Other·August 13, 2019

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 facility reported incident (FRI). FRI number: CA00639436. Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 39230. The inspection was limited to the specific FRI investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for FRI CA00639436.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 07/25/2019 §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 provide the required assistance to prevent accidents for one of three sampled residents (Resident 1) including: 1. Failure to provide Resident 1 with extensive 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: MSM711 Facility ID: CA970000095 If continuation sheet 1 of 8 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: _______________ 055288 (X3) DATE SURVEY COMPLETED 07/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUTUMN HILLS HEALTH CARE CENTER 430 N Glendale Ave Glendale, CA 91206 (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 assistance (staff provide weight-bearing support) during dressing and required twoperson assist during transfer (how resident moves to and from bed, chair, wheelchair, standing position). 2. Failure to provide Certified Nursing Assistant 1 (CNA 1) with instructions and training on safe techniques on dressing Resident 1. 3. Failure to implement the facility's policy on Rehabilitation Admission and Discharge by not providing ongoing education and caregiver training. 4. Failure to implement the facility's policy on Dressing and Grooming Education, by CNA 1 not instructing Resident 1 to lie down on the bed when putting an incontinent brief on Resident 1, who could not stand without support. 5. Failure to implement the facility's policy on Fall Prevention, by not having a fall prevention program for Resident 1 that provided care staff with creative, functional strategies to prevent fall. As a result, on 5/20/19 at 10 a.m., Resident 1 fell and sustained fractures (break of bones) of both knees, the right thigh, and left lower leg requiring transfer to General Acute Care Hospital 1 (GACH 1). Resident was admitted, family opted for no surgery, and returned back to the facility on 5/31/19. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted Resident 1, on 5/5/14, with the most recent readmission dated 5/31/19. Resident 1's diagnoses included dementia (decline in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MSM711 Facility ID: CA970000095 If continuation sheet 2 of 8 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: _______________ 055288 (X3) DATE SURVEY COMPLETED 07/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUTUMN HILLS HEALTH CARE CENTER 430 N Glendale Ave Glendale, CA 91206 (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 memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), polyosteoarthritis (multiple joint pain and stiffness), and osteoporosis (a condition in which the bone becomes brittle and fragile). A review of Resident 1's Minimum Data Set (MDS - standardized assessment and carescreening tool) dated 5/8/19, indicated Resident 1's cognition (mental process of acquiring knowledge and understanding) was severely impaired, required extensive assistance (staff provide weight-bearing support) with one-person physical assist with dressing, toilet use, personal hygiene and needed two-person physical assist with transfer. A review of Resident 1's Fall Risk Data Collection, dated 5/8/19, indicated Resident 1's total fall risk score was 20 (a total of 10 or above represented high risk). Resident 1 had gait (manner of walking) and balance problems. A review of Resident 1's care plan for the risk of falls and injury, initiated on 5/8/19, included in the interventions to establish Resident 1's physical function and provide Resident 1 with the necessary assistance. A review of Resident 1's care plan for self-care deficit, revised on 5/14/19, had in the approaches assisting with activities of daily living (ADLs - transferring, dressing, personal hygiene, and bathing). A review of Resident 1's care plan for the risk of spontaneous fracture related to osteoporosis/osteoarthritis, revised on 5/14/19, included in the approaches assessing Resident 1's functional limitations quarterly or as indicated and helping with ADLs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MSM711 Facility ID: CA970000095 If continuation sheet 3 of 8 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: _______________ 055288 (X3) DATE SURVEY COMPLETED 07/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUTUMN HILLS HEALTH CARE CENTER 430 N Glendale Ave Glendale, CA 91206 (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 physician's order, dated 2/13/19, indicated Physical Therapist (PT) to evaluate and treat Resident 1 due to difficulty in walking. A review of Resident 1's PT Evaluation and Plan of Treatment form, dated 2/13/19, