she could not find a documented vital signs during her shift. LVN 1 stated she did not call NP 1 or MD 1 again, after LVN 4 called and left a voicemail to NP 1 on 1/29/19 at 8:34 p.m. During a telephone interview on 4/19/19 at 1:26 p.m., LVN 4 stated on 1/29/19, during the 3 p.m. to 11 p.m. shift, she reported Resident 1's condition to LVN 1, the incoming nurse, for 11 p.m. to 7 a.m. shift. LVN 4 stated that she "visually checked" Resident 1 every hour. LVN 4 stated she could not recall if she called NP 1 again after the first attempt. During an interview, on 4/19/19 at 3:14 p.m., Resident 1's records were reviewed together with the DON. The licensed nurses progress notes did not indicate documented evidence of a follow-up call to NP 1 or Resident 1's attending physician (MD 1) after 8:34 p.m. The progress notes did not indicate a documented medical status of Resident 1 after 8:34 p.m. (1/29/19) to 7:34 a.m., the next day (1/30/19). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N3QM11 Facility ID: CA970000125 If continuation sheet 4 of 15 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 08/20/2019 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 DON stated the licensed nurses should have called 911 on 1/29/19, at 8:34 p.m., because NP 1 had not returned the call or to call the physician again after 30 minutes so Resident 1 could be evaluated in the acute hospital. During a telephone interview on 4/22/19 at 10:56 a.m., the DON stated that after the nurses' hand-off report at 11 p.m., the incoming charge nurse (LVN 1) should have assessed and documented Resident 1's vital signs and blood sugar at the beginning of her shift. The DON stated that LVN 1 should have followed up the call with the attending physician or NP 1. The DON stated that if the attending physician does not call back, the licensed nurse could call the facility's medical director. During a telephone interview on 5/20/19 at 11:25 a.m., NP 1 stated he did not receive a call or voicemail on 1/29/19 about Resident 1's dizziness and low BP. NP 1 stated that if the facility called to inform him that the BP was low at 95/45 mm/hg, NP 1 stated he would have ordered to transfer Resident 1 to the acute hospital or call 911 because the BP was very low. During the same telephone interview, on 5/20/19 at 11:30 a.m., Physician 1 (MD 1) stated that he could not remember if the facility notified him of the Resident 1's current BP issues. MD 1 stated that if the licensed nurse had called him, he would ask questions such as if Resident 1 had any other changes in condition and vital signs. MD 1 stated that he would try to rule out any other causes of the resident's condition. During a telephone interview on 5/21/19 at 2:40 p.m., the DON stated the facility did not have a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N3QM11 Facility ID: CA970000125 If continuation sheet 5 of 15 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 08/20/2019 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 policy on physician notification. During a telephone interview, on 6/6/19 at 12:36 p.m., the facility's Medical Director stated that if the issue discussed with the NP was questionable, the facility should have consulted with the physician. A review of the facility's policy and procedure titled, "Change in a Resident's Condition or Status," (undated), indicated the charge nurse would notify the resident's attending physician or on-call physician when there has been a significant change in the resident's physical/emotional/mental condition. The charge nurse would record in the resident's medical record information relative to changes in the resident's status.

