Other·May 16, 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 the investigation of an Entity Reported Incident (ERI). ERI Number: 509795 Representing the Department of Public Health: Surveyor ID #: 36459 RN, HFEN The inspection was limited to the specific ERI investigation and does not represent the findings of a full inspection of the facility. A deficiency was issued for entity-reported incident 509795.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(h)

F323 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to identify and evaluate accident risks and hazards and did not implement interventions when necessary for one of four sampled residents (Resident 1). For Resident 1, who was assessed for high risk for falls and 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: Y8WT11 Facility ID: CA920000062 If continuation sheet 1 of 7 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: _______________ 055013 (X3) DATE SURVEY COMPLETED 04/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (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 dementia (decrease in the ability to think and remember, affects a person's daily functioning), the facility failed to monitor the side effects of a sedative medication after administration, failed to stay and talk to the resident one to one, per the plan of care interventions, and left Resident 1 unattended in the dining room. These deficient practices resulted in Resident 1 suffering a fall with injuries, which included a fractured left wrist, fractured left hip, a fractured left thigh bone, and required surgery. Findings: A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility on 6/1/16, and readmitted on 11/8/16, with diagnoses including osteoporosis (a condition in which the bones become weak and brittle), dementia, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), and anxiety (feeling of worry, nervousness, or unease, typically about an event or something with an uncertain outcome). A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated 9/7/16, indicated Resident 1 had severe cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions that affect everyday life) and Resident 1 required extensive assistance with transfer and toilet use. A review of Resident 1's care plan, initiated on 6/2/16 and updated 9/27/16, indicated Resident 1 had a potential risk for falls related to poor safety awareness, due to dementia and decrease in mobility. The goal indicated the resident would be free from falls or injury daily and the care plan interventions included keeping environment free from safety hazards. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Y8WT11 Facility ID: CA920000062 If continuation sheet 2 of 7 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: _______________ 055013 (X3) DATE SURVEY COMPLETED 04/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (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 care plan, initiated 7/21/16, updated 9/27/16, indicated Resident 1 had behavioral symptoms related to dementia with behavioral disturbance, manifested by restlessness and trying to get out of the wheelchair. The care plan intervention indicated to stay and talk to the resident one to one. According to the Fall Risk Predictive Factors Assessment, dated 9/6/16, Resident 1 was a high risk for falls due to resident having impaired mobility, poor recall, judgement and safety awareness. The fall risk assessment indicated Resident 1 required the use of an assistive device (wheel chair). A review of the psychiatric visit note, on 9/9/16, indicated a recommendation for Ativan (controlled substance [has a potential for abuse], sedative / hypnotic medication used to treat anxiety) 0.5 milligrams (mg) every six hours as needed for irritability and restlessness. According to the Interdisciplinary Team (IDT) notes for Psychoactive follow up, dated 9/28/16, Resident 1 had increasing anxiousness and poor safety awareness. A review of the IDT notes for Behavioral Issues or Psychotropic Medications, dated 10/6/16, indicated there was a concern regarding Resident 1's behavior of screaming, however the IDT note did not indicate what action was taken regarding the behavior concern. A review of the facility's in-service documents with the Director of Nursing, dated 10/20/16, indicated residents at risk for falls should not be left unattended. A review of the medication administration history (MAH) from 10/1/16 to 11/1/16, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Y8WT11 Facility ID: CA920000062 If continuation sheet 3 of 7 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: _______________ 055013 (X3) DATE SURVEY COMPLETED 04/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (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 indicated Resident 1 received Ativan 0.5 mg by mouth every six hours as needed a total of 37 times (approximately more than once per day). There was no documentation in the MAH regarding monitoring of the side effects from the Ativan after administration. According to Nurses Drug Guide, 2017, the side effects of Ativan include drowsiness, sedation, dizziness, and unsteadiness, and disorientation. A review of the MAH, dated 11/1/16, indicated Resident 1 received Ativan 0.5 mg at 3:06 p.m., for behavior issues (irritability / restlessness), but was not effective. A review of Resident 1's progress note, dated 11/1/16, at 10:23 p.m., indicated licensed vocational nurse 2 (LVN 2) documented