Other·September 3, 2020

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following represents the findings of the Department of Public Health during the investigation of a complaint. Complaint Number: CA00697030 Representing the Department of Public Health: HFEN ID: 41852 The inspection was limited to the specific complaint incident investigated and does not represent the findings on a full inspection of the facility. Two deficiencies were issued for Complaint Number CA00697030

F620 SS=D Admissions Policy CFR(s): 483.15(a)(1)-(7)

F620 §483.15(a) Admissions policy. §483.15(a)(1) The facility must establish and implement an admissions policy. §483.15(a)(2) The facility must(i) Not request or require residents or potential residents to waive their rights as set forth in this subpart and in applicable state, federal or local licensing or certification laws, including but not limited to their rights to Medicare or Medicaid; and (ii) Not request or require oral or written assurance that residents or potential residents are not eligible for, or will not apply for, Medicare or Medicaid benefits. (iii) Not request or require residents or potential residents to waive potential facility liability for losses of personal property. §483.15(a)(3) The facility must not request 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: OQT811 Facility ID: CA970000125 If continuation sheet 1 of 16 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 08/03/2020 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 require a third party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility. However, the facility may request and require a resident representative who has legal access to a resident's income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the resident's income or resources. §483.15(a)(4) In the case of a person eligible for Medicaid, a nursing facility must not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the State plan, any gift, money, donation, or other consideration as a precondition of admission, expedited admission or continued stay in the facility. However,(i) A nursing facility may charge a resident who is eligible for Medicaid for items and services the resident has requested and received, and that are not specified in the State plan as included in the term ''nursing facility services'' so long as the facility gives proper notice of the availability and cost of these services to residents and does not condition the resident's admission or continued stay on the request for and receipt of such additional services; and (ii) A nursing facility may solicit, accept, or receive a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to a Medicaid eligible resident or potential resident, but only to the extent that the contribution is not a condition of admission, expedited admission, or continued stay in the facility for a Medicaid eligible resident. §483.15(a)(5) States or political subdivisions may apply stricter admissions standards under State or local laws than are specified in this section, to prohibit discrimination against individuals entitled to Medicaid. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQT811 Facility ID: CA970000125 If continuation sheet 2 of 16 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 08/03/2020 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 §483.15(a)(6) A nursing facility must disclose and provide to a resident or potential resident prior to time of admission, notice of special characteristics or service limitations of the facility. §483.15(a)(7) A nursing 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 paragraph (c)(9) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure new Residents (Resident 2 and 3) were not admitted to the facility per Public Health mandate during the Coronavirus outbreak ([COVID-19], an illness caused by a virus that can spread from person to person). This deficient practice caused an increased risk for residents and staff to acquire respiratory illness that could lead to serious harm and or death. Findings: During an observation on 7/16/2020 at 7:35 AM, Resident 2 and Resident 3 were in their room. A review of the admission record on 7/16/2020 at 10:35 AM, indicated Resident 2 was admitted on 7/8/2020 with diagnoses including polyneuropathy (damage or disease affecting peripheral nerves in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning pain), hypertension (HTN - elevated blood pressure) , and spinal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQT811 Facility ID: CA970000125 If continuation sheet 3 of 16 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 08/03/2020 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 stenosis (narrowing of the spinal cord causing nerve pinching which leads to persistent pain in the buttocks, limping, lack of feeling in the lower extremities, and decreased physical activity). A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 7/15/2020 indicated Resident 2 was cognitively intact (independently makes decisions) and required limited assistance with 1 person assist for activities of daily living (ADLs - transfers, personal hygiene, walking, and bathing) A review of Resident 2's Physician's orders dated 7/8/2020 indicated orders to admit Resident 2 to the facility. A review of the admission record indicated Resident 3 was admitted on 7/8/2020 with diagnoses including hypertension (HTN elevated blood pressure), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental disorder characterized by feelings of excessive uneasiness and apprehension). A review of Resident 3's MDS dated 7/15/2020 indicated Resident 3 was cognitively intact (independently makes decisions) and required limited assistance with 1 person assist for activities of daily living. A review of Resident 3's Physician's orders dated 7/8/2020 indicated orders to admit Resident 2 to the facility. During an observation and concurrent interview on 7/16/2020 at 8:56 AM, Resident 2 stated CNA 1 came into his room and took his vitals. Resident 2 stated he has been at the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQT811 Facility ID: CA970000125 If continuation sheet 4 of 16 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 08/03/2020 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 since 7/8/2020. During an interview on 7/16/2020 at 2:02 PM with Director of Staff Development (DSD) she stated she did not get confirmation from Public Health for new admissions. She stated the facility can not admit new residents without a clearance from Public Health. During an interview on 7/17/2020 at 10:59 AM, the Public Health Nurse (PHN) stated she informed in the email dated 6/25/2020 at 10:40 AM that if any staff or resident test positive during any of the two rounds of mass testing more than 4 weeks after the COVID-19 outbreak was originally closed then re-open outbreak and close to admissions. She stated the facility was not supposed to admit new residents. During an interview on 7/17/2020 at 11:15 AM, the Administrator (Admin) stated an email from Public Health Nurse (PHN) indicated if residents test positive from response testing then facility will close to new admissions. The Admin stated the facility was not supposed to admit Resident 2 and 3 on 7/8/2020, per Public Health mandate. A review of the PHN email dated June 25, 2020 at 10:40 AM to facility, indicated if residents test positive from response testing more than 4 weeks after the outbreak was originally closed then re-open the outbreak and close to admission. A review of the facility polices and procedures titled, "Admissions Policies," indicated it shall be the responsibility of the Administrator, through the admissions department, to assure that the established admission policies are followed by the facility and resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQT811 Facility ID: CA970000125 If continuation sheet 5 of 16 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 08/03/2020 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

F880 Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 SS=L PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQT811 Facility ID: CA970000125 If continuation sheet 6 of 16 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 08/03/2020 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) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of COVID-19 (Coronavirus disease 2019, a highly contagious viral infection that spread from person-toperson affecting the respiratory system) for two of two residents (Residents 2 and 3) quarantined (restricted movement of people intended to prevent the spread of disease) for possible COVID-19 infection out of a total of 47 residents in the facility. The facility also failed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQT811 Facility ID: CA970000125 If continuation sheet 7 of 16 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 08/03/2020 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 provide a safe environment for four nursing staff (Certified Nursing Assistants 1, 2, 3 (CNAs 1, 2, and 3) and Licensed Vocational Nurse 1 (LVN 1) and three kitchen staff (KSs 1, 2 and 3) out of 30 facility staff, who required to be quarantined and off work. The facility failed to: a. Ensure LVN 1 and CNAs 1 and 3 donned (put on) Personal Protective Equipment (PPE protective clothing, goggles, head/shoe covers, mask, gown, gloves or other garments or equipment designed to protect the wearer's body from infection) while caring for Residents 2 and 3, who were potentially COVID-19 positive (Persons Under Investigation [PUI]) quarantined for 14 days since admission to rule out COVID-19. b. Ensure there were PPE supplies and a signage outside the room of Residents 2 and 3, indicating the type of isolation needed and the PPE to use to enter the room. c. Ensure newly admitted Residents 2 and 3 were quarantined for 14 days as PUI for potential COVID-19. d. Ensure the Infection Preventionist (IP) nurse was knowledgeable on cohorting (imposed grouping of people, such as residents, potentially exposed to designated diseases) residents as per recommendation from the Public Health Nurse (PHN). e. Ensure only assigned dedicated healthcare staff to care for Residents 2 and 3 who were PUIs and for Residents 1 and Resident 4 (was not in the facility at the time) who were positive for COVID-19. f. Ensure CNA 1, LVN 1, KS 1 and KS 2 were off work and quarantined, as per PHN recommendation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQT811 Facility ID: CA970000125 If continuation sheet 8 of 16 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 08/03/2020 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 These deficient practices had the potential to result in the spread of COVID-19 placing remaining residents in the facility and the staff at risk to be infected with COVID-19 and becoming seriously ill, leading to hospitalization and/or death. On 7/16/2020 at 4:25 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator, the Director of Nursing (DON), and the Infection Preventionist (IP) Nurse for the facility's failure to implement measures to prevent the transmission of COVID-19 infection that threatened the health and safety of the residents and staff. On 7/18/2020 at 1 p.m., after the facility submitted an acceptable plan of action (POA), the survey team verified and confirmed on-site the implementation of the POA through observation, interview and record review. The IJ situation was removed in the presence of the Administrator, DON, and IP. The accepted POA included the following actions: 1. In-service education to all staff on infection control prevention with emphasis on proper use of PPE, signage outside the residents rooms, PPEs outside resident rooms, transmissionbased precautions, cohorting and zoning, dedicated staff for positive COVID-19, PUIs and not infected residents, and mandatory 14 days quarantine of residents and staff who were potentially infected. 