Health inspection·February 14, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the repositioning (turning) schedule for one of two sampled residents (Resident 1). Residents Affected - Few This failure had the potential for Resident 1 to be at risk for worsening skin condition and/or pressure injury (damage to an area of the skin caused by constant pressure on the area for a long time). Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on [DATE] with diagnoses of acute respiratory failure (a condition in which the lungs were not able to release enough oxygen into the blood), dependence on ventilator (a machine to support or replace the breathing of a person who was ill or injured), type 2 diabetes mellitus (characterized by high levels of blood sugar in the blood) with foot ulcer (an open sore or wound), and pressure induced deep tissue damage (area of intact skin that looks purple or dark red due to damage to tissues under the skin) of right and left elbow, sacral region (area below the spine and above the tailbone), and right hip. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/10/2023, the MDS indicated, Resident 1 had severely impaired (weakened) cognition (the act of knowing and understanding). The MDS indicated, Resident 1 was dependent (helper did all of the effort and the resident did none of the effort to complete the activity, or the assistance of two or more helpers was required for the resident to complete the activity) on staff for Resident 1 to roll left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). The MDS indicated, Resident 1 was at risk of developing pressure ulcers or injuries. During a review of Resident 1's Care Plan (CP), initiated and revised on 2/9/2024, the CP indicated, Resident 1 was at risk for developing pressure ulcer and other types of skin breakdown. The CP indicated, for the staff to turn and position Resident 1 as needed when in bed or wheelchair. During a review of Resident 1's Order Summary Report (OSR) dated 2/14/2024, the OSR indicated, a physician's order dated 1/30/2024, for treatment on the sacrum (area below the spine and above the tailbone) every day for 30 days for ulceration of skin for skin maintenance. During a review of Resident 1's OSR dated 2/14/2024, the OSR indicated, a physician's order dated 1/31/2024, for treatment on the right dorsal (relating to the back) foot every day for 30 days for (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 02/14/2024 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)