Other·October 25, 2017

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 an Entity- Reported Incident (ERI). Entity-reported incident: 543261 Representing the Department: Surveyor ID #: 37989 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 number 543261.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 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: MPHQ11 Facility ID: CA970000147 If continuation sheet 1 of 6 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: _______________ 056242 (X3) DATE SURVEY COMPLETED 09/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTLAKE CONVALESCENT HOSPITAL 316 S Westlake Ave 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 (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to identify and evaluate accident risks and hazards, and did not implement and monitor / modify interventions when necessary for one of three sampled residents (Resident 1). For Resident 1, who had history of fall, major depressive disorder, and verbalized he was sad, the facility failed to closely observe Resident 1 for worsening of depression / suicidal thinking, and failed to monitor the resident with routine checks and document the outcome, per facility policy. This deficient practice caused Resident 1 to attempt suicide, falling down 12 flights of stairs, which resulted in a concussion (brain injury that is caused by a sudden blow to the head), a skull fracture, and a cervical spine fracture (broken neck). Approximately two weeks later, Resident 1 required spine surgery (which connects the skull to the neck). Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MPHQ11 Facility ID: CA970000147 If continuation sheet 2 of 6 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: _______________ 056242 (X3) DATE SURVEY COMPLETED 09/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTLAKE CONVALESCENT HOSPITAL 316 S Westlake Ave Los Angeles, CA 90057 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility, on 1/7/17, with diagnoses including major depressive disorder (characterized by a persistent low mood that is accompanied by loss of interest or pleasure in normally enjoyable activities), and epilepsy (a brain disorder that causes people to have seizures [uncontrolled shaking movement]). A review of the Medication Administration Record (MAR) dated 1/8/17, indicated Resident 1 received Phenobarbital 97.2 mg, via gastrostomy tube (Gtube) once per day for epilepsy. The Nurse's Drug Guide 2017, indicated Phenobarbital was classified as a sedative - hypnotic, with adverse effects of anxiety, thinking abnormalities, dizziness, confusion and depression. A review of the care plan, dated 1/10/17, indicated Resident 1 had a history of fall and the interventions indicated to monitor Resident 1 for sedation, dizziness, monitor resident location with visual checks every two hours and as needed. According to the Minimum Data Set (MDS - an assessment and care plan screening tool), dated 4/19/17, Resident 1 had moderate cognitive impairment, and had the ability to usually understand and be understood by others. The MDS, under section G0110, Functional Status (activities of daily living selfperformance), indicated Resident 1 required assistance with a one person physical assist for bed mobility, transferring, and locomotion on unit. The MDS, under section G0600 for mobility devices, indicated Resident 1 used a wheelchair aid in ambulation. Further review of the MDS indicated depression was not documented as an active diagnoses for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MPHQ11 Facility ID: CA970000147 If continuation sheet 3 of 6 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: _______________ 056242 (X3) DATE SURVEY COMPLETED 09/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTLAKE CONVALESCENT HOSPITAL 316 S Westlake Ave Los Angeles, CA 90057 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1. A review of the progress notes, dated 7/3/17, indicated Resident 1 verbalized he was sad and depressed. A review of the care plan, dated 7/3/17, indicated Resident 1 had episodes of depression manifested by anti-depressant medication. The care plan interventions included to encourage verbalization of feelings and concerns, monitor Resident 1's activity, behavior, spend time with resident on a one to one basis, and social service department to do room visit regularly and check needs and concerns. A review of the MAR, dated 7/3. 7/4, 7/7 and 7/8/17, indicated Resident 1 had episodes of isolation. A review of the MAR dated 7/4/17 indicated Resident 1 received Lexapro (antidepressant) 10 mg daily for self isolation related to major depressive disorder. The Nurse's Drug Guide 2017, indicated Lexapro had a black box warning, was associated with suicidal thinking, and to closely observe for worsening of depression or suicidality. However this was not included in Resident 1's care plan. According to the July 2017 MAR there was no documentation of monitoring Resident 1 for adverse reactions to the Phenobarbital or the Lexapro. A review of the round the clock monitoring form, dated 7/8/17, indicated the time and the initials of the person monitoring Resident 1, however the outcomes of the monitoring were not documented, per facility policy. The facility's undated policy and procedure titled, "Routine Resident Checks," indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MPHQ11 Facility ID: CA970000147 If continuation sheet 4 of 6 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: _______________ 056242 (X3) DATE SURVEY COMPLETED 09/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTLAKE CONVALESCENT HOSPITAL 316 S Westlake Ave 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 staff shall make routine resident checks to help maintain resident safety and well-being. The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident's condition and medical needs. The charge nurse shall keep documentation related to the routine checks, including the time, identity of the person making checks, and any outcomes of each checks. A review of the summary of incident form, documented by the Administrator, dated 7/8/17, indicated the facility had an outside patio which had a door going down to ground level, and the door had a latch and alarmed when it was opened. The summary of incident indicated Resident 1 was found outside, beside the kitchen, lying on his left side with the wheelchair beside the resident. Resident 1 was noted with a laceration on top of the scalp, 911 was called, and Resident 1 was transferred to the general acute care hospital (GACH) for further evaluation and treatment. A review of the GACH 1 transcription report, dated 7/9/17, indicated Resident 1 was a 45 year old male, who stated he wanted to kill himself and threw himself down 12 flights of stairs. The final diagnoses of the report indicated Resident 1 had a suicidal attempt with polytrauma (occurs when a person experiences injuries to multiple body parts) and a concussion (brain injury that is caused by a sudden blow to the head). Resident 1 had a skull fracture, C2 / C3 spine fractures, and a cervical spine fracture (broken neck). The report indicated Resident 1 was transferred to GACH 2 due to need of specialized care. During an observation, on 7/20/17, at 8 a.m., while conducting a facility tour with Registered Nurse 1 (RN 1), the gate on the facility's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MPHQ11 Facility ID: CA970000147 If continuation sheet 5 of 6 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: _______________ 056242 (X3) DATE SURVEY COMPLETED 09/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTLAKE CONVALESCENT HOSPITAL 316 S Westlake Ave 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 second floor patio which led to the first floor, had 15 steps of stairs, and was observed unlocked and not secured with an alarm. During a concurrent interview, RN 1 stated the second floor patio gate remained unlocked due to fire hazard, and an alarm was attached to the gate in order to alert the facility's staff when someone was attempting to open the gate. During an interview with the Assistant Director of Nursing (ADON), on 7/20/17, at 11:45 a.m., she stated when they found Resident 1 downstairs, they did not hear the alarm system turn on. ADON stated no one was with Resident 1 during the time he fell, and no one witnessed the incident. Furthermore, ADON stated the resident reported to her that he fell off from the second floor patio. On 7/20/17, at 12:15 p.m., during an interview, Certified Nursing Assistant 2 (CNA 2), stated she saw Resident 1 roaming around the facility in his wheelchair around 11:45 a.m., on the date of the incident (7/8/17). CNA 2 stated when she heard Resident 1 had fallen and was found on the first floor, she did not hear the patio gate alarm noise turn on at any time inside the facility. During an interview, on 7/20/17, at 1:20 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 had expressed feelings of being sad and depressed to him, and he reported it to the Psychiatrist immediately. LVN 1 stated they should have closely monitored Resident 1 to prevent accidents or falls. A review of the surgical progress note from GACH 2 indicated Resident 1 had an occiput (the back of the head or skull) to C5 fusion surgery (a spine surgery which connects the skull to the neck) on 7/20/17. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MPHQ11 Facility ID: CA970000147 If continuation sheet 6 of 6