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

F684 09/19/2019 § 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 interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) who received four blood pressure (The pressure of the blood in the circulatory system, often measured for diagnosis) medications (Coreg, Lisinopril, Aldactone, and Amiodarone), identified with repeated low blood pressure (BP) and had a change of condition was provided with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N3QM11 Facility ID: CA970000125 If continuation sheet 6 of 15 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 08/20/2019 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 necessary care and services, including but not limited to: 1. Failure to notify Resident 1's physician of low blood pressure on 1/15/19, 1/18/19, 1/20/19, 1/23/19, 1/24/19, 1/25/19, 1/26/19, 1/27/19, 1/28/19, and 1/29/19. 2. Failure to follow physician order to hold blood pressure medication when Resident 1's blood pressure was less than 100/60 millimeters of mercury (mm/Hg) 3. Failure to notify the physician when Resident 1 complaint of dizziness when standing up and low blood pressure reading on 1/29/19 at 8:34 p.m. 4. Failure to re-assess and monitor Resident 1 after 1/29/19 at 8:34 p.m., after the resident complaint of dizziness and was identified with low blood pressure. These deficient practices resulted to Resident 1 found unresponsive, pale skin, cold to touch, and fixed, dilated pupils on 1/30/19 at 5:50 a.m. and was pronounced dead at 6:04 a.m. by paramedics. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on 10/15/18, and readmitted back to the facility on 1/14/19, with diagnoses that included diabetes (high blood sugar), anemia (low blood count) and congestive heart failure (CHF - the heart is unable to pump blood around the body). A review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool) dated 12/7/18, indicated the resident had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N3QM11 Facility ID: CA970000125 If continuation sheet 7 of 15 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 08/20/2019 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 no cognitive (process of acquiring knowledge and understanding through thought, experience, and the senses) impairment. The MDS indicated Resident 1 required supervision of staff with bed mobility and walking, limited assistance with transfers, dressing, toilet use, and personal hygiene. A review of Resident 1's Physician's Orders dated 1/14/19, indicated the resident medication order included the following: 1. Coreg (for high blood pressure) 3.125 milligram (mg) tablet twice a day for hypertension (high blood pressure). Hold medication if blood pressure (The pressure of the blood in the circulatory system, often measured for diagnosis) is less than 100/60 millimeters of mercury (mm/Hg). Normal blood pressure reading is less than 120 /80 mm Hg. 2. Lisinopril (for high blood pressure) 2.5 mg tablet once a day for hypertension. Hold medication if blood pressure is less than 100/60 mm/Hg. 3. Aldactone (water pill) 25 mg tablet once a day for cardiomyopathy (Disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). Hold medication if blood pressure is less than 100/60 mm/Hg. A review of Resident 1's Physician Orders indicated to continue previous scheduled medication orders. A review of Resident 1's recapitulated (summarized) Physician Orders dated 1/1/19, reviewed by a licensed nurse on 12/29/18, indicated Resident 1's previously scheduled medications included Amiodarone hydrochloride (HCL-medication to restore FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N3QM11 Facility ID: CA970000125 If continuation sheet 8 of 15 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 08/20/2019 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 normal heart rhythm), one tablet by mouth daily for cardiomyopathy. Hold if systolic blood pressure (SBP-pressure in the blood vessels when the heart contracts) less than 100, diastolic blood pressure (DBP-the blood pressure when your heart muscle is between beats) of less than 60, and heart rate (HR) of less than 60 beats per minute (bpm) (Reference range 60 to 100 bpm). A review of Resident 1's Medication Sheets dated 1/14/19 to 1/30/19, indicated the following: 1. Coreg was held for nine days, at 7 a.m. because Resident 1's blood pressure was less than 100/60 mm/Hg, on; 1/15/19 for BP of 99/74 1/18/19 for BP of 95/67 1/20/19 for BP of 90/75 1/23/19 for BP of 97/69 1/24/19 for BP of 96/70 1/25/19 for BP of 90/65 1/26/19 for BP of 98/74 1/27/19 for BP of 90/68 1/28/19 for BP of 96/76 - Coreg was held for three days at 5 p.m. because Resident 1's blood pressure was less than 100/60 mm/Hg, on; 1/19/18 for BP of 90/64 1/24/19 for BP of 92/60 1/29/19 for BP of 98/50 2. Lisinopril was held for seven days because Resident 1's blood pressure was less than 100/60 mm/Hg, at 9 AM on; 1/15/19 for BP of 98/74 1/18/19 for BP of 96/71 1/20/19 for BP of 98/66 1/22/19 for BP of 98/69 1/24/19 for BP of 95/72 1/25/19 for BP of 91/68 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N3QM11 Facility ID: CA970000125 If continuation sheet 9 of 15 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 08/20/2019 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 