Other·December 28, 2019

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 one Facility-Reported Incidents (FRIs) during an annual recertification visit conducted 11/16/2019. FRI number: CA00651472 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 38552 Health Facilities Evaluator Nurse ID: 35004 Health Facilities Evaluator Nurse ID: 36500 Health Facilities Evaluator Nurse ID: 38601 One deficiency was issued for FRI number CA00651472; Refer to Ftag 689. Highest Severity and Scope: G Total Census: 87 Sample Size: 42 Based on interview and record review, the facility failed to prevent a fall accident for one of eight sampled residents reviewed for the care area of accidents (Resident 384). Certified Nursing Assistant 1 (CNA 1) left Resident 384 unsupervised in the shower room. This deficient practice resulted in a left femur (thighbone) fracture (broken bone) for Resident 384. The facility transferred Resident 384 to a general acute care hospital (GACH) on 08/20/2019. Resident 384 underwent a left hip percutaneous pinning (a type of surgery to repair a broken hip) on 08/23/2019 to repair the fracture. Resident 384 experienced left hip pain after the fall and received Tramadol medication 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: E1W511 Facility ID: CA920000005 If continuation sheet 1 of 9 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: _______________ 055002 (X3) DATE SURVEY COMPLETED 11/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY MANOR HEALTHCARE 11723 Fenton Ave Sylmar, CA 91342 (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 (pain reliever which is used to treat moderate to severe pain). Resident 384 stayed in the GACH for eight days. Findings: A review of Resident 384's skilled nursing facility admission record indicated Resident 384 was initially admitted to the facility on 02/22/2019, with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) with behavioral disturbance, history of falling, restless leg syndrome (condition that causes an uncontrollable urge to move your legs, due to an uncomfortable sensation), age related debility (physical weakness), and cerebral infarction (stroke) without residual deficits (remaining after a disease). A review of Resident 384's Fall Risk Assessment dated 02/22/2019, indicated Resident 384 was at moderate risk for falls. Resident 384 had one to two falls in the past three months before admission to the facility. Resident 384 had the following conditions: decreased muscular coordination, jerking or unstable when making turns, and balance problem while walking. The Assessment indicated Resident 384 takes one to two of these medications currently and or within the last seven days: antihistamines (Claritin, medication used to treat allergies or cold and flu symptoms) and antihypertensive (Lisinopril, medication to keep blood pressure normal). A review of Resident 384's History and Physical dated 02/23/2019, indicated that the resident had unsteady gait and generalized weakness, transient ischemic attack (TIAtemporary blockage of blood flow in the brain), and history of falls. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E1W511 Facility ID: CA920000005 If continuation sheet 2 of 9 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: _______________ 055002 (X3) DATE SURVEY COMPLETED 11/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY MANOR HEALTHCARE 11723 Fenton Ave Sylmar, CA 91342 (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 384's Care Plan addressing falls, initiated on 02/23/2019, indicated the resident was at high risk for further falls related to history of falls, impaired cognition and comorbidities (presence of one or more additional conditions co-occurring with a primary condition). The interventions included were to monitor the environment for wet spots, and observe/anticipate/intervene for factors causing falls (e.g. mobility problem-standing, transferring, walking). A review of Resident 384's Care Plan addressing Activities of Daily Living (ADL), initiated on 02/24/2019, indicated the resident required assistance with ADL functions secondary to difficulty walking and generalized muscle weakness. The Care Plan indicated the ADLs fluctuate depending on cognition, mood, and behavior. The interventions included to provide physical assistance by staff with bathing/showering, extensive assistance by staff to dress, and extensive-total assistance by staff to move between surfaces. A review of Resident 384's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 05/28/2019, indicated the resident had intact cognitive skills (the process of acquiring knowledge and understanding through thought, experience, and the senses for decision making), but required cueing for recall (remembering). Resident 384 required one-person physical assistance for bathing (how the resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower). A review of Resident 384's Fall Risk Assessment dated 05/28/2019, indicated Resident 384 had a balance problem while standing and required use of assistive devices (e.g. cane, walker, wheelchair, furniture). