Other·December 5, 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 a Complaint and Entity Reported Incident. Complaint Number: CA00653654 Entity Reported Incident:CA00653368 Representing the Department of Public Health: Health Facilities Evaluator Nurse: 36395 The inspection was limited to the specific complaint and Entity Reported Incident investigated and does not represent the findings of a full inspection of the facility. A deficiency was issued for complaint number CA00653654 and Entity Reported Incident:CA00653368.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 01/10/2020 §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 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: 0MSK11 Facility ID: CA970000147 If continuation sheet 1 of 7 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 11/08/2019 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 review, the facility failed to identify and evaluate accident risks and hazards, and did not implement and monitor interventions when necessary for one of three sampled residents (Resident 1). For Resident 1, who was assessed as a high fall risk, the facility failed to develop a plan of care with interventions to address the resident's identified risk for falls and failed to ensure Resident 1 received two or more person physical assist when turning. These deficient practices resulted in Resident 1 suffering a fall with injuries and having to be taken to the general acute hospital (GACH) where he was found to have a massive brain bleed and pronounced brain dead the day following day. Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on 5/20/19 with diagnoses that included, but were not limited to, ventilator (a machine that delivers breaths to patients who are physically unable to breathe) dependency, gastrostomy tube (feeding tube placed through the abdomen into the stomach), nephrostomy (drainage tube placed into the kidney to drain urine directly from the kidney), and indwelling catheter (a sterile tube inserted in the bladder to drain urine). A review of the Minimum Data Set (MDS, an assessment and care screening tool) dated 5/30/19 indicated Resident 1 was totally dependent on staff for day-to-day, basic selfcare tasks (i.e., activities of daily living-ADLs). The MDS indicated Resident 1 required two or more people to physically assist him with bed mobility, transfers, and bathing. The MDS also indicated Resident 1 had severely impaired daily decision-making skills. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0MSK11 Facility ID: CA970000147 If continuation sheet 2 of 7 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 11/08/2019 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 Order Summary Report dated 9/12/19 indicated Resident 1 was prescribed enoxaparin (an anticoagulant that is used to prevent blood clots) 40 milligrams (mg) subcutaneously (medication administered under the skin) daily. A review of the Care Plan dated 8/31/19 indicated Resident 1 was at risk for bleeding due to the use of enoxaparin. Care plan interventions included to handle Resident 1 gently and carefully during care. A review of Resident 1's fall care plan initiated on 9/1/19 indicated Resident 1 was a high fall risk due to cognitive impairment and poor trunk control, and required total assistance with ADLs related to the use of medical tubings. The care plan goal indicated Resident 1 would have no fall or injury daily for three months and the interventions included to assist with all transfers. The care plan intervention did not indicate Resident 1 required two person assistance during transfers, bed mobility, and bathing. A review of the Progress Notes dated 9/4/19 at 11:33 a.m. indicated the Certified Nursing Assistant 1 (CNA 1), while providing nursing care, turned Resident 1 to his left side to remove the dirty linen from underneath him. Upon turning the resident, the note indicated Resident 1 exhibited jerking movement that caused the resident's legs to slide off the bed and resulted in the resident's fall to the ground. A review of the Change of Condition (COC) form dated 9/4/19 at 11:50 a.m. indicated Resident 1 was found on the floor beside his bed, lying on his side, and facing the window. The COC also indicated Resident 1 was wearing a cranial helmet, and his nephrostomy FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0MSK11 Facility ID: CA970000147 If continuation sheet 3 of 7 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 11/08/2019 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 tube had become dislodged. The COC indicated there was no bleeding at the site and a dry dressing was applied. The COC also indicated licensed nurses completed a body assessment and revealed Resident 1 was awake with no seizure activity. The COC indicated there were no bruises or open wounds, and Resident 1 had no facial grimacing. The COC indicated licensed nurses conducted a neurological exam (assessment of the sensory and motor responses), which revealed Resident 1's pupils (opening in the center of the iris [structure that gives eyes color]) were equal, round, and reactive to light. The COC indicated Resident 1's physician was notified and an order was received to transfer Resident 1 via paramedics to the nearest hospital. A review of the General Acute Care Hospital (GACH 1) neurosurgery consult