Health inspection·March 12, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services to prevent a fall (unintentionally coming to rest on a lower-level surface) for two of three sampled residents (Residents 2 and 3) by failing to: 1. Ensure Certified Nurse Assistant (CNA) 5 kept Resident 2's bedside tray, water pitcher and cup within reach of Resident 2 while in bed. 2. Ensure LVN 1 and CNA 4 provided Resident 3 with adequate supervision while Resident 3 was in the restroom unassisted. 3. Ensure Residents 2 and 3 had a red star emblem placed on/and or located the head of bed, assistive devices such as wheelchairs, outside Residents 2 and 3's room on the name sign and a wrist band indicating Residents 2 and 3 were fall risks, based on the facility's policy and procedure (PP) titled. Fall Prevention Program. As a result of these failures, on 2/24/2024 at 2:05 pm, Resident 2 fell out of bed while reaching for the water pitcher, that was not within reach. Resident 2 suffered a head laceration (deep cut or tear to skin) to the occiput (back of head). Resident 2 had to be transferred to General Acute Care Hospital (GACH) 1 on 2/24/2024 and required two staples (used to close wounds that are too big or complex to close with traditional sutures) to close the laceration. Please include the GACH documentation in the findings below. Resident 3 suffered a head laceration to the right eyebrow. Resident 3 had to be transferred to GACH 1 on 3/10/2024 at 12:43 pm and required 4 sutures to close the laceration. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included muscle weakness (weakening of muscle caused by disuse of the muscles or other conditions), history of falling, and other abnormalities of gait and mobility (inability to walk normally due to injuries or underlying conditions). During a review of Resident 2's Nursing admission Assessment (NAA), dated 2/16/2024, the Nursing admission Assessment indicated Resident 2 required one-person assistance with bed mobility, transfers, and walking in the room. The Nursing admission Assessment indicated Resident 2 had a weak gait. The NAA indicated Resident 2 forgets limits or overestimated Resident 2's own ability to ambulate. The NAA indicated Resident 2 was at a high risk for falls and had a history of previous falls. Page 1 of 5 056228 056228 03/12/2024 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 2's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 2/21/2024, the MDS indicated Resident 2 had moderately impaired cognition. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half effort) with eating, oral hygiene, upper and lower body dressing, personal hygiene, sitting to lying, sitting to stand, and chair/bed-to-chair transfers. The MDS indicated Resident 2 was dependent (helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of 3 or more helpers is required for the resident to complete the activity) with toileting hygiene, showering/bathing self, and putting on/taking off footwear. During a review of Resident 2's Care Plan (CP), dated 2/21/2024, the CP indicated Resident 2 was at risk for injuries related to falls. The CP goal indicated Resident 2 would have a decrease in significant injury as a result of falls in the next three months. The CP interventions included to maintain call light within reach, and answer promptly, monitor, anticipate and intervene for factors causing prior falls such as bowel/bladder urgency and mobility problems such as standing, transferring, and walking. During a review of Resident 2's Situation-Background-Assessment-Recommendation (SBAR- a written communication tool that helps provide essential, concise information, usually during crucial situations), dated 2/24/2024 at 2:05 pm, the SBAR indicated Resident 2 had an incident of falling. The SBAR indicated Resident 2 had a small amount of blood to the occiput (the back of the head or skull) from a tear that was noted. During a review of Resident 2's PN, dated 2/25/2024 at 8:50 am, the PN indicated Resident 2 had a 1 centimeter (cm- unit of measurement) by 1.5 cm wound to the back of the head with two staples. During a review of Resident 2's Progress Notes (PN), dated 2/24/2024 at 6:07 pm, the PN indicated Resident 2 was transferred to GACH 1 for further evaluation. During a review of the GACH Emergency Department (ED) report, the ED report indicated Resident 2 was brought in from the nursing home for S/P fall at 2 p.m., with a laceration to the back of the head. The GACH CT Scan of the Head report dated 2/24/2024, indicated Resident 2 had a small right occipital laceration with overlying cutaneous staples with no intracranial hemorrhage, midline shift or mass effect. During a review of Resident 2's Post Fall Assessment (PFA), dated 2/26/2024 at 3:30 pm, the PFA indicated Resident 2 was found on Resident 2's back with the head towards the foot of the bed. The PFA indicated 2 had been by Resident 2's self at the time of the fall. The PFA indicated Resident 2 had attempted to reach for the water pitcher and cup on the other side of the bed when Resident 2 lost Resident 2's balance and fell. During a review of the IDT Post Event Review, dated 2/26/24, the review indicated Resident 2 was found on the floor lying down in a supine position (back) near the floor mat with the head positioned toward the foot part of the bed. The IDT Post Event review further noted, Resident 2 stood up unassisted while trying to reach Resident 2's water and lost balance. During a concurrent observation and interview on 