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E1W511 Facility ID: CA920000005 If continuation sheet 3 of 9 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: _______________ 055002 (X3) DATE SURVEY COMPLETED 11/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY MANOR HEALTHCARE 11723 Fenton Ave Sylmar, CA 91342 (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 384's Fall Risk Assessment dated 05/28/2019 indicated Lisinopril and Claritin increased the score for risk for falls. A review of the Order Summary Report dated 08/01/2019 indicated Resident 384 was receiving Lisinopril Tablet 20 milligrams (mg) by mouth once a day for hypertension (high blood pressure) and Claritin tablet 10 mg by mouth one time a day for allergic rhinitis (runny or stuffy nose). A review of Resident 384's Progress Notes indicated the following: 1. On 08/20/2019 at 09:40 AM, Registered Nurse 2 (RN 2) documented the CNA reported Resident 384 was on the shower floor. RN 2 assessed the resident in bed. The resident stated his groin was sore, 2/10 pain (pain rating scale of 0-10, 0 being no pain, 10 being the worst pain possible). RN 2's skin assessment showed Resident 384 had a scratch to the left hip, an abrasion on the head and a left elbow skin tear over ecchymotic (reddened) with no active bleeding. PRN (as needed) Tylenol (Medication Administration Record indicated Tylenol 325 mg, 2 tablets were given at 09:58 AM, medication to treat minor aches and pain, and reduces fever), was given. Treatment was provided to the head abrasion and left elbow skin tear. At 09:50 AM, the physician was notified regarding the "event" and he ordered a left hip and head X-ray STAT (immediately). 2. RN 2 documented on 08/20/2019 at 12:55 PM, the result of the left hip X-ray showed intertrochanteric (between the highest part of the thigh bone, bony protrusions of the thigh bone) fracture extending in the sub capital region (femoral head) of the left femoral neck FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E1W511 Facility ID: CA920000005 If continuation sheet 4 of 9 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: _______________ 055002 (X3) DATE SURVEY COMPLETED 11/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY MANOR HEALTHCARE 11723 Fenton Ave Sylmar, CA 91342 (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 (just below the ball and socket of hip joint). The result was relayed to the physician, and an order was obtained to transfer the resident to a hospital. The physician was informed Resident 384 was complaining of pain 6/10 on his left groin and Tylenol was ineffective. The physician gave an order to give the resident Tramadol medication, 50 milligrams (mg), one tablet (Medication Administration Record indicated it was given at 01:33 PM) and PRN every 6 hours for moderate to severe pain. 3. RN 2 documented on 08/20/2019 at 01:30 PM, the Tramadol one tablet was administered by the charge nurse for left hip pain 6/10 (moderate pain). 4. RN 2 documented on 08/20/2019 at 02:20 PM, Resident 384 left the facility by ambulance. A review of the Administrator Investigative Report for Resident 384 incident date of 08/20/2019 and reviewed on 08/23/2019 indicated the following: 1. Resident 384 was found on the shower floor lying on his left side. 2. CNA 1 stated the resident wanted to be dressed in the shower. CNA 1 instructed the resident that she would get his items and instructed him to remain seated. Resident 384 got up while the CNA was not in the shower room. 3. CNA 1 should not leave any resident-even alert, cognitive residents (in the shower). A review of the Post Fall Assessment Form dated 08/20/2019, indicated Resident 384 had a fall at 09:40 AM. Resident 384 was trying to ambulate and lost his balance. The Post Fall recommendations indicated not to leave the resident unattended and redirect the resident as needed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E1W511 Facility ID: CA920000005 If continuation sheet 5 of 9 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: _______________ 055002 (X3) DATE SURVEY COMPLETED 11/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY MANOR HEALTHCARE 11723 Fenton Ave Sylmar, CA 91342 (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 GACH Progress Notes dated 08/28/2019, indicated Resident 384 presented from the skilled nursing home with a left hip fracture (broke hip) seen on X-ray. Resident 384 reported slipping in the shower and falling on his left side as well as hitting his head, but denied loss of consciousness. Since the fall, Resident 384 reported left hip pain with movement. A repeat X-ray in Emergency Department (ED) showed age indeterminate left subcapsular femoral neck fracture. Resident 384 went to the operating room on 08/23/2019 for percutaneous pinning by orthopedic (medical specialist trained to deal with problems in the bones, ligaments, and muscles) surgery. A review of the nursing facility's Admit/Readmit Nursing Evaluation dated 08/28/2019 indicated Resident 384 was admitted to the facility with diagnoses including left hip fracture after mechanical fall, status post left hip percutaneous pinning on 08/23/2019, hypertension and heart failure. A review of Counseling/Disciplinary Notice to CNA 1 dated 08/23/2019, indicated a final conference warning was given to CNA 1 for failure to perform work as required; the employee did not follow facility policy regarding resident ADLS, specific to showers. During an interview on 11/16/2019 at 10:00 AM, Resident 384 stated he remembered slipping and falling in the shower room. When asked to discuss the details of his fall, Resident 384 stated, "I don't want to relive my fall." During a telephone interview on 11/16/2019 at 12:54 PM, Resident 384's Family Member 1 (FM 1) stated that it was "upsetting" to see the resident in wheelchair. FM 1 stated that