1/28/19 for BP of 98/62 3. Aldactone was held for six days because Resident 1's blood pressure was less than 100/60 mm/Hg; 1/15/19 for BP of 98/74 1/18/19 for BP of 96/71 1/20/19 for BP of 98/66 1/22/19 for BP of 98/69 1/24/19 for BP of 95/72 1/25/19 for BP of 91/68 - Aldactone was administered outside of the blood pressure parameters on 1/28/19 for BP of 98/60 4. Amiodarone was held for five days because Resident 1's blood pressure was less than 100/60 mm/Hg, on; 1/15/19 for BP of 98/74 and HR of 72 1/18/19 for BP of 96/71 and HR of 74 1/20/19 for BP of 98/66 and HR of 90 1/24/19 for BP of 95/72 and HR of 88 1/25/19 for BP of 98/61 and HR of 70 - Amiodarone one tablet was administered outside of the blood pressure parameter on 1/22/19 for BP of 98/69 and HR of 88, and on 1/28/19 for BP of 94/62 and HR of 74 A review of Resident 1's Licensed Nurses Progress Notes dated 1/24/19, at 12:54 p.m., indicated Licensed Vocational Nurse 2 (LVN 2) notified Nurse Practitioner 1 (NP 1 - a nurse who is qualified to treat certain medical conditions without the direct supervision of a doctor) of Resident 1's blood pressure medications being held in the mornings due to low blood pressures. The notes indicated no new orders. A review of Resident 1's Nephrology (a doctor that specialized with kidney disease)/Internal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N3QM11 Facility ID: CA970000125 If continuation sheet 10 of 15 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 08/20/2019 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 Medicine Notes dated 1/24/19, written and signed by NP 1, indicated that Resident 1 had complained of one episode of nausea. The progress note did not indicate Resident 1's repeated low blood pressure results. A review of Resident 1's Physician Order indicated the following: - 1/26/19 at 7:05 a.m., indicated Albuterol (relaxes muscles in the airways) two puffs every six hours, as needed for shortness of breath. - 1/27/19 at 11 a.m., indicated Zofran 4 mg, one tablet by mouth every six hours as needed for nausea and vomiting. A review of Resident 1's care plans there was no care plan for Resident 1 multiple blood pressure medication and the repeated occurrences of low blood pressure. There was no care plan regarding Resident 1 shortness of breath or nausea and vomiting. A review of Resident 1's "72 Hour Observation" dated 1/29/19, 3 pm to 11 pm shift, indicated to observe Resident 1 because of complaint of dizziness and low blood pressure. A review of Resident 1's Licensed Nurses Progress notes indicated the following: - 1/29/19 at 5:38 p.m., indicated Resident 1 complained of "feeling dizzy" when he stood up. The notes indicated Resident 1's vital signs included a blood pressure of 98/50 mm/Hg, pulse rate of 60, respiration of 18, and temperature of 97.9 degrees Fahrenheit and fingerstick blood sugar (FSBS- measuring sugar in the blood) of 130 mg/dL. - At 8:34 p.m., indicated Resident 1's blood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N3QM11 Facility ID: CA970000125 If continuation sheet 11 of 15 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 08/20/2019 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 pressure of 95/45 mm/Hg. The notes indicated the NP 1 was call and there was no answer. The note indicated that LVN 4 left a message to NP 1. - 1/30/19 at 7:34 a.m., indicated Resident 1 was found unresponsive at 5:50 a.m. with skin pale and cold to touch, pupils fixed and dilated, with a very faint, weak pulse. LVN 1 documented calling 9-1-1 (emergency number to summons paramedics). The notes indicated when the paramedics arrived, Resident 1 was pronounced dead at around 6 a.m. LVN 1 documented that "NP 1 ... was made aware." A review of Resident 1's Licensed Nurses Progress notes there was no documented evidence that Resident 1's was assessed from 8:34 p.m. on 1/29/19 (When the resident was identified with low blood pressure) to 5:50 a.m. on 1/30/19, (10 hours and 16 minutes) when the resident was found unresponsive. A review of Resident 1's Prehospital Care Report Summary from the Los Angeles Fire Department dated 1/30/19, indicated that the paramedics arrived in the facility at 6:04 a.m. The report summary indicated that Resident 1 was dead prior to the paramedics' arrival. The assessment indicated that Resident 1's skin color was pale, cold, and with absent of lung sounds. The assessment indicated that Resident 1's body was mottled (patches of different shades of colors) and had lividity (a dark purple discoloration of the body, after death had occurred). A review of Resident 1's death certificate indicated that the resident died on 1/30/19. The death certificate indicated that the immediate cause of death was cardiopulmonary arrest (loss of heart function) secondary to myocardial infarction (loss of heart muscle due to loss of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N3QM11 Facility ID: CA970000125 If continuation sheet 12 of 15 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 08/20/2019 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 blood supply) and atherosclerotic heart disease (the narrowing and hardening of blood vessels. On 4/19/19 at 12:50 p.m., during an interview and concurrent record review of Resident 1's