Health inspection·March 21, 2025

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 that one of four sampled residents (Resident 2) received continuous supervision and assistance, when the staff assigned to monitor Resident 2 left the resident unattended while he was sitting in a chair and had fallen asleep. This failure had the potential to result in harm to Resident 2, including injury from an unassisted fall. Findings: A review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included muscle wasting and atrophy (a disease that causes loss and weakening of muscles). A review of Resident 2's Minimum Data Set (an assessment tool), dated January 26, 2025, indicated Resident 2 had a Brief Interview for Mental Status (tool used to assess a resident's cognitive function) score of 6 (severe cognitive impairment). A review of Resident 2's Nurse's Notes, dated February 7, 2025, at 5:42 p.m., indicated, .(Certified Nurse Assistant [CNA] 4's name) assigned 1 on 1 to resident .Resident was found on the floor .Per (CNA 4) she went to grab resident dinner from the food cart in the hallways .upon arriving to resident room she found resident .in the floor .Resident stated that he fell asleep sitting on the chair in his room and fell .Resident sustained a 3 cm (centimeter - unit of measurement) cut and bump to left forehead .complained of .pain on the stated site .Send to ER (emergency room) for further eval (evaluation) and treatment . On March 18, 2025, at 3:46 p.m., during an interview with the Director of Nursing (DON), she stated residents on one-on-one monitoring require the assigned staff to continuously monitor them to ensure their safety. The DON further stated Resident 2 was on one-on-one monitoring due to elopement behavior and had a fall on February 7, 2025, at 5:42 p.m., sustaining a 3 cm laceration and bump on the left forehead. The DON stated Resident 2 was sitting on a chair inside his room when CNA 4 stepped out to grab Resident 2's dinner from the food cart located in the hallway in front of Resident 2's door. The DON further stated when CNA 4 returned to the room, she found Resident 2 on the floor. The DON stated Resident 2 had fallen asleep, slid out of the chair, and fell. (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: 555740 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 555740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Real Post Acute 1665 East Eighth Street Beaumont, CA 92223 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)