Health inspection·September 10, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care and services to prevent a fall (unintentionally coming to rest on the ground, or lower level) for one of three sampled residents (Resident 1) as indicated in the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, by failing to:1. Implement a resident-centered fall prevention plan of care for Resident 1.2. Monitor Resident 1's response to fall prevention interventions. 3. Assess the causative factors of Resident 1's multiple falls per Resident 1's Care Plan (CP, a form where one can summarize a person's health conditions, specific care needs, and current treatments).As a result, on 9/3/2025 at 9:45 AM, Resident 1 fell onto the floor mat on the right side of the bed. Resident 1 sustained a fracture (a break or crack in a bone) in the subtrochanteric left femur extending into the less trochanter (near the left hip and upper part of the thigh bone), and a nondisplaced fracture through the right intertrochanteric region (break in the upper part of the thigh bone where the fragments remain aligned and in their normal position). Resident 1 was transferred and admitted to General Acute Care Hospital (GACH) 1 on 9/3/2025 at 10:28 AM.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including encephalopathy (brain disorder that affects normal function leading to a range of symptoms like confusion, memory problems, and physical symptoms such as tremors or difficulty walking) and type 2 diabetes (condition in which the body cannot properly store or use sugar, the body's main source of energy).During a review of Resident 1's untitled Care Plan Report (CP), date initiated5/8/2025 and revised on 6/9/2025, the CP indicated Resident 1 had altered behavior patterns related to constant attempts to get out of bed unassisted and was at risk for falls. The CP's interventions indicated to assess what may cause and trigger Resident 1's behavior; attempt to reduce/ eliminate those triggers if possible. The CP's goal was to reduce the episodes of behavior daily and minimize the risk of decline daily through the next assessment on 11/3/2025.During a review of Resident 1's Licensed Nursing Note (LNN), dated 7/24/2025 at 11:34 AM, the LNN indicated Resident 1 was found in Resident 1's room, sitting on the floor mat and holding onto the [bed's] side rail.During a review of Resident 1's Interdisciplinary Team (IDT, a group of different healthcare professionals who meet to plan, coordinate, and implement a resident's care) - Narrative - Other Concerns (IDTN), dated 7/25/2025, the IDTN indicated the interdisciplinary (two or more professionals or departments) team conference was conducted due to Resident 1's fall incident that occurred on 7/24/2025. The IDTN indicated the facility implemented the following interventions: low bed, floor mats on each side of the bed, call light within resident's reach, bed alarm, room near the nurse's station, bilateral upper side rails, physical therapy reassessment for bed mobility training, improved body mechanics, sequencing of movements, and safety with completing transfers. The IDTN further indicated to have Resident 1 out of bed with structured activities to promote socialization and engagement.During a Page 1 of 4 056291 056291 09/10/2025 Casa Bonita Convalescent Hospital 535 E Bonita Avenue San Dimas, CA 91773

F 0689 Level of Harm - Actual harm Residents Affected - Few review of Resident 1's LNN dated 8/27/2025 at 9 PM, the LNN indicated Resident 1's bed alarm was beeping, and Resident 1 was noted attempting to get out of bed and was found leaning on the bed's side rails. The LNN indicated Resident 1 had episodes of getting out of bed and attempted to self-transfer, but the LNN did not indicate the number of episodes or if the episodes had increased or decreased.During a review of Resident 1's untitled CP, date initiated 8/27/2025 and revised 8/29/2025, the CP indicated Resident 1 had altered behavior patterns related to: Resident 1 attempting to get out of bed. The CP's interventions indicated to assess what may cause behavior and what may trigger Resident 1's behavior; attempt to reduce/ eliminate those triggers if possible. The CP's goal was to reduce the episodes of behavior daily through the next assessment and minimize the risk of decline daily through the next assessment on 11/3/2025.During a review of Resident 1's IDTN dated 8/28/2025, the IDTN indicated an interdisciplinary team conference was conducted due to Resident 1 sliding from the bed onto the floor mat on 8/27/2025. The IDTN indicated the facility implemented and exhausted multiple interventions to promote safety and the current plan of care would remain in place and be monitored for effectiveness. The IDTN did not indicate any new fall prevention interventions.During a review of Resident 1's Change of Condition (COC, a sudden clinically important deviation in the resident's health or functioning that requires further assessments and interventions), dated 9/3/2025, the COC indicated on 9/3/2025 at 9:43 AM, the charge nurse was in the hallway and heard Resident 