Health inspection·February 5, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 2/2/2024 at 9:26 AM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated, Resident 1 was confused and non-compliant (not following the rules). She would ask where she was, and I would tell her that she was inside a facility. When I would try to change her, she would scream and not let me change her. CNA 1 stated Resident 1 was not able to walk. CNA 1 stated, I provided frequent visual monitoring to Resident 1 and I reported to my charge nurse. I did not document my visual observations in the resident's medical chart. During a concurrent interview and record review on 2/2/2024 at 2:40 PM, with the facility ' s Assistant Director of Nursing (ADON) Resident 1's care plans were reviewed. The ADON stated Resident 1 was non-compliant with her care, had previous history of fall and episodes of hallucination (a sight, sound, smell, taste, or touch that a person believes to be real but is not real ) and she refused to be transferred to hospital for evaluation after she fell on 1/19/2024. The ADON stated Resident 1 was trying to get out of bed. She was on psychotropic medication which could affect her decision making. The ADON stated he initiated a person-centered care plan for Resident 1's high risk for fall on 1/18/2024. The ADON stated one of the care plan interventions was to visibly observe the resident frequently. The ADON stated, Frequently means that the CNA assigned to the resident is required to watch the resident frequently, every hour. Staff were providing the frequent monitoring for Resident 1 but there is no specific chart regarding their hourly monitoring inside Resident 1's chart. Licensed nurses document resident's frequent visual monitoring in the nursing note section. During a concurrent interview and record review on 2/2/2024 at 1:20 PM, with Licensed Vocational Nurse 2 (LVN 2), Resident 1's fall care plan and nursing notes were reviewed. LVN 2 stated one of the care plan interventions for Resident 1 was to visibly observe the resident frequently. LVN 2 stated, This means we go to the resident's room at least every hour or every two hours to check on the resident. LVN 2 stated, We do not document the exact time and frequency that we perform this monitoring. We just document in the nursing notes that we perform the frequent visual checks. LVN2 stated there was no nursing progress note in Resident 1's medical records for 1/18/2024, during the 7AM-3PM shift. LVN 2 stated documenting frequent visual check in the nursing note without frequency and time was not an effective way to implement Resident 1's care plan intervention. LVN 2 stated the potential outcome was recurrent falls. During a telephone interview on 2/5/2024 at 8:05 AM with LVN 1 who was assigned to Resident 1 on 1/18/2024, during the 11PM-7AM shift, LVN 1 stated Resident 1 was confused and unable to walk. LVN 1 stated, On 1/19/2024, at around 3 AM, I made my rounds, and I went to Resident 1's room. Resident 1 thought there was someone outside the facility, so I went to the window, and I checked. I showed her that no one was there, and I even opened the curtains for her to look outside. I got her situated and I walked out. Within a minute or two of going to the nurse ' s station, I heard noises coming from Resident 1's room. When I got to Resident 1's room, she was on the floor. LVN 1 stated that Resident 1 stated she got up to use the restroom. LVN 1 stated, Resident 1 was a new admission; we did not know her behavior. We were monitoring her frequently. I was monitoring her pretty much every hour. I did not document each time that I checked in on Resident 1 in her chart. A review of the facility's policy and procedure titled, Care Plans-Comprehensive Person-Centered, revised March 2022, indicated a person-centered care plan includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident ' s problem areas and their causes, and relevant clinical decision making. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055538 If continuation sheet Page 2 of 3 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 055538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonnie Brae Skilled Nursing 420 South Bonnie Brae St. Los Angeles, CA 90057 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Fall Risk Assessment, revised 12/2022, indicated the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered fall prevention plan based on relevant assessment information. The staff will seek to identify environmental factors that may contribute to falling such as lighting and room layout. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055538 If continuation sheet Page 3 of 3