Health inspection·June 14, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of five sampled resident's (Resident 1) Actual Fall care plan (CP, provides direction on the type of nursing care an individual needs that includes goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet a goal], and an evaluation plan) interventions were revised to reflect the current status of Resident 1 in accordance with the facility's policy and procedures (P&P). This failure had the potential to result with implementation of inadequate interventions for Resident 1 and a decline in Resident 1's physical well-being. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was originally admitted to the facility on [DATE] to Room A (Rm A). Resident 1 had multiple diagnoses including repeated falls, abnormalities of gait (a manner of walking or moving on foot), mobility, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), muscle weakness, and unsteadiness on feet. During a review of Resident 1's CP titled, Actual Fall, target date 12/5/22, the CP indicated the goal was to minimize risk of falls/injury and one of the interventions included, Place resident close to nursing station for close observation. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/9/23, the MDS indicated, Resident 1's cognitive (ability to think and process information) status was severely impaired. The MDS indicated, Resident 1 required one-person physical assistance for locomotion on unit (how resident moved between locations in his/her room and adjacent corridor on same floor). During an observation on 6/14/23, at 7:00 a.m., in the resident care area, Resident 1's room, (Rm A), was located on the west side at the end of hallway, adjacent to the activities and dining area, on the opposite end of the nursing station. During an interview on 6/14/23, at 7:15 a.m., with Licensed Vocational Nurse (LVN 3), LVN 3 stated, after every fall incident, care plans were updated and interventions that were in place were reviewed for effectiveness, reevaluated, and updated for new interventions if needed and any changes to be made. LVN 3 stated, it was important to revise care plans to prevent future falls and optimize care. (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: 056291 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 056291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Bonita Convalescent Hospital 535 E Bonita Avenue San Dimas, CA 91773 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)