Licensed Nurse Progress Notes with LVN 1, LVN 1 stated that on 1/29/19 during the 11 p.m. to 7 a.m. shift, LVN 4 informed her that Resident 1 had a change of condition. LVN 1 stated the resident had a low BP and was feeling dizzy. LVN 1 stated that LVN 4 wrote Resident 1's change of condition on the facility's "72-hour observation" communication book. LVN 1 stated that she "Peeked in" on Resident 1's room around midnight and observed Resident 1's chest was rising. LVN 1 stated she could not find documented vital signs during her shift. LVN 1 stated she could not recall calling NP 1 or MD 1 after LVN 4 called NP 1 on 1/29/19 at 8:34 p.m., LVN 1 stated NP 1 called back on 1/30/19 at 6 a.m., after Resident 1 had expired. LVN 1 stated that Resident 1 had already expired when the paramedics arrived in the facility. LVN 1 could not find documented evidence of Resident 1's medical status and recorded vital signs after LVN 2's last note on 1/29/19 at 8:34 p.m. On 4/19/19 at 1:26 p.m., during a telephone interview with LVN 4, LVN 4 stated that she was the nurse on duty on 1/29/19, during the 3 p.m. to 11 p.m. shift, LVN 4 stated she could not recall if she called NP 1 again after the first attempt. LVN 4 stated she did not recheck Resident 1's blood pressure and did not call the NP nor the physician. On 4/19/19 at 3:14 p.m., during an interview and concurrent review of Resident 1's care plans with the Director of Nurses (DON), the DON stated that there was no care plan develop for four blood pressure medications of Resident 1. The DON reviewed Resident 1's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N3QM11 Facility ID: CA970000125 If continuation sheet 13 of 15 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 08/20/2019 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 Licensed Nurses Progress Notes, the DON was not able to provide documented evidence that Resident 1 was assess and a follow-up call was made to NP 1 or MD 1 after 8:34 p.m., on 1/29/19. On 4/25/19 at 8:18 a.m., during a telephone interview Certified Nurse Assistant 1 (CNA 1) stated that on 1/29/19, during the start of his shift (11 p.m.-7 a.m.), he saw Resident 1 in his room and the resident was "sleeping normally." CNA 1 stated that he would usually wait until the licensed nurse tells him to check the resident's vital signs. CNA 1 stated that when LVN 1 saw Resident 1 in the morning of 1/30/19, he was called right away and yelled to go to Resident 1's room because "he was not okay." On 5/8/19 at 3:05 p.m., during a telephone interview, the DON stated that that she could not find a specific care plan developed for the use of multiple blood pressure medications. The DON stated that when Resident 1 was placed on the 72-hour monitoring log, the nurse should monitor and document the resident's status at least every shift, and more if needed depending on the licensed nurses' assessment. The DON stated she could not find licensed nurses' documentation or Resident 1's blood pressure after the 3 p.m. to 11 p.m. shift. On 5/20/19 at 11:25 a.m., during a telephone interview, NP 1 stated that on 1/24/19, he was informed of Resident 1's repeated low BPs. NP 1 stated he told LVN 2 to continue to monitor Resident 1 blood pressure and to hold the blood pressure medications according to the parameters and to call if the resident blood pressure continued to go down or the heart rate was abnormal. NP 1 stated he did not receive a call or voicemail on 1/29/19. NP 1 stated that if the facility called to inform him that the BP was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N3QM11 Facility ID: CA970000125 If continuation sheet 14 of 15 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 08/20/2019 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 low at 95/45 mm/hg, NP 1 stated he would have ordered to transfer Resident 1 to the acute hospital or call 9-1-1 because the BP was very low. NP 1 stated he did not remember getting a voicemail about the Resident 1 on 1/29/19. NP 1 stated the facility called early in the morning (1/30/19) to inform him that 9-1-1 was called and that was the time he called the facility immediately. On 5/20/19 at 11:30 a.m., during an interview, Physician 1 stated that it would be helpful when the licensed nurses call and notify him when medications "had been held for so many days." Physician 1 stated that he would try to rule out any other causes of the resident's condition. A review of the facility's undated policy and procedure titled, "Change in a Resident's Condition or Status," indicated the charge nurse would notify the resident's attending physician or on-call physician when there has been a significant change in the resident's physical/emotional/mental condition. The charge nurse would record in the resident's medical record information relative to changes in the resident's status. A review of the facility's policy and procedures titled "Blood Pressure, Measuring" with revised date 9/2010, indicated that hypotension was defined as blood pressure less than 100/60 mm/Hg. Hypotension should be reported to the physician. Staff should record several readings throughout the day, including before and after meals. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N3QM11 Facility ID: CA970000125 If continuation sheet 15 of 15