3/11/2024 at 1:05 pm, with CNA 3, inside of Resident 2's room, CNA 3 stated Resident 2's water pitcher was not on the bedside tray. CNA 3 stated Resident 2's water pitcher and cup were on Resident 2's bedside table, on the back left corner, where the 056228 Page 2 of 5 056228 03/12/2024 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some left side of the head of the bed was. CNA 3 stated Resident 2 could not reach the water pitcher and cup while it was on the bedside table. CNA 3 stated Resident 2's bedside tray was pushed away from the bed to the left wall, parallel with the bed. CNA 3 stated Resident 2's bedside tray was not within reach of Resident 2. CNA 3 stated Resident 2's water pitcher and cup needed to be on the bedside tray, and the bedside tray needed to be next to the bed, so Resident 2 could reach both the water pitcher and cup. CNA 3 stated keeping the bedside tray, water pitcher and cup within reaching distance of Resident 2, kept Resident 2 safe from falls. During an interview on 3/11/2024 at 3:20 pm, with CNA 5, CNA 5 stated Resident 2 was considered a high fall-risk resident. CNA 5 stated on 2/24/2024 at approximately 2 pm, CNA 5 checked on Resident 2 and observed Resident 2 sleeping. CNA 5 stated when CNA 5 checked on Resident 2, Resident 2's bedside tray was on the right side of the bed, not within reach of Resident 2. CNA 5 stated CNA 5 did not move the bedside tray closer to Resident 2 when CNA 5 checked on Resident 2. During an interview on 3/11/2024 at 3:31 pm, with LVN 2, LVN 2 stated LVN 2 was the person who found Resident 2 after Resident 2 fell. LVN 2 stated Resident 2 was bleeding from Resident 2's occiput (the back of the head or skull). LVN 2 stated keeping the bedside tray within reach would be considered an intervention used to prevent Resident 2 from falling. LVN 2 stated if Resident 2's bedside tray, water pitcher, and cup had been within reach, Resident 2's fall could have been avoided. 2. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE], with diagnoses that included dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities) generalized muscle weakness, and difficulty walking. During a review of Resident 3's CP initiated 4/21/2023, the CP indicated Resident 3 was at risk for injuries related to falls. The CP goals indicated Resident 3 would have a significant decrease in injury as a result from falls. The CP interventions included to maintain call light within reach, and answer promptly, monitor, anticipate/intervene for factors causing prior falls such as bowel/bladder urgency and mobility problems such as standing, transferring, and walking, and to place Resident 2 in a highly monitored area. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had severely impaired cognition. The MDS indicated Resident 3 required setup or clean-up assistance (helper sets up or cleans up while the resident completes the activity and helper assists only prior to or following the activity) with eating, oral hygiene, and upper body dressing. The MDS indicated Resident 3 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity and may be provided throughout the activity or intermittently) with lower body dressing, putting on/taking off footwear, and lying to sitting on the side of the bed. The MDS indicated Resident 3 required partial/moderate assistance (helper does less than half the effort and lifts or holds trunk or limbs but provides less than half the effort) with showering/bathing self, sitting to standing, and chair/bed-to-chair transfers. The MDS indicated Resident 3 required substantial/maximal assistance with personal hygiene. The MDS indicated Resident 3 was dependent with toileting hygiene. During a review of Resident 3's SBAR dated 3/10/2024 at 10 am, the SBAR indicated Resident 3 had a fall. The SBAR indicated Resident 3 had a laceration to the right side of eyebrow with minimal bleeding. 056228 Page 3 of 5 056228 03/12/2024 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0689 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 3's PFA dated 3/10/2023 at 12:31 pm, the PFA indicated Resident 3 was found on the bathroom floor between the left side of toilet (if sitting on the toilet) and bathroom wall. The PFA indicated Resident 3 was in a semi-seated position with both legs extended and head up, with right side of body lying toward the toilet bowl due to Resident 3 having right-sided weakness. The PFA indicated no one was present at the time Resident 3 fell. Residents Affected - Some During a review of Resident 3's GACH 1 General ED Report dated 3/10/2024 at 12:34 pm, the reported indicated Resident 3 had a 2.5 cm laceration to the right eyebrow after falling into the toilet bowl. The report indicated Resident 3 received 4 sutures to repair and close the laceration. During an interview on 3/11/2024 at 2:45 pm, with LVN 1, LVN 1 stated keeping Resident 3 in a highly monitored area meant to keep Resident 3 in activities or by the nursing station, being monitored by staff at all times. LVN 1 stated it was important to be aware of Resident 3's needs to avoid Resident 3 from getting hurt. LVN 1 stated on the morning of 3/10/2024, CNA 4 informed LVN 1 around 9:00 am that Resident 3 was taken to the activity room. LVN 1 stated the activity room did not open until 9:30 am or 10 am everyday. LVN 1 stated on the morning of 3/10/2024 was busy with other residents and did not see Resident 3 go back to the room. LVN 1 stated based off Resident 3's care plan, someone should have assisted Resident 