Other·October 4, 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 Department of Public Health during the investigation of an entity-reported incident. Entity-reported incident: 607057 Representing the Department: Surveyor ID #: 38487 RN, HFEN The inspection was limited to the specific entity-reported incident investigated and does not represent the findings of a full inspection of the facility. A deficiency was issued for entity-reported incident 607057.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 10/04/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the resident received supervision and assistance device to prevent elopement (unsupervised wandering which results in a resident leaving the nursing home facility), for one of two sampled residents (Resident 1). For Resident 1, who wore a 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: 9RKR11 Facility ID: CA970000145 If continuation sheet 1 of 8 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 09/04/2019 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 Wanderguard (a device placed on the resident's extremity used to alert the staff of an elopement attempt) and was wheelchair bound, the resident was able to roll herself more than 150 feet from the facility's lobby to open the double glass doors, down to the ramp, then hit her head on the wall at the end of the ramp without staff intervention. This deficient practice resulted in Resident 1's sustaining a closed head injury (blow to the head) with left medial (middle) orbital (around the eye) fracture, forehead abrasion (skin cut) requiring skin adhesive for closure, knee contusion (tissue damage) with left patella (kneecap) fracture, pain, and required care at the general acute care hospital (GACH). Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility, on 9/11/13, with diagnoses including dementia (decline in cognitive function, memory loss which interferes with daily life) and cerebral infarction (damage to brain from blood flow disruption). A review of Resident 1's Physician Order, dated 6/30/18, indicated the physician ordered for a placement of Wanderguard and monitoring for wandering behavior every shift. A review of the Minimum Data Set (an assessment and care-screening tool), dated 7/8/18, indicated Resident 1 was moderately impaired in cognition. According to the MDS, Resident 1 required supervision with bed mobility, transfer, and eating, and limited assistance with walking, dressing, toilet use, and personal hygiene. According to a review of the Initial History and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9RKR11 Facility ID: CA970000145 If continuation sheet 2 of 8 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 09/04/2019 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 Physical, dated 8/6/18, Resident 1 did not have the capacity to understand and make decisions. A review of the Physical Therapy (PT) Discharge Summary, dated 9/24/18, indicated Resident 1 required minimal assist with bed mobility, transfers, and bed mobility. Resident 1 was able to walk 50 feet using a two-wheeled walker with minimal assist. A review of Resident 1's Progress Notes, dated 10/4/18 at 3:02 p.m., indicated, "The registered nurse received patient (Resident 1) on her wheelchair without assistance. Noted patient having behaviors of continuously wandering and trying to elope. Verbally educated to reality, but still very confused and stated she needed to go home. Alert and confused, getting aggressive and violent when nurses stopped her to go out or brought her back to activity room or her room. Patient has order of Wanderguard alarm in working condition, answered promptly to prevent unassisted elopement." A review of Resident 1's Progress Notes, dated 10/4/18 at 7:50 p.m., indicated "Heard another alarm from front door, paged nurses to check front door and ran to the door, three nurses get to the door right away but patient already slid down to the end of slope still sitting on her wheelchair. Noted bleeding left eye lid and nose. Resident 1 complained of pain on both knees. Skin laceration on left eye lid 1 cm (centimeter) length, open skin on both side of her nose, both knees with skin redness." A review of Resident 1's Physician Order, dated 10/4/18, at 8:33 p.m., indicated to transfer Resident 1 to the emergency room (ER) of the GACH, status post fall. The Nurses Notes, dated 10/4/18, at 10:10 p.m., indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9RKR11 Facility ID: CA970000145 If continuation sheet 3 of 8 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 09/04/2019 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 Resident 1 arrived in ER and the resident's family member was notified. A review of the GACH emergency department record, dated 10/5/18, indicated Resident 1 had an abrasion to left frontal head, ecchymosis (bruising) noted left frontal head, and 1 cm laceration to left forehead. Resident 1 had an abrasion to the left hand and a small abrasion to the right knee. Resident 1 had some pain and swelling associated with abrasion to the left knee. Resident 1's left frontal head abrasion was 1 cm in length and was repaired with skin adhesive. Resident 1's differential (diagnoses) included, but not limited to, closed head injury (blow to the head), knee contusion (injured tissue), patella fracture, facial fracture, facial contusion, and lacerations to name a few. Resident 1 had pain with range of motion to the left lower extremity. Resident 1 was placed on a knee immobilizer and had x-ray that demonstrated a non-displaced fracture of the left patella. CT scan showed a left medial orbital wall fracture. According to the facility's letter, dated 10/5/18, Resident 1 was admitted back to the facility at 3 a.m., no surgery necessary, a knee brace was applied (not indicating which side of the knee). A review of Resident 1's Physician Phone Order, dated 10/5/18, indicated to give two tablets of Tylenol 325 milligrams (mg) by mouth every six hours for pain management on the left orbital and patella fracture for seven days. The treatment orders for upper nose, left eye, the right and left knee skin abrasion, indicated to cleanse with normal saline (NS, salty water), pat dry, and apply Bacitracin (antibiotic) ointment and