Other·September 19, 2018

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey for the investigation of one facility reported incident. Facility Reported Incident # CA00553994. Representing the California Department of Public Health: Surveyor Federal ID number 36631, HFEN The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. One Deficiency was issued for facility reported incident number CA00553994.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 08/23/2018 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5DDJ11 Facility ID: CA250000110 If continuation sheet 1 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555740 (X3) DATE SURVEY COMPLETED 07/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA REAL POST ACUTE 1665 E 8th St Beaumont, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident A), when the resident was left in another resident's room (Resident B) to use the bathroom unattended. This failure caused Resident A to fall and sustained a hip fracture. Findings: On October 2, 2017, at 12:20 p.m., an unannounced visit to the facility was conducted to investigate Resident A's fall incident. On October 2, 2017, Resident A's record was reviewed. Resident A was admitted at the facility on July 10, 2008, with diagnoses which included history of falling, muscle weakness, Alzheimer's disease (progressive mental deterioration), cataract (clouding of the lens in the eye which leads to a decrease in vision) and macular degeneration (incurable eye disease resulting to loss of vision). Resident A's MDS (minimum data set- an assessment tool) dated September 19, 2017, indicated the following: 1. Section C- Cognitive Patterns- BIMS (brief FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5DDJ11 Facility ID: CA250000110 If continuation sheet 2 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555740 (X3) DATE SURVEY COMPLETED 07/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA REAL POST ACUTE 1665 E 8th St Beaumont, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE interview of mental status) score was 9 (moderately impaired); and 2. Section G- Functional Status- toilet use (how resident uses the toilet room, transfer on/off toilet). Resident A needed supervision and a set up help. Resident A's fall risk assessment dated June 20, 2017, indicated Resident A had a score of 13, and was categorized as high risk. Resident A's nurses notes dated September 20, 2017, indicated, "At around 12:30 pm cna (certified nursing assistant) called cn (charge nurse) to room 11, cn went there and saw resident 14 d (Resident A) laying (sic) on the floor in between the 4 beds. 3 cnas were assisting, resident was screaming and yelling "let me get up" cna and cn trying to convince him to stay where he was and not move, but he kept yelling and screaming getting agitated, moving and reaching for his w/c (wheelchair). Cn asked him (Resident A) what happened and he said he pushed me pointing to 11 a (Resident B), when 11 a (Resident B) was asked he said he pushed him because he was in his room..." Resident A's SBAR (situation background assessment recommendation- communication form of change of condition) dated September 20, 2017, indicated, "Resident was pushed by another. Resident can't moved (sic) left lower leg, refused to be touched ... possible fracture ...transfer to the hospital ..." The facility physician order dated September 20, 2017, indicated," Send to (name of acute hospital) ER (emergency room) for further txt (treatment) and eval (evaluation) ..." Resident A's acute hospital notes dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5DDJ11 Facility ID: CA250000110 If continuation sheet 3 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555740 (X3) DATE SURVEY COMPLETED 07/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA REAL POST ACUTE 1665 E 8th St Beaumont, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE September 20, 2017, indicated Resident A had a left hip displaced fracture (bone breaks into two or more parts and the bones get displaced from their original position). Resident A's acute hospital operative report dated September 21, 2017, indicated Resident A undergone ORIF (open reduction internal fixation- surgical procedure to fix a severe bone fracture, or break) of the left hip. Resident A's Admission Nursing Assessment dated September 26, 2017, indicated Resident A was readmitted to the facility with three surgical sites (left hip, left midlateral thigh, and left lateral thigh). Resident A's nurses' skilled notes dated September 27, 2017, indicated Resident A was evaluated by PT (physical therapy) and OT (occupational therapy). The notes further indicated Resident A would benefit from rehabilitation due to muscle weakness, difficulty in walking due to the surgery (ORIF). On October 2, 2017, at 12:20 p.m., the Director of Nursing (DON) was interviewed. She stated Resident A wanted to use