dated 9/4/19 at 5:21 p.m. indicated Resident 1 had a computerized tomography (CT) scan of the head (a special x-ray machine that takes pictures of the brain, skull, sinuses and blood vessels) which demonstrated a massive intraventricular hemorrhage (bleeding inside the spaces of the brain) and hydrocephalus (abnormal accumulation of cerebrospinal fluid [CSF-a clear colorless body fluid found in the brain and spinal cord]). Resident 1 had pupils that were non-reactive and had no motor response to pain. An emergent ventriculostomy (catheter placed into the ventricles [fluid filled empty space] of the brain to drain the CSF) was indicated to relieve the hydrocephalus. A review of Resident 1's previous computed tomography of the brain from a GACH (GACH 2) dated 7/15/19 indicated there was no previous intracranial hemorrhage at the time of the scan. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0MSK11 Facility ID: CA970000147 If continuation sheet 4 of 7 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 11/08/2019 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 Anesthesia Record dated 9/4/19 at 5:01 p.m. indicated Resident 1 underwent a ventriculostomy (a neurosurgical procedure that involves creating a hole [stoma] within a cerebral ventricle for drainage. It is done by surgically penetrating the skull, dura mater, and brain such that the ventricle of the brain is accessed). A review of the Pulmonary Consultation dated 9/5/19 at 9:22 a.m. indicated Resident 1 had a massive brain injury, and his pupils were fixed, dilated, and unresponsive. The consultation also indicated Resident 1's overall prognosis was poor. A review of the Progress Record dated 9/6/19 indicated Resident 1 was declared brain dead by two physicians on 9/5/19 and Resident 1's family was notified. A review of GACH 1's discharge summary dated 9/18/19 indicated Resident 1 was placed on comfort care. GACH 1's discharge summary indicated Resident 1 was pronounced dead on 9/10/19. During an observation and concurrent interview on 9/12/19 at 12:28 p.m. in the presence of an interpreter (CNA 2), CNA 1 stated on 9/4/19, at about 11:30 a.m., Resident 1 had a bowel movement and needed to be cleaned. CNA 1 stated she raised Resident 1's bed about 2.5 feet from the floor. CNA 1 stated she started cleaning Resident 1's left side. After cleaning the left side, CNA 1 stated, she moved to the right side of Resident 1's bed. CNA 1 started cleaning Resident 1's right side and turned Resident 1 to the left side to remove the dirty linen. At that point, CNA 1 stated Resident 1's body "jerked" and fell off the bed. CNA 1 stated she tried to stop the fall, but Resident 1 had still fallen onto the floor. CNA 1 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0MSK11 Facility ID: CA970000147 If continuation sheet 5 of 7 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 11/08/2019 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 was lying on his side, facing the window. CNA 1 stated she screamed for help. During a telephone interview on 9/12/19 at 1:05 p.m., registered nurse supervisor 1 (RNS 1) stated he was called to Resident 1's room when Resident 1 fell from the bed. RNS 1 stated he assessed Resident 1, who was wearing a cranial helmet. RNS 1 stated the ventilator tubing had disconnected during the fall but was immediately reconnected to the ventilator by the respiratory therapist. RNS 1 stated Resident 1 had no obvious injuries. RNS 1 stated Resident 1's physician was notified and an order to transfer Resident 1 via paramedics to the nearest hospital was given. During an interview with the licensed vocational nurse 1 (LVN 1) on 9/12/19, at 1:14 p.m., LVN 1 stated Resident 1 fell on 9/4/19, at about 11:33 a.m. LVN 1 stated when cleaning Resident 1, there should always be two people assisting. LVN 1 stated CNA 1 should have called for help to clean Resident 1. LVN 1 stated CNA 1 could have called another staff member to help clean Resident 1. During an interview with CNA 1 on 9/12/19 at 2:20 p.m., CNA 1 stated she did not ask for help to clean Resident 1 because everybody was busy. CNA 1 stated Resident 1 had a bowel movement and she "had to clean him." During an interview with the MDS nurse on 9/12/19 at 3:13 p.m., the MDS nurse stated Resident 1 was totally dependent with ADLs and required two person physical assistance with bathing, bed mobility, and transfers. The MDS nurse stated Resident 1's two-person assistance during care should have been followed. During a telephone interview with the Director FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0MSK11 Facility ID: CA970000147 If continuation sheet 6 of 7 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 11/08/2019 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 of Nursing (DON) on 9/13/19 at 3:33 p.m., the DON stated Resident 1's fall could have been prevented if CNA 1 had another staff to assist her while providing peri-care to Resident 1. A review of the undated facility policy titled "Safety and Supervision of Residents" indicated staff should use various sources to identify risk factors for residents, including the information obtained from the medical history, physical examination, observation of the resident, and the MDS. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0MSK11 Facility ID: CA970000147 If continuation sheet 7 of 7