Health inspection·June 22, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to document an assessment (monitor for medical changes) for one of three residents (Resident 3) after a fall. This failure had the potential for Resident 3's overall medical condition to decline and go undetected by the facility. Findings: An abbreviated survey was conducted on May 24, 2023, at 5:47 AM to investigate a complaint regarding Quality of Care. During review of Residents 3's Face sheet (general demographics), the document indicated Resident 3 was admitted to the facility on [DATE], with diagnoses to include: diabetes (body doesn't produce enough insulin) and heart failure (heart doesn't pump enough blood for your body,) During a review of the clinical record for Resident 3, the SBAR (Communication Form for changes in conditions) dated May 22, 2023, at 9:50 PM, indicated The change in condition . Resident 3 had an unwitnessed fall. Resident fell inside the room when transferring himself from one wheelchair to another wheelchair. He complained that he hit his head and complained of right hip pain. Doctor notified. Resident refused to go to the doctor. During an interview and concurrent record review of Resident 3's clinical records with Registered Nurse (RN 1), on May 24, 2023, at 6:43 AM, RN 1 stated, I didn't know resident 3 had a fall. I didn't know he fell. We are supposed to be doing neuro checks when there is an unwitnessed fall. Honestly, I don't know how we were documenting on him after a fall. There is no neuro check sheet. The documentation we do, if unwitnessed, we do neuro checks. I have not made any notes regarding Resident 3's fall. During a review of the clinical records for Resident 3 with the Director of Nursing on May 24, 2023, at 2:22 PM, the DON stated The RN didn't know resident 3 was status post fall. He should have known, and he should have been doing neuro checks for the safety of the resident and per policy. The facility could not provide documentation that RN 1 completed neuro checks and or monitoring for medical changes after Resident 3's fall. The facility policy and procedure titled Change in Residents Condition or Status dated May 2017, (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: 056136 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 056136 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Mesa Care Center 867 E. 11th St Upland, CA 91786 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)