Health inspection·March 15, 2024

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 California Department of Public Health during the investigation of a Entity Reported Incident (ERI). ERI Number: CA00881140 Representing the Department: Health Facilities Evaluator Nurse: 48026. 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 CA00881140 (Refer to F689).

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of two 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: JDG211 Facility ID: CA910000058 If continuation sheet 1 of 7 PRINTED: 05/13/2026 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: _______________ 555726 (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MAR VISTA COUNTRY VILLA HEALTHCARE & WELLNESS CENTRE, LP 3966 Marcasel Ave Los Angeles, CA 90066 (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 sampled residents (Resident 1), who was assessed at risk for fall by failing to: 1. Ensure Certified Nurse Assistant 1 (CNA 1) provided two-person physical assistance (had help from another staff member) when turning Resident 1 in bed as indicated in Resident 1's Minimum Data Set (MDS- a required standardized assessment and care planning tool) dated 12/20/2023. 2. Ensure CNA 1 checked Resident 1's Low Air Loss mattress (LAL, mattress that operates using a blower-based pump that was designed to circulate a constant flow of air) to make sure the LAL mattress was on static mode (firm surface set in place and unlikely to move) before CNA 1 turned Resident 1 to Resident 1's right side while giving Resident 1 a bed bath. As a result, Resident 1 fell from Resident 1's bed to the floor, on 01/19/2024, at 11:30 AM, Resident 1 sustained a fracture (break in a bone) of the right distal (a part of the body that is farther away from the center of the body) femur (thigh) and experienced pain (unrated) on the right leg. Findings: A review of Resident 1's Admission Record (background information; a document containing demographic and diagnostic information) indicated Resident 1 was admitted to the facility on 11/19/2020 and was readmitted on 12/23/2022 with diagnoses including multiple sclerosis (MS - a long lasting and disabling disease in which the body attacks itself affecting the brain and spinal cord [a long ropelike structure that sends commands from the brain to the body and vice versa]), abnormalities of gait (a person's manner of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JDG211 Facility ID: CA910000058 If continuation sheet 2 of 7 PRINTED: 05/13/2026 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: _______________ 555726 (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MAR VISTA COUNTRY VILLA HEALTHCARE & WELLNESS CENTRE, LP 3966 Marcasel Ave Los Angeles, CA 90066 (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 walking) and mobility (ability to move freely and easily), and quadriplegia (paralysis [complete or partial loss of muscle strength], that affects all four limbs and body from the neck down). A review of Resident 1's untitled Care Plan, initiated on 12/21/2021, and revised on 1/19/2024 indicated Resident 1 was at risk for falls related to the disease processes of impaired mobility, abnormalities of gait, muscle weakness, right arm weakness, and paraplegia (paralysis of the legs and lower body). The goal was for Resident 1 to be free from falls and the intervention was to provide a safe environment for Resident 1. A review of Resident 1's untitled Care Plan, initiated on 12/21/2021, and revised on 7/27/2023 indicated Resident 1 had self-care performance deficit (falling short of a desired amount) related to MS, muscle weakness, difficulty walking, and paraplegia. The goal was for Resident 1 to maintain current level of function in activities of daily living (ADL). The interventions were for Resident 1 to receive assistant from one to two staff for bed bath, turning, and repositioning in bed. A review of Resident 1's Fall Risk Evaluation, dated 11/26/2023, indicated Resident 1 was at risk for falls due to inability to perform gait (pattern of walking) and stand or move without falling. The goal was for Resident 1 to be free from falls and the intervention was to implement fall risk precautions. A review of Resident 1's MDS, dated 12/20/2023, indicated Resident 1 had moderately impaired cognition (mental ability to make decisions of daily living). Resident 1 had impairment (loss of part or all physical ability) on one side of the upper extremity (arm) and both sides on the lower extremities (legs). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JDG211 Facility ID: CA910000058 If continuation sheet 3 of 7 PRINTED: 05/13/2026 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: _______________ 555726 (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MAR VISTA COUNTRY VILLA HEALTHCARE & WELLNESS CENTRE, LP 3966 Marcasel Ave Los Angeles, CA 90066 (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 1 required substantial/maximal assistance (helper does more than half the effort; helper lifts or holds trunk or limbs) when rolling from lying on back to left and right side and returning to lying on back on the bed. The MDS indicated Resident 1 was dependent on two or more staff for shower/bathing, dressing, personal hygiene, and lying down. A review of Resident 1's Nurses Progress Notes, dated 01/19/2024, at 10:21 PM, indicated Resident 1 complained of lower legs and lower back pain (unrated) after a fall. The notes indicated a Medical Doctor (MD) was notified and the MD ordered to transfer Resident 1 to a general acute care hospital (GACH) for a stat (immediate) X-ray (medical imaging technique that provide detailed images of the inside of the body) of the lower back and both lower extremities (legs). A review of Resident 1's Change in Condition (COC - a decline or improvement in a resident's mental, psychosocial, or physical functioning that requires a change in the resident's comprehensive plan of care) Evaluation completed by the DON, dated 01/19/2024 at 12:19 PM, indicated on 01/19/2024, Resident 1 was receiving a bed bath and CNA 1 was repositioning Resident 1 when the resident slipped from CNA 1's hands and fell to the floor. A review of the facility's fall investigation report, dated 01/24/2024, indicated CNA 1 failed to ensure Resident 1's LAL mattress was on a static/firm mode while turning