the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E1W511 Facility ID: CA920000005 If continuation sheet 6 of 9 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: _______________ 055002 (X3) DATE SURVEY COMPLETED 11/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY MANOR HEALTHCARE 11723 Fenton Ave Sylmar, CA 91342 (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 used to be "walking fine." FM 1 was aware of the fall but stated that the resident was not supposed to be in the shower without help. During an interview on 11/17/2019 at 07:51 AM, Registered Nurse 2 (RN 2) stated Licensed Vocational Nurse 1 (LVN 1) notified him that Resident 384 fell in the shower room (on 08/20/2019). RN 2 performed a head to toe assessment after the resident was put back to bed. RN 2 stated the resident complained of pain of the left hip and called the physician at around 09:50 AM (Unable to recall exact time). The physician ordered an X-ray of the left hip and left pelvis. The X-ray results showed the resident had left intertrochanteric fracture extending in the sub capital region of the left femoral neck. RN 2 notified the physician of the X-ray results and the physician gave an order to transfer the resident to the hospital. During a telephone interview on 11/17/2019 at 10:40 AM, Certified Nursing Assistant 1 (CNA 1) stated she was the assigned to Resident 384 when he fell in the shower room on 08/20/2019. CNA 1 stated she brought the resident to the shower room between 09:30 AM-09:40 AM (unable to recall exact time) using the wheelchair (W/C) and transferred the resident to the shower chair when they got to the shower room. After the shower, she transferred the resident from the shower chair to a "regular chair." CNA 1 stated when she was dressing the resident, she realized she dropped the resident's underwear on the way to the shower room. The resident stated to CNA 1 he wanted to get dressed in the shower room and that he will wait for CNA 1 in the shower room, while she gets the underwear. CNA 1 stated she instructed him to remain in the chair. CNA 1 stepped out of the shower room. CNA 1 stated on her way to the resident's room, she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E1W511 Facility ID: CA920000005 If continuation sheet 7 of 9 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: _______________ 055002 (X3) DATE SURVEY COMPLETED 11/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY MANOR HEALTHCARE 11723 Fenton Ave Sylmar, CA 91342 (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 heard a noise coming from the shower room that sounded like "a chair banging the wall." CNA 1 ran back to the shower room and saw the resident on the floor laying down on his left side. CNA 1 then called for help and a CNA and two Licensed Vocational Nurses came over and assisted the resident off the floor. They transferred the resident to the bed at around 10:00 AM (Unable to recall the exact time). CNA 1 stated she should not have left the resident by himself in the shower room. CNA 1 stated, "I made a big mistake." During a telephone interview on 11/17/2019 at 04:01 PM, the Nurse Practitioner (NP) stated Resident 384's physician notified her to assess the resident after the fall in the facility on 08/20/2019 (Unable to recall exact time). The NP stated that during the assessment, the resident was in pain. The NP stated she maneuvered the resident's hip, performed an internal and external rotation and stated Resident 384 "seemed very uncomfortable, seemed highly likely that he probably had a fracture." During an interview on 11/17/2019 at 04:43 PM, the Director of Nursing (DON) stated Resident 384 required one-person assists with bathing/shower. The DON stated the resident had a history of falls, and CNA 1 should have not left the resident in the shower room. The DON stated that CNA 1 was counseled for not following facility policy on not leaving the resident alone in the shower. A review of the facility policy and procedure titled, "Bath, Shower," dated 2006, indicated "never leave the resident alone in the shower room." A review of the facility policy and procedure titled, "Falls Management System," last reviewed by the Policy Review Committee on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E1W511 Facility ID: CA920000005 If continuation sheet 8 of 9 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: _______________ 055002 (X3) DATE SURVEY COMPLETED 11/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY MANOR HEALTHCARE 11723 Fenton Ave Sylmar, CA 91342 (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 12/06/2018, indicated that each resident is assisted in attainting or maintaining their highest practicable level of function through providing the resident adequate supervision to prevent accidents. A review of the facility policy and procedure titled, "Safety and Supervision of Residents," last reviewed by the Policy Review Committee on 12/06/2018, indicated resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. ResidentOriented Approach to Safety included implementing interventions to reduce accident risks and hazards as follows: A. communicating specific interventions to all relevant staff; B. assigning responsibility for carrying out interventions; C. providing training as necessary; D. ensuring that interventions are implemented; and E. documenting interventions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E1W511 Facility ID: CA920000005 If continuation sheet 9 of 9