2. The DON informed LVN 1 and CNA 2 on 7/18/2020 Resident 4 was identified to have FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQT811 Facility ID: CA970000125 If continuation sheet 9 of 16 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 08/03/2020 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 COVID-19 positive diagnosis. 3. The Director of Staff Development (DSD) and DSD Designee assigned trained staff to work on the COVID-19 positive residents Red Zone unit exclusively and provided staff with necessary PPEs (N95 masks, gloves, gowns, and face shields). 4. On 7/17/2020, proper signages were posted, infection control carts with the necessary supplies and PPEs were placed outside the rooms. 5. Dedicated staff would continue to care for residents in the COVID-19 unit and PUI unit until residents completes 14 days without symptoms and are moved to the general population, per PHN recommendation on 7/14/2020 as they had been exposed to positive COVID-19. Findings: A review of the facility's census dated 7/16/2020, indicated facility had 47 residents in-house. A review of Resident 1's Admission Record (Face Sheet) indicated an admission on 5/4/2016 and a re-admission dated 7/11/2020 with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and anxiety disorder (a feeling of apprehension and fear, characterized by physical symptoms such as palpitations, sweating, and feelings of stress). A review of Resident 1's the Minimum Data Set (MDS - a standardized assessment and carescreening tool) dated 7/18/2020 indicated Resident 1 was unable to make decisions, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQT811 Facility ID: CA970000125 If continuation sheet 10 of 16 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 08/03/2020 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 required limited assistance with one person assist with activities of daily living (ADLs transfers, personal hygiene, dressing, and toilet use). A review of Resident 1's COVID-19 test result collected 7/9/2020 indicated positive for COVID-19. A review of Resident 4's Admission Record (Face Sheet) indicated an admission dated 12/22/15 and re-admitted on 7/5/2020 with diagnoses including heart failure (the heart is unable to provide adequate blood flow to other organs). A review of Resident 4's MDS, dated 7/12/2020 indicated Resident 4 was able to make decisions, and required extensive assistance with one person assist with activities of daily living (ADLs - personal hygiene, and dressing). A review of Resident 4's COVID-19 test result collected 7/9/2020 indicated positive for COVID-19. A review of Resident 4's Physician's Order indicated resident was transferred out to hospital on 7/13/2020 for poor oral intake. A review of Resident 2's Admission Record (Face Sheet) indicated an admission dated 7/8/2020 with diagnoses including hypertension (elevated blood pressure) and anxiety disorder (a feeling of apprehension and fear, characterized by physical symptoms such as palpitations, sweating, and feelings of stress). A review of Resident 2's the Minimum Data Set (MDS - a standardized assessment and carescreening tool) dated 7/15/2020 indicated Resident 2 was able to make decisions, had no memory problems, and required limited FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQT811 Facility ID: CA970000125 If continuation sheet 11 of 16 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 08/03/2020 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 assistance with one person assist with activities of daily living (ADLs - transfers, personal hygiene, walking, and bathing). A review of Resident 2's Physician's orders indicated no order to place the resident on droplet isolation precautions (used when a person has an infection with germs that can be spread to others by speaking, sneezing, or coughing). A review of the facility's COVID-19 Mitigation Plan indicated newly admitted residents would be placed in droplet isolation (quarantined) for potential COVID-19 for a 14-day period. A review of Resident 3's Admission Record indicated the facility admitted the resident on 7/8/2020 with diagnoses including hypertension and anxiety. A review of Resident 3's MDS dated 7/15/2020 indicated Resident 3 was cognitively intact and required limited assistance with one-person assist with ADLs. A review of Resident 3's Physician's orders indicated no order to place the resident on droplet isolation precautions. On 7/16/2020 at 7:35 a.m., Residents 2 and 3 were observed in their room without any signage indicating they were on droplet isolation precautions. The two residents' room did not have outside the door, a cart containing supplies and equipment dedicated to use with them only (PPEs, stethoscope [medical device for listening to internal sounds of human body], blood pressure cuff, etc.). At the time of the observation, Certified Nursing Assistant 1 (CNA 1) entered Resident 3's room to provide care. CNA 1 did not put on PPE. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQT811 Facility ID: CA970000125 If continuation sheet 12 of 16 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 08/03/2020 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 7/16/2020 at 7:50 a.m. during an interview, CNA 1 stated he was assigned to care for Residents 2 and 3, who were not in isolation precautions because there were no isolation signs outside the rooms or isolation carts (with PPE and equipment) by the entrance of their rooms. CNA 1 stated he was also assigned to other residents (non-quarantined residents). On 7/16/2020 at 7:57 a.m., during an observation and concurrent interview on CNA 2 was observed exiting Resident 1's room, who was on droplet isolation precaution for COVID-19 (there was a sign posted outside the room and a cart with PPEs and supplies). CNA 2 stated she was assigned to provide care to resident with COVID-19 and residents who did not have COVID-19. CNA 2 stated she worked full time in the facility and during her shifts, she alternated between taking care of residents in quarantine and non-quarantine zones. On 7/16/2020 at 8:50 a.m., after taking care of Resident 1, who