Health inspection·November 20, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of five sampled residents (Resident 3). Residents Affected - Few * The facility failed to monitor Resident 3's wound separation for the forehead area and skin breakdown for the left and right arm area every shift as ordered. * The facility failed to notify the physician of the changes in Resident 3's wound separation for the forehead area and skin breakdown for the left and right arm area as documented on the TAR. These failures had the potential to negatively impact Resident 3's well-being. Findings: Review of the facility's P&P titled Skin Assessment revised 12/19/22,showed a full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition. Medical record review for Resident 3 was initiated on 11/14/24. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's SBAR Communication Form showed Resident 3 had an unwitnessed fall on 10/28/24. The form further showed Resident 3 sustained a small laceration (a cut or tear in the skin) to the forehead related to the fall. a. Review of Resident 3's Order Summary Report showed a physician's order dated 11/1/24, to monitor the following area every shift: - for the forehead area laceration with bond/glue, to monitor the wound separation. - for the left arm area, to monitor for further skin breakdown; and - for the right arm area, to monitor for further skin breakdown. Review of Resident 3's TAR for November 2024 showed the 3-11 shift assessments for the following areas and dates were left blank: - for the forehead area on 11/4, 11/5, 11/10, 11/11, 11/12, and 11/13/24. (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: 055622 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 055622 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonita Hills Post Acute 1233 West LA Habra Boulevard LA Habra, CA 90631 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)