Other·July 26, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during an Abbreviated survey for a Complaint investigation. Complaint Number: CA 00580850. Representing the Department: Health Facilities Evaluator Nurse ID: 09848 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for Complaint number CA00580850.

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

F607 07/28/2018 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to: 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: EGX011 Facility ID: CA970000145 If continuation sheet 1 of 3 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: _______________ 056321 (X3) DATE SURVEY COMPLETED 06/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OLYMPIA CONVALESCENT HOSPITAL 1100 S Alvarado St Los Angeles, CA 90006 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. Report an injury of unknown origin within a regulated time frame 2. Conduct and submit a complete investigation and report the findings of the investigation to the Department of Public Health within five days for one of thee sampled residents (Resident 1). This deficient practice placed the resident and other residents at risk for potential abuse. Findings: An unannounced facility visit was conducted on 6/16/18 at 10:15 a.m. regarding bruising found along Resident 1's rib and breast area from the general acute care hospital (GACH). A review of Resident 1's admission records indicated she was admitted on 3/25/18 with diagnoses that included end stage renal disease (kidney disease), dependence on renal dialysis, type 2 diabetes mellitus (abnormal blood sugar) and hypertension (high blood pressure). During an interview with Resident 1 on 4/16/18 at 3:45 p.m., she stated did not know how she had bruises. The resident stated that a Hoyer (mechanical lift) lift was used to transfer her when she was at dialysis (hemodialysis, where blood is removed from the body and filtered through a man-made membrane called a dialyzer, or artificial kidney, and then the filtered blood is returned to the body). Resident 1 stated that Certified Nurse Assistant 1 (CNA 1) lifted her from bed to wheelchair using his hands under her arms. A review of electronic Interdisciplinary progress notes dated 3/27/18 indicated the resident was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EGX011 Facility ID: CA970000145 If continuation sheet 2 of 3 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: _______________ 056321 (X3) DATE SURVEY COMPLETED 06/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OLYMPIA CONVALESCENT HOSPITAL 1100 S Alvarado St Los Angeles, CA 90006 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE found to have discoloration to the mid chest area and both enlarged and hardened upper breast areas. During an interview with the Director of Nursing (DON) on 6/15/18 at 3:30 p.m., she stated the facility did not do an investigation regarding the bruising on 3/27/18 and did not report to the department (of Public Health). The DON stated the bruising was from an unknown origin. The DON further stated the facility should have investigated the incident and reported to the department. A review of an undated facility policy titled "Resident Freedom from Abuse, Neglect, Exploitation and Misappropriation of Property" indicated an injury of unknown source occurred when the source of the injury was not observed by any person or the source of injury could not be explained by the resident and the injury was suspicious because of the extent or location of the injury. The facility had procedures that included immediately reporting all alleged violations to the Administrator/ Director of Nursing, state agency, adult protective services and to all required agencies within specific time frames. The facility had procedures that included identifying staff responsible for investigation, identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses and others who may have had knowledge of the allegation and providing a complete and thorough documentation of the investigation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EGX011 Facility ID: CA970000145 If continuation sheet 3 of 3