leave open to air one time daily, for 14 days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9RKR11 Facility ID: CA970000145 If continuation sheet 4 of 8 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 09/04/2019 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 On 10/22/18, at 9:29 a.m., Resident 1 was interviewed with the Assistant Director of Nursing (ADON) providing translation. Resident 1 could not remember the circumstances surrounding her alleged elopement and subsequent injuries. Resident 1 was observed to have a cast to the left leg from the mid-thigh extending to the ankle. Resident 1 was observed to have a Wanderguard to the right wrist. On 10/22/18, at 9:51 a.m., the Physical Therapist 1 (PT 1) was interviewed. PT 1 stated prior to Resident 1's incident of elopement and subsequent injuries, she was able to walk with minimal assistance. After the incident, Resident 1 was non-weight bearing because of the cast to the left leg. PT 1 stated Resident 1 cannot walk. On 10/22/18, at 10:30 a.m., the Registered Nurse Supervisor 1 (RNS 1), the first responder after Resident 1's alleged elopement, was interviewed over the phone. RNS 1 stated on the day of the alleged elopement, "She (Resident 1) was wandering. She wants to go to some place from before, in Korea." RNS 1 stated she placed Resident 1 in a wheelchair and was "closely" monitoring her. RNS 1 stated Resident 1 was last seen sometime before 8 p.m., on 10/4/18, at the nurses' station. While RNS 1 was allegedly in another resident's room, she heard the Wanderguard® alarm sound. RNS 1 stated she responded to the alarm "very fast, few minutes." When RNS 1 made it to the front door of the facility, Resident 1 was at the end of the ramp, which is sloped. Resident 1 was sitting in the wheelchair and was presumed to have hit the wall at the end of the ramp. Resident 1 was bleeding from a laceration to the left eyebrow and was complaining of knee pain for which she was medicated. Resident 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9RKR11 Facility ID: CA970000145 If continuation sheet 5 of 8 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 09/04/2019 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 transferred to the GACH. RNS 1 did not have an explanation as to how Resident 1 was able to trigger the Wanderguard® alarm, open the facility front door while in the wheelchair, and allegedly elope, without staff intervention. On 10/22/18, at 11:26 a.m., the facility was observed with the Administrator. The Administrator stated the nurse's station where Resident 1 was allegedly last seen was approximately 150 feet from the facility's lobby. The lobby was approximately 28 feet in length to the double glass doors, the entrance to the facility. From the entrance to the facility to the street, the ramp was approximately 40 feet in length. The Administrator had no explanation as to how Resident 1 was able to allegedly travel, via wheelchair, the distance from the nurses' station to the lobby and to the front doors, trigger the Wanderguard® alarm, elope, and have an accident at the end of the ramp, without staff intervention. The facility's policy titled, "Elopement Risk Reduction Approaches," revised June 2017, was concurrently reviewed with the Administrator. The policy indicated to create activity zones with recreational opportunities, such as multi-sensory theme boxes that residents can explore with staff encouragement. Provide cueing to help residents to orient themselves (e.g., memory boxes, recognizable personal furnishings, large signs or pictures). Install non-intrusive alarm systems that alert staff to resident exiting. Post signs at exterior doors to alert visitors that residents with dementia may try to leave with them. The Administrator confirmed these approaches indicated by the policy were not implemented; the Administrator did not have an explanation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9RKR11 Facility ID: CA970000145 If continuation sheet 6 of 8 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 09/04/2019 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 On 10/22/18, at 12:01 p.m., the Director of Nursing (DON) was interviewed. The DON stated and confirmed there was no care plan for elopement risk prior to the incident. The DON stated a elopement risk care plan should have been developed, in accordance with the interdisciplinary team recommendations. The care plans must be developed and implemented with resident-specific interventions. The DON did not have an explanation for not having an elopement risk care plan. A review of Resident 1's Wander and Elopement Risk Assessment, dated 7/8/18, was concurrently reviewed with the DON. The DON stated and confirmed this wander and elopement risk indicated Resident 1 had a low risk for wandering and elopement. The DON confirmed the assessment was not updated to reflect Resident 1's high risk for wandering, requiring a Wanderguard®, but should have been updated. The DON had no explanation. The facility's policy titled, "Elopement Risk Reduction Approaches," revised June 2017, was concurrently reviewed with DON. The policy indicated accompany wandering residents on their journeys when supervision was required to ensure safety or encourage a meaningful, alternate activity. Help noncognitively impaired residents to understand wandering as a symptom of dementia. Develop a care plan and an update process to promote choice, mobility and safety. Base the care plan on assessments and family and caregiver involvement. The DON confirmed there was no documented evidence these approaches indicated by the policy were implemented. A review of the facility's policy titled, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9RKR11 Facility ID: CA970000145 If continuation sheet 7 of 8 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 09/04/2019 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 "Wandering and Elopement," revised 6/1/17, indicated the facility would identify residents at risk for elopement and minimize any possible injury as a result of elopement. The purpose was to enhance the safety of residents of the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9RKR11 Facility ID: CA970000145 If continuation sheet 8 of 8