Other·November 13, 2017

F000 INITIAL COMMENTS

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 Department of Public Health during an investigation of an Entity Reported Incident (ERI) during an Abbreviated Survey. ERI Number: CA00544503 - Substantiated Representing the Department of Public Health: Surveyor ID: 36504 RN, HFEN The inspection was limited to the specific ERI investigated and does not represent the findings of a full inspection of the facility. One deficiency was written for ERI Number: CA00544503.

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

F323 10/20/2017 (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 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: C6QE11 Facility ID: CA910000048 If continuation sheet 1 of 5 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: _______________ 056308 (X3) DATE SURVEY COMPLETED 10/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (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 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 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 adhere to the plan of care and provide adequate supervision and the use of an assistive to prevent falls for one of three sampled residents (Resident 1). Resident 1, who was assessed as a high risk for falls and required close monitoring and the use of an alarm to prevent falls was left unattended in the bathroom and fell sustaining injuries. This deficient practice resulted in Resident 1 falling while in the bathroom unattended and sustained a non-displaced fracture (broken bone) to the cervical spine (bones of the neck), laceration (skin cut) to the left cheek (face) and left upper eye that required a 911 transfer to the hospital for wound closure, evaluation and treatment. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6QE11 Facility ID: CA910000048 If continuation sheet 2 of 5 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: _______________ 056308 (X3) DATE SURVEY COMPLETED 10/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (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 A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on 1/17/17. Resident 1's diagnoses included chronic atrial fibrillation (irregular heartbeat), muscle atrophy (wasting of the muscle), difficulty in walking, lack of coordination, and abnormal posture. A review of a "Fall Risk" assessment, dated 1/17/17, indicated the Resident 1 was assessed as a high risk for fall, had problems balancing while standing and walking, decreased muscular coordination, jerking with an unstable gait when making turns and required the use of an assistive device while walking. A review of Resident 1's plan of care titled, "High Risk for fall," dated 1/18/17, the listed staff interventions included to apply a tab alarm (a pressure alarm placed under specific body areas to detect movement to prevent falls) while the resident was in the toilet and to monitor the resident's whereabouts at all time. A review of Resident 1's Quarterly Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated 5/2/17, indicated the resident required extensive assistance with transferring, toileting, bed mobility, dressing, and hygiene. During an interview on 7/28/17 at 12:10 p.m., Resident 1 stated she fell in bathroom after attempting to stand from the commode and did not call for the staff's assistance. The resident stated as a result of the fall she has to wear a neck collar (used to stabilize a neck fracture) due to the fall. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6QE11 Facility ID: CA910000048 If continuation sheet 3 of 5 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: _______________ 056308 (X3) DATE SURVEY COMPLETED 10/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (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 A review of the facility's undated investigation report indicated on 7/14/17 at approximately 4:30 p.m., the resident was assisted to the toilet and CNA1 left the resident unattended with the door ajar. CNA 1 was assisting another resident in the adjacent room when she heard a banging noise and went and found the resident on the floor bleeding from the left facial area. The report indicated first aid was provided and 911 was called for further evaluation and treatment. Resident 1 returned to the facility on 7/15/17 with the diagnoses of C-spine fracture, facial laceration with swelling and sutures. On 7/28/17 at 1:30 p.m., during an interview, Certified Nurse Assistant 1 (CNA1) stated she assisted Resident 1 to the bathroom, but was called by another resident for help. CNA 1 stated she left Resident 1 and gave her the call button and instructed the resident to call when she was ready to get off the commode. CNA 1 stated while assisting the resident in the next room, she heard Resident 1 call for help and fall. CNA 1 stated she accompanied the Charge Nurse into the resident's bathroom and observed Resident 1 lying on her left side on the bathroom floor bleeding from the left side of the eye and cheek. CNA 1 stated that she did not apply the tab alarm to Resident 1 while she was on the toilet, as per the resident's plan of care and should have. During an interview on 8/14/17 at 4:46 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 should not have been left alone in the bathroom because she had the tendency of getting up without calling for help, and all the CNAs who had provided care for the resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6QE11 Facility ID: CA910000048 If continuation sheet 4 of 5 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: _______________ 056308 (X3) DATE SURVEY COMPLETED 10/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (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 were aware of the behavior. A review of the general acute care hospital's (GACH) history and physical (H/P), dated 7/18/17 (four days after the resident fell), indicated the resident was transferred to the GACH after a fall with cervical spine fracture, facial laceration requiring four sutures (used to close open wounds) to the left temple area. The H/P indicated the resident was required to wear the neck collar at all times and to follow up with the neurosurgeon (a physician who specializes in the care and treatment of the nervous system, the brain and/or spine) in six weeks. A review of the facility's undated policy titled "Falls-Clinical Protocol," indicated frail elderly individuals are often at a greater risk for serious adverse consequences of falls, thus the interventions should be followed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6QE11 Facility ID: CA910000048 If continuation sheet 5 of 5