3 back to the room and to the restroom. LVN 1 stated Resident 3's fall and injury could have been avoided had Resident 3 been appropriately monitored. During an interview on 3/11/2024 at 2:37 pm, with CNA 4, CNA 4 stated CNA 4 took Resident 3 to the activity room at approximately 9:20 am. CNA 4 stated the activity room usually opened between 9:30 am and 10 am. CNA 4 stated if the activity room is not open, the front desk receptionist will monitor Resident 3. CNA 4 stated CNA 4 did not see Resident 3 go back to the room. CNA 4 stated CNA 4 could not keep track of Resident 3 at all times. CNA 4 stated Resident 3 needed to stay in a highly monitored area. During an interview on 3/11/2024 at 3:02 pm, with Activities Assistant (AA) 1, AA 1 stated on 3/10/2024, the activity room opened at 9:30 am. AA 1 stated Resident 3 did not go to the activity room that day. During an interview on 3/11/2024 at 3:20 pm, with Receptionist (R) 1, R 1 stated (in general) receptionists did not have to communicate with nurses or CNA when a resident left the front lobby area to back to their room. 3. During a concurrent observation and interview on 3/12/2024 at 1:30 pm, with LVN 3, in Resident 2's room, Resident 2's room was observed. LVN 3 stated Resident 2 was part of the falling star program. LVN 3 stated the falling star program was used for residents who were considered high fall-risks. LVN 3 stated there was supposed to be a yellow star on Resident 2's name sign at the door. LVN 3 stated there was not a star next to Resident 2's name on the room sign. LVN 3 stated there was no star placed on the head or foot of Resident 2's bed. LVN 3 stated there was not a star placed on Resident 2's wheelchair. During a concurrent observation and interview on 3/12/2024 at 1:35 pm, with LVN 3, in Resident 3's room, Resident 3's room was observed. LVN 3 stated there was not a star next to Resident 3's name sign at the door. LVN 3 stated there was no star placed on the foot of Resident 3's bed. LVN 3 stated there was a star on the head of Resident 3's bed, however the star was yellow. LVN 3 stated the yellow star indicated Resident 3 was a fall risk. LVN 3 stated Resident 3 was not wearing a yellow wrist band to indicate Resident 3 was a fall risk. LVN 3 stated there was not a star placed on Resident 056228 Page 4 of 5 056228 03/12/2024 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3's wheelchair. LVN 3 stated if a resident did not have the appropriate signage or was not wearing a wrist band, it was possible staff would not otherwise know Residents 2 or 3 were high fall risks, and Residents 2 and 3 could fall and get hurt. During a interview on 3/12/2024 at 12:55 pm, with the Director of Nursing (DON), the DON stated when a resident was identified as a high fall-risk, staff should implement interventions such as the use of floor mats to help avoid injuries, keeping the bed in the lowest position, keeping residents close to the nursing station when possible, and encourage residents to attend daily activities to help keep their attention diverted and so staff could keep an eye on the resident. The DON stated those interventions were supposed to prevent the possibility of falls and/or subsequent injuries. The DON stated water pitchers should be within reach of a resident. The DON stated it a water was not within reach of a resident and the resident reaches for the water pitcher; it was possible the resident could call. The DON stated it was possible Resident 2's fall and injury could have been avoided had staff kept the bedside tray and water pitcher within reach of Resident 2. The DON stated if staff had communicated with one another that Resident 3 was leaving the front lobby and going back towards Resident 3's room, Resident 3 could have gotten assistance to the bathroom and the fall and injury could have been avoided. During a concurrent interview and record review on 3/12/2024 at 1:45 pm, with the Administrator (ADM), the facility's PP titled, Fall Prevention Program, was reviewed. The ADM stated the PP indicated to use a red falling star emblem on a resident ' s head of bed, assistive devices such as wheelchairs, outside the resident ' s room on the name sign, and that a resident would wear a wrist band. The ADM stated the facility had never used red stars before. The ADM stated the facility only used yellow stars to indicate a resident was a high fall risk. The ADM stated using a yellow star to indicate a resident was a fall risk when the PP indicated to use red, could be confusing to staff, and could leave to residents being at risk for falls. During a review of the facility's PP titled, Fall Prevention Program, dated 12/2026, the PP indicated the facility would identify interventions related to the resident's specific risks and causes to try and prevent the resident form falling and try to minimize complications from falling. The PP indicated care plan interventions should include the treatment prescribed by the physician and interdisciplinary recommendations. The PP indicated the care plan should include close observation and increased supervision, staff assistance to the toilet or bedside commode, and use of monitoring or sensor devices. The PP indicated to implement the use of a red star for residents who were considered high fall-risks. The PP indicated a falling star emblem be placed and/or located at the head of bed, assistive devices like wheelchairs, outside the resident ' s room on the name sign, and the use of a wrist band. 056228 Page 5 of 5