1's bed alarm sounding inside Resident 1's room. The COC indicated Licensed Vocational Nurse (LVN) 2 found Resident 1 lying on the floor mat. The COC indicated Resident 1 was noted with a small skin tear on the left elbow and Resident 1 complained of 10 out of 10 pain (pain scale 0 to 10, 0 means no pain and 10 means the worst possible pain felt) bilateral (relating to both sides) hip pain. The COC indicated 911 was called and Resident 1 was transferred to GACH 1 on 9/3/2025, at 10:15 AM.During a review of Resident 1's GACH 1's History and Physical Reports (HPR) dated 9/3/2025, the HPR indicated Resident 1 was taken to GACH 1 via ambulance due to an unwitnessed fall from Resident 1's bed. The HPR indicated Resident 1 was a poor historian and not able to answer questions but complained of pain on both lower extremities (legs). The HPR indicated Resident 1 underwent an X-ray (form of electromagnetic radiation used to create images of inside the body) of the hip which showed an acute (recent) displaced comminuted fracture (severe bone injury where the bone is broken into multiple pieces and misaligned) in the left hip and a nondisplaced fracture (broken bone where the fragments remain in their normal position) through the right hip.During a review of Resident 1's IDTN dated 9/4/2025, the IDTN indicated an interdisciplinary team conference was conducted due to Resident 1's unwitnessed fall on 9/3/2025. The IDTN indicated the facility continued to implement the least restrictive measure to promote resident safety and dignity. The IDTN did not indicate any new fall prevention interventions.During an interview on 9/9/2025 at 9:49 PM with Registered Nurse (RN) 1, RN 1 stated Resident 1 did not like to stay in bed and had a history of fidgeting behaviors. RN 1 stated Resident 1 could independently move from a sitting to standing position but was unsteady. RN 1 stated Resident 1 was often kept at the nurse's station for close monitoring and only brought back to the room if Resident 1 requested. RN 1 stated the facility did not use sitters (a healthcare worker who provides continuous, non-medical supervision to residents to ensure their safety and prevent incidents like falls). RN 1 further stated RN 1 did not know if Resident 1 would say what Resident 1 wanted when attempting to get up because Resident 1 only spoke Spanish and RN 1 would need someone to translate.During an interview on 9/9/2025 at 12:10 PM with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 1 did not like to stay in the room or be in bed. CNA 1 stated that as soon as Resident 1 was awake, Resident 1 was trying to get out of bed. CNA 1 stated Resident 1 was usually at the nurse's station or 056291 Page 2 of 4 056291 09/10/2025 Casa Bonita Convalescent Hospital 535 E Bonita Avenue San Dimas, CA 91773

F 0689 Level of Harm - Actual harm Residents Affected - Few in activities because Resident 1 was at a high fall risk and needed close monitoring. CNA 1 stated Resident 1 would even attempt to stand while Resident 1 was in the wheelchair. CNA 1 further stated Resident 1 only stayed in bed if Resident 1 was really tired or sleeping.During an interview on 9/9/2025 at 12:41 PM with RN 2, RN 2 stated Resident 1 was known to have a history of trying to get out of bed, self-transferring (transfer from bed to chair without assistance from staff) and usually made attempts to get out of bed early in the morning. RN 2 stated Resident 1 attempted to get out of bed as soon as Resident 1's eyes opened [in the early morning] and Resident 1 loved to socialize and spend time in activities.During an interview on 9/9/2025 at 1 PM with the Physical Therapy Director (PTD), the PTD stated prior to Resident 1's fall on 9/3/2025, Resident 1 had received physical therapy for strengthening exercises and was working with Resident 1 to stand for long periods of time, balancing, and walking with a walker up to 50 feet. The PTD stated prior to Resident ‘s fall on 9/3/2025, Resident 1's strength had improved, and Resident 1 was able to complete sit-to-stand exercises with minimum assistance but required one person assistance due to Resident 1's impulsiveness, poor balance and trunk control.During an interview on 9/10/2025 at 10:36 AM with LVN 2, LVN 2 stated Resident 1 was sleeping just prior to the fall that occurred on 9/3/2025 and LVN 2 was frequently rounding (visually checking on Resident 1) every 15 minutes to check on Resident 1. LVN 2 stated, LVN 2 was in the hallway near Resident 1's room and heard the bed alarm sounding. LVN 2 stated Resident 1 was discovered in the room, on the floor on the right side of the bed with Resident 1's full body parallel to the bed. LVN 2 stated Resident 1 had facial grimaces and cried in pain. LVN 2 stated Resident 1's fall was unavoidable because Resident 1 was already under frequent monitoring every 15 minutes and the facility does not use sitters. LVN 2 stated the staff (in general) all knew Resident 1 was at high risk of falls and knew Resident 1 moved around a lot, so staff frequently monitored Resident 1 as much as possible. LVN 2 stated Resident 1's most