Health inspection·April 25, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy and procedure on Resident lifting/Assisting Transfer Policy, regarding resident lifting for dependent residents (Resident 1). Residents Affected - Few Certified Nurse Assistant (CNA) 1 and CNA 2 did not use the mechanical lift transfer to Resident 1, who was totally dependent with transfers, held Resident 1 ' s arm pits to stand up from the wheelchair. This deficient practice had result in Resident 1 ' s left shoulder fracture and hospitalization. Findings: A review of the admission Record indicated Resident 1 was originally admitted on [DATE], with diagnoses that included but not limited to sclerosis (an abnormal hardening of a tissue or body part (as arteries or muscles) that occurred in several serious diseases), hemiplegia (paralysis that affected only one side of body) on left and right side, osteoporosis, left hand contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that caused the joints to shorten and become very stiff). A review of the Resident 1 ' s History and Physical (H&P), dated 3/24/24, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 3/21/24, indicated the resident had impairment on both sides of upper and lower extremities. The MDS indicated Resident 1 was dependent (helper did all of the effort. Resident did none of the effort to complete the activity) on staff with transfers, sit to stand, dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 1 ' s care plan, revised on 4/2/24, indicated the resident was at risk for spontaneous/pathological/stress fracture related to: osteoporosis, with intervention to handle gently and carefully during care. A review of Resident 1 ' s Radiology Results Report, dated 4/10/24, indicated probable acute left humeral (upper arm bone) neck fracture (a break or a crack in a bone). A review of the Resident 1 ' s Physician orders dated 4/10/24, indicated Transfer pt [patient] to [acute hospital] for further eval [evaluation] of left shoulder, discomfort pain and swelling. (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055181 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055181 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Conv Center 8035 E Hill Drive Rosemead, CA 91770 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)