had COVID-19, CNA 2 proceeded to assist Resident 4 who was not on isolation precautions. CNA 2 was observed wheeling Resident 4 from the shower room to his room, after a shower. CNA 2 was not wearing PPEs. On 7/16/2020 at 8:55 a.m., CNA 1 was observed entering Resident 2's room to take Resident 2's vital signs (blood pressure, respiratory and heart rate and temperature) without putting PPEs. Upon leaving the room, in an interview, CNA 1 stated he did not need PPEs because Resident 2 was not in isolation precautions. On 7/16/2020 at 9 a.m. during an interview, Resident 2 confirmed CNA 1 took his vital signs without any personal protective equipment. Resident 2 stated he has been at the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQT811 Facility ID: CA970000125 If continuation sheet 13 of 16 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 08/03/2020 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 since 7/8/2020. During an interview on 7/16/2020 at 1:25 p.m. the Director of Nursing (DON) confirmed Residents 2 and 3 were admitted on 7/8/2020 and were not placed on quarantine for 14 days as recommended by the PHN. The DON stated new admitted residents are tested for COVID-19 and the policy is to quarantine and isolate new Residents for 14 days regardless of initial COVID-19 test results. Then, re-test for COVID-19, and if negative the resident is removed from quarantine. The DON could not explain the reason the staff did not quarantine Residents 2 and 3. On 7/16/2020 at 4 p.m., during an interview, CNA 3 stated she had been assigned to Residents 2 and 3 and she did not wear any PPE because there was no signs outside the rooms indicating the residents were on isolation precautions and the licensed nurses did not advise her to wear PPEs. On 7/16/2020 at 4:10 p.m., during an interview, the IP confirmed Residents 2 and 3 were not placed in droplet isolation precautions since their admission dated 7/8/2020. The IP did not explain the reason the policy and the PHN recommendations were not followed. A review of the Staffing Assignments for 7/9 and 7/16/2020, indicated CNAs 1 and 3 and LVN 1 were assigned to quarantine and nonquarantined residents during the morning shift. On 7/17/2020 at 7:40 a.m., during an interview, LVN 1 he stated the facility had only Resident 1 in the Red Zone (for COVID-19 positive residents). LVN 1 stated Residents 2 and 3 were not on isolation. on 7/17/2020 at 11:15 a.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQT811 Facility ID: CA970000125 If continuation sheet 14 of 16 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 08/03/2020 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 interview, the Administrator stated the facility's policy and procedure on transmission-based precaution and COVID19 mitigation plan indicated new admitted residents are to be placed in isolation for 14 days in the Yellow Zone. The Red Zone was for COVID-19 positive residents and the Green Zone was for COVID-19 negative residents. b. During an observation on 7/16/2020 at 8:15 a.m. KS 1, KS 2 and Dietary Service Supervisor were working in the kitchen. KS 1 and KS 2 were observed preparing food and cleaning the kitchen. At the time of the observation, three kitchen staff (KS1, KS2, and KS3) stated they were scheduled to work on that day (7/16/2020) and they prepared and served breakfast. On 7/16/2020 at 8:30 a.m. during an interview, PHN stated KS 1, KS 2, LVN 1, and CNA 2 were last exposed to a COVID-19 positive Resident/Staff on 7/11/2020 and the recommendation was for them to quarantine for 14 days or allowed to work only on the Red Zone (COVID-19 positive residents) only if there was staffing shortage. A review of an email from the PHN, dated 7/14/2020, to the facility indicated PHN recommended exposed or positive staff should quarantine, but if staffing issues nursing staff could work on the Red Zone only, and kitchen staff to be quarantined. A review of facility's policy and procedures titled, "Isolation - Initiating Transmission Based Precautions," revised April 2012 indicated if a resident is suspected of, or identified as, having a communicable infections disease, the charge Nurse or Nursing Supervisor shall notify the infection Preventionist and the resident's attending physician for appropriate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQT811 Facility ID: CA970000125 If continuation sheet 15 of 16 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 08/03/2020 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 Transmission Based precautions. When transmission-based precautions are implemented, the IP or designee shall ensure that protective equipment, gloves, gowns, masks, etc., is maintained near the resident's room ensuring everyone entering the room can access what they need. The policy indicated to post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of the precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room. The facility's policy titled, "Mitigation Plan," undated, indicated to test residents prior to admission or re-admission, including transfers from hospitals or other healthcare facilities. If the hospital does not test the resident, the facility will test and quarantine the resident upon admission. Residents admitted should be tested prior to admission and if they test negative, should be quarantined for 14 days and then re-tested. If negative, the resident can be released from quarantine. Place residents into three separate cohorts based on the test results. Facility will cohort all unknown asymptomatic and untested residents in the Yellow Zone and will be treated with contact and droplet precautions until a negative test result can be achieved or the resident meets the time criteria to return to the Green Zone based on current Centers for Disease Control (CDC) guidance for removal of transmission-based precautions. Residents positive for COVID-19 are cohorted on the Red Zone. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQT811 Facility ID: CA970000125 If continuation sheet 16 of 16