effective fall prevention interventions were the bed alarm and close monitoring.During an interview on 9/10/2025 at 11:06 AM with Certified Nurse Assistant (CNA) 2, CNA 2 stated Resident 1 was very active and liked to sit up a lot. CNA 2 stated the morning of 9/3/2025, CNA 2 was checking on Resident 1 when in bed every 10 to 20 minutes. CNA 2 stated Resident 1 was impulsive and often attempted to get up without asking for [staff] assistance even if a staff member was positioned next to Resident 1. CNA 2 stated Resident 1 would have benefitted from having a sitter for closer monitoring because of Resident 1's impulsiveness but the facility did not use sitters.During an interview on 9/10/2025 at 11:16 AM with the Director of Nursing (DON), the DON stated the facility re-evaluated fall preventions as needed and at least quarterly. The DON stated Resident 1 was a high fall risk and already had fall mats, bedside rails, a low bed and bed alarms in place prior to the fall on 7/24/2025 and the only fall prevention interventions changed after the 7/24/2025 fall was related to Resident 1's physical therapy. The DON stated more emphasis was given to Resident 1's bed mobility training during physical therapy but no other interventions were implemented. The DON stated after the fall on 8/27/2025, [the facility] continued the same interventions with minor changes in physical therapy for Resident 1. The DON stated after the fall on 9/3/2025, Resident 1 was moved to another room closer to the nurse's station but Resident 1's previous rooms were also located near the nurse's station. The DON stated the facility exhausted every option to prevent falls for Resident 1 and the facility did not use sitters. The DON stated the facility had evaluated the effectiveness of Resident 1's fall prevention interventions as indicated in the IDTN dated 8/28/2025. The DON stated Resident 1's fall prevention interventions were deemed effective because Resident 1 would have fallen more frequently without the interventions in place. The DON further stated there was no documentation to indicate interventions were monitored for 056291 Page 3 of 4 056291 09/10/2025 Casa Bonita Convalescent Hospital 535 E Bonita Avenue San Dimas, CA 91773

F 0689 Level of Harm - Actual harm Residents Affected - Few effectiveness.During an interview on 9/10/2025 at 12:49 PM with the PTD, the PTD stated Resident 1's physical therapy goals had not changed from 7/2025 to 9/2025 and [the facility worked with] Resident 1 on bed mobility and strengthening exercises the entire time. The PTD stated there were slight differences in emphasis depending on Resident 1's progress but the big picture remained constant.During a concurrent interview and record review on 9/10/2025 at 3:18 PM with the Administrator (ADM), Resident 1's untitled CPs, dated 5/8/2025 and dated 8/29/2025, the CP indicated Resident 1 had altered behavior patterns related to attempting to get out of bed unassisted and expected behavior related to movement to floor mat were reviewed. The ADM stated Resident 1's fall prevention interventions listed in the CPs were standard interventions and the facility had done everything possible without resorting to restraints (devices or equipment used to a person's body to restrict their freedom of movement or normal access to their body). The ADM stated a sitter was provided to preserve Resident 1's dignity. When asked if the facility had assessed causative factors of Resident 1's behavior as indicated in the CPs, the ADM stated the ADM was not aware of causative factors and if causative factors were a listed intervention, it [the CPs] should have been followed. The ADM stated the facility treated the falls but did not look into the possible causes of the falls and did not know if Resident 1 had increased impulsive behavior leading to further falls.During a concurrent interview and record review on 9/10/2025 at 3:18 PM with the ADM, the facility's P&P titled, Falls and Fall Risk, Managing, dated 3/2018, was reviewed. The P&P indicated under Resident-Centered Approaches to Managing Falls and Fall Risk, 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident with a history of falls. The ADM stated Resident 1's fall prevention care plan indicated standard fall prevention interventions used for any resident that was at high risk for falls. The P&P further indicated under Monitoring Subsequent Falls and Fall Risk: 1. the staff will observe each resident's response to interventions intended to reduce falling or the risks of falling. The ADM stated the current interventions in place were effective because Resident 1 would have otherwise fallen more often. The ADM stated the facility did not have documented evidence to indicate fall prevention interventions were evaluated for effectiveness and the facility did not do the depth of evaluation that was perhaps needed.During a review of the facility's undated P&P titled, Falling Star Program, the P&P indicated recommendations to ensure a successful program included: evaluation for appropriate useful interventions for fall reduction. 056291 Page 4 of 4