the bathroom on September 20, 2017, at approximately 12:30 p.m. The DON stated Resident A's bathroom was occupied by another resident. The DON stated Certified Nursing Assistant (CNA) 1 wheeled Resident A at the entry door of Room 11 and left Resident A to use the bathroom unattended. She stated CNA 1 left Resident A at Room 11 and assisted another resident. The DON stated CNA 1 saw Resident A lying on the floor near Resident B's bed, and heard Resident A saying, "He pushed me," pointing his finger at Resident B. On October 2, 2017, at 1:20 p.m., Resident B was interviewed. Resident B stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5DDJ11 Facility ID: CA250000110 If continuation sheet 4 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555740 (X3) DATE SURVEY COMPLETED 07/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA REAL POST ACUTE 1665 E 8th St Beaumont, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident (Resident A) entered his (Resident B) curtain and "space" and felt "threatened." Resident B stated the resident (Resident A) "just kept on approaching," so he placed his hand out to keep him off his space. Resident B stated Resident A tripped on the ground. On October 2, 2017, at 1:45 p.m., the Registered Nurse Supervisor (RNS) was interviewed. She stated Resident A's body assessment was done after the incident of fall on September 20, 2017. The RNS stated Resident A was very guarded with his left hip and verbalized pain. She stated she could tell there was something wrong with Resident A. On October 2, 2017, at 2 p.m., The DON was re-interviewed. She stated Resident A should have not been left unattended in Room 11. The DON stated Resident A needed supervision. On October 6, 2017, at 2:45 p.m., CNA 1 was interviewed. CNA 1 stated she was helping a resident at Room 14's bathroom when Resident A verbalized wanting to use the bathroom. CNA 1 stated she instructed Resident A to use the bathroom in Room 11. She stated she walked Resident A to the door of Room 11 and left. On October 9, 2017, at 10:10 a.m., CNA 2 was interviewed, and stated she saw CNA 1 wheel Resident A inside Room 11. CNA 2 stated, "I would not have left" Resident A inside Room 11 unattended. She stated the resident (Resident B) occupying Room 11 was very "territorial." CNA 2 further stated Resident A could not ambulate as he used to after the incident of fall on September 20, 2017. Resident A's MDS dated October 3, 2017 (13 days after the incident of fall), Section G FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5DDJ11 Facility ID: CA250000110 If continuation sheet 5 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555740 (X3) DATE SURVEY COMPLETED 07/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA REAL POST ACUTE 1665 E 8th St Beaumont, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (Functional Status) indicated Resident A needed an extensive assistance with a two person physical assist. On October 9, 2017, at 10:15 a.m., Resident A was observed sitting on his wheelchair being propelled by the DON to his room. During a concurrent interview with Resident A, he stated he could not walk anymore and his hip hurts. On October 9, 2017, at 11:10 a.m., Licensed Vocational Nurse (LVN)1 was interviewed. She stated Resident A should have not been left in Room 11 unattended. LVN 1 stated the resident occupying the room (Room 11) was "not friendly" to both staff and residents. On March 28, 2018, at 4 p.m., the DON was interviewed regarding the facility's investigation of the fall incident involving Resident A. She stated Resident A should have been taken by the staff to an unoccupied room to use the bathroom. The DON stated Resident B did push Resident A. She further stated Resident A sustained a fracture due to the incident. A review of the facility's undated policy and procedure titled "Fall Prevention Program," indicated, "...Purpose: 1. To improve the quality of life and quality of care for residents...The goal of this program is to prevent falls, reduce both the incidence of fall, and or injuries that may accompany falls. Process...Identify specific patterns, situations and behaviors associated with the fall incidence. Establish a common method of communication to remind staff to monitor these residents for fall prevention...Staff will be alerted to those residents at risk, trained on the care plan interventions designed to prevent or reduce repeated falls..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5DDJ11 Facility ID: CA250000110 If continuation sheet 6 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555740 (X3) DATE SURVEY COMPLETED 07/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA REAL POST ACUTE 1665 E 8th St Beaumont, CA 92223 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: 5DDJ11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA250000110 (X5) COMPLETE DATE If continuation sheet 7 of 7