Resident 1 had episodes of restlessness and always wanting to stand up when in bed or wheelchair. LVN 2 documented for staff to watch for Resident 1's safety. A review of Resident 1's progress note, dated 11/2/16, at 10:26 a.m., indicated LVN 3 documented Resident 1 was found on the floor in the dining room by the Activity Director. Resident 1 was found lying on her left side with left arm underneath her, approximately 8 feet from wheelchair. LVN 3 documented Resident 1 complained of severe pain to the left shoulder and was unable to move left leg. A review of the physician's order, dated 11/2/16, indicated Resident 1 was transferred to the general acute care hospital (GACH), via 911 related to a fall incident, complaining of severe pain to left shoulder and unable to move legs. According to the progress note, dated 11/2/16, at 3 p.m., Resident 1 returned to the skilled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Y8WT11 Facility ID: CA920000062 If continuation sheet 4 of 7 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: _______________ 055013 (X3) DATE SURVEY COMPLETED 04/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (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 nursing facility (SNF) with a left wrist splint and continued complaints of pain. A review of the progress note, dated 11/2/16, at 4:09 p.m., indicated Resident 1 was unable to move left leg and had severe pain to left leg. A review of the progress note, dated 11/2/16, at 11:30 p.m., indicated the physician was notified of the x-ray results, Resident 1 had a fracture to the left proximal femur (fracture to the upper part of the thigh bone). A review of the physician's order, dated 11/2/16, indicated Resident 1 was transferred to the GACH a second time, via 911 due to left femur fracture. According to the GACH x-ray report of the left wrist, dated 11/2/16, Resident 1 had an intraarticular fracture of the distal left radius (fracture that extends into the wrist joint towards the end of the radius (fore arm) bone). A review of the GACH x-ray report of the left hip, dated 11/3/16, indicated Resident 1 had an intertrochanteric comminuted fracture of the left hip and proximal femur (fracture to the upper part of the thigh bone into more than two fragments). A review of the operating room note, dated 11/4/16, indicated Resident 1 went to surgery for a left hip fracture. The resident had a closed reduction with intramedullary rodding (reducing a fracture without making an incision in the skin and rods were used to align and stabilize the broken bones), and a long arm cast was placed to the left upper extremity. During an interview with the Director of Nursing (DON), on 11/18/16, at 11:32 a.m., he stated Resident 1 was the last resident in the dining room and when the Activity Director went to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Y8WT11 Facility ID: CA920000062 If continuation sheet 5 of 7 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: _______________ 055013 (X3) DATE SURVEY COMPLETED 04/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (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 room, the resident was on the floor. The DON stated staff was given instructions to stay with the residents when in the dining room, but during the incident with Resident 1, there was no staff in the room. During an interview, on 11/18/16, at 11:45 a.m., the Activity Director stated when she entered the dining room, she found Resident 1 on the floor, and there was no other staff in the room when Resident 1 was found. On 11/18/16, at 12:15 p.m., during an interview, LVN 1 stated she was in the medication room when she received a call regarding Resident 1's fall in the dining room. LVN 1 stated, "There is always staff in the dining room with the residents, but in that moment the Activity Director had left and was on her way back when the fall happened." LVN 1 stated Resident 1 usually remained with staff because the resident had a "tendency to try and move herself out of her wheelchair." During an interview, on 11/18/16, at 12:45 p.m., the Registered Nurse Supervisor stated Resident 1 was assessed and was seen "lying on her left hand and right knee over left knee." The Registered Nurse Supervisor stated there should always be staff in the dining room supervising the resident, "That is what staff are told by the DON." On 1/11/17, at 3:02 p.m., during an interview, the DON stated he always emphasized with his staff not to leave residents who were high risk for falls unattended, especially in common areas and dining areas. During an interview, on 2/27/17, at 10:14 a.m., the DON stated there was no routine monitoring for the side effects for Ativan and the side effects should be monitored and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Y8WT11 Facility ID: CA920000062 If continuation sheet 6 of 7 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: _______________ 055013 (X3) DATE SURVEY COMPLETED 04/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (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 captured in the nursing weekly summary reports, but it was not. A review of the facility's policy and procedure titled, "Fall Risk Management," dated 12/2014, indicated the purpose of the policy was to make every reasonable effort to ensure each resident received adequate supervision. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Y8WT11 Facility ID: CA920000062 If continuation sheet 7 of 7