Health inspection·January 10, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review, the facility failed to ensure the 10-foot ladder (steps) was secured in the facility's safe storage location and failed to report the unusual occurrence to the appropriate agencies, for two of 3 sampled residents, (Resident 1, and Resident 2). This failure resulted in an intruder to enter 1 of 3 resident ' s room, placing the residents' safety at risk to danger and resulted in the delay of the investigation by the California Department of Public Health. Findings: a). During a review of Resident 1 ' s admission record dated 1/10/2024, the admissions record indicated Resident 1, a [AGE] year-old female, was admitted to the facility on [DATE] and was re- admitted on [DATE] with diagnosis of morbid obesity (overweight) due to excess calorie (serious health condition that results from an abnormally high body mass that is diagnosed by having a body mass index greater than 40), cerebral infarction (occurs when the blood supply to part of the brain is blocked or reduce), and depression (serious mood disorder). During a review of Resident 1 ' s Minimum Data Set (MDS-an assessment and care planning tool) dated 11/28/23, the MDS indicated Resident 1 has clear speech, the ability to express ideas and wants, and understands. The MDS indicated Resident 1 is dependent on staff (helper does all the effort) for toileting hygiene, shower/bathe, and upper and lower body dressing. During an interview on 1/10/2024 at 12:20 p.m., with Resident 1 in her room, Resident 1 stated an intruder came through the sliding glass door and she got scared when the police came. Resident 1 stated the intruder moved quickly and did not touch her or her roommate. b). During a review of Resident 2 ' s admission record dated 1/10/2024, the admissions record indicated Resident 2, a [AGE] year-old male, was admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnosis of alcohol abuse, personal history of self-harm, and bilateral osteoarthritis (a wear and tear disease) of knees. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 has clear speech, difficulty communicating some words or finishing thoughts but is able if prompted or given time, and usually understands. The MDS indicated Resident 2 is dependent on staff for toileting hygiene, shower/bathe, and personal hygiene. Page 1 of 3 555368 555368 01/10/2024 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 1/10/2024 at 12:30 p.m., with Resident 2, the roommate of Resident 1, Resident 2 stated the intruder moved her bed to come into the room. Resident 2 stated the police came and were looking around the room. Resident 2 stated the intruder was scared. During an interview on 1/10/2024 at 1:10 p.m., with the director of staff development (DSD), the DSD stated the intruder incident occurred about a month ago, she notified the Administrator, and the police came to the facility and picked up the intruder. The intruder used the ladder that was in the parking garage to access resident rooms. During an interview on 1/11/2024 at 10:55 a.m., with the Maintenance Supervisor, the maintenance supervisor stated ladders are stored inside the parking garage and they are not locked up. The intruder used a 10-foot ladder to get into Resident ' s 1 and 2 ' s room. The intruder broke the sliding door stopper on the tract to enter the room. The maintenance supervisor stated the ladders should not have been left unattended, this may have jeopardized Resident's safety. During an interview on 1/10/2024 at 1:55 p.m., with the Administrator, the Administrator stated an intruder came through the sliding glass door. The Administrator stated the DSD contacted him, and the police came to the facility. The Administrator acknowledged that The California Department of Public Health (Department) and the Ombudsman (patient advocate) were not notified about the unusual incident of the intruder breaking into Resident's 1 and 2's room. The Administrator stated failure to report may have delayed the Department's investigation. During an interview on 1/11/2024 at 10:55 a.m., with the Maintenance Supervisor, the Maintenance Supervisor stated ladders are stored inside the parking garage and they are not locked up. The intruder used the 10-foot ladder to get into Resident's 1 and 2's room. The intruder broke the sliding door stopper on the tract to enter the room. The Maintenance Supervisor stated the ladders should not have been left unattended, this may have jeopardized Resident's safety. During a review of the facility ' s policy and procedure (P&P) titled Preventative Maintenance Program, revised 2023, the P&P indicated, preventative maintenance program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The maintenance director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. The maintenance director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. During a review of the undated P&P titled Maintenance Supervisor Job Description, the P&P indicated the primary purpose of this position is to assist in supervising the day-to-day activities of the Maintenance department in accordance with current federal, state, and local standards, guidelines, and regulations governing the facility, and as may be Director of Maintenance to assure the facility is maintained in a safe and comfortable manner. During a review of the facility's policy and procedure (P&P) titled Unusual Occurrence Reporting, revised 2023, the P&P indicated as required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees, or visitors. The facility will report other unusual occurrences via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident required by federal and state regulations. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and 555368 Page 2 of 3 555368 01/10/2024 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0689 other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555368 Page 3 of 3