Resident 1 in bed on 1/19/2024.The report indicated Resident 1 fell out of bed and sustained a fracture of the right distal femur. Resident 1 was immediately transferred to the hospital due to pain (unrated). The hospital informed the facility that Resident 1 had a right distal femur fracture. On FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JDG211 Facility ID: CA910000058 If continuation sheet 4 of 7 PRINTED: 05/13/2026 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: _______________ 555726 (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MAR VISTA COUNTRY VILLA HEALTHCARE & WELLNESS CENTRE, LP 3966 Marcasel Ave Los Angeles, CA 90066 (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 1/22/2024, Resident 1 was readmitted to the facility with "half cast, (the hard part of a splint [a rigid or flexible device that maintains in position a displaced or movable part] also used to keep in place and protect an injured part does not wrap all the way around the injured area." A review of GACH Patient Report for Resident 1, dated 01/29/2024, indicated, right knee follow-up Xray report indicated fracture distal femur unchanged. The Xray was in comparison with right knee Xray completed on 01/19/2024. During an observation in Resident 1's room and concurrent interview with Resident 1 on 02/01/2024 at 3:26 PM, Resident 1 was lying in bed. Resident 1 was not moving the right arm and the lower extremities. Resident 1 stated she was "partially blind (very limited vision) in my right eye because of MS." Resident 1 stated she was not able to move her lower body (from the waist down), Resident 1 stated Resident 1's "right arm was very weak", and the "left arm was weak." Resident 1 stated that during bed bath (on 119/2024), CNA 1 was standing behind Resident 1 and assisted Resident 1 with turning from Resident 1's back onto Resident 1's right side. Resident 1 stated, "I fell off the bed as soon as I turned over." Resident 1 stated several nurses came into the room after CNA 1 called for help. Resident 1 stated, "I told everyone that my leg was hurting, I said it many times" immediately after the fall. Resident 1 stated a nurse (unidentified) gave Resident 1 Percocet (controlled medication for pain relief) to control the pain on Resident 1's right leg. Resident 1 stated Resident 1's right leg was "still hurting a lot.". Resident 1 stated "only 1 staff (in general)" provided bed bath for her. During an interview with CNA 1 on 02/02/2024 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JDG211 Facility ID: CA910000058 If continuation sheet 5 of 7 PRINTED: 05/13/2026 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: _______________ 555726 (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MAR VISTA COUNTRY VILLA HEALTHCARE & WELLNESS CENTRE, LP 3966 Marcasel Ave Los Angeles, CA 90066 (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 at 11:30 AM, CNA 1 stated on 1/19/2024, CNA 1 was providing a bed bath to Resident 1 assisting Resident 1 turn to Resident 1's right side away from CNA 1, and Resident 1 fell from the bed to the floor. CNA 1 stated Resident 1 was on a LAL mattress CNA 1 stated CNA 1 saw "some kind of movement/motion" and that's when Resident 1 fell. CNA 1 stated Resident 1 was on the floor facing up and the resident's head was near the foot of the bed. CNA 1 stated Resident 1 could not move Resident 1's legs and her arms due to weakness CNA 1 stated a second person/staff should have assisted her to turn and bathe Resident 1. CNA 1 stated, "it's so easy for [Resident 1] to fall. CNA 1 stated she did not ask another staff to assist with Resident 1's bed bath due to "no one was available." During an interview with LVN 2 on 02/02/2024 at 12:44 PM, LVN 2 stated that on 01/19/2024 morning (unable to recall the time), LVN 2 heard CNA 1 calling for help. LVN 2 stated LVN 2 went into Resident 1's room and saw Resident 1 lying on the floor facing up. LVN 2 stated Resident 1 was lifted off the floor and transferred back to bed. LVN 2 stated having another staff (any nursing staff) assist CNA 1 due to Resident 1 has MS and Resident 1 could not perform ADL due to weakness on all extremities (arms and leg). LVN 2 staff two staff providing bed bath for Resident 1 could have prevented Resident 1 from falling. During an interview with LVN 1 on 02/02/2024 at 4:02 PM, LVN 1 stated Resident 1's arms were weak, and Resident 1 was unable to move lower extremities. LVN 1 stated Resident 1 needed two people/staff to perform ADLs. During an observation in Resident 1's room and a concurrent interview with the DON on 02/02/2024 at 5:55 PM, the DON stated, "two FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JDG211 Facility ID: CA910000058 If continuation sheet 6 of 7 PRINTED: 05/13/2026 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: _______________ 555726 (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MAR VISTA COUNTRY VILLA HEALTHCARE & WELLNESS CENTRE, LP 3966 Marcasel Ave Los Angeles, CA 90066 (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 CNAs (in general) were "supposed" to perform ADLs on Resident 1. A review of the facility's policy and procedures (P&P) titled, "Positioning and Body Alignment," dated 01/01/2012, indicated, "staff must be aware of any limitation a resident may have in positioning." A review of the Low Air Loss (LAL) Mattress Instruction Manual Guide, undated, indicated staff must be carefully assessed for the best ways to keep the residents from harm, such as falling. Staff must identify safety risks involving the bed, mattress. The LAL mattress instruction indicated static mode was when the redistribute body mass over a greater surface area at the constant air pressure base on the resident comfort weight setting, and alternating pressure mode was alternating cell cycle with periodic pressure relief (pressure disturbed in wavelike movements). A review of the facility's P&P titled, "Fall Management Program," dated 03/31/2021, indicated, "The purpose of fall management program was to "provide residents a safe environment that minimizes complications associated with falls. Licensed nurse will complete a fall risk evaluation and document interventions for every Resident regardless of fall risk evaluation score." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JDG211 Facility ID: CA910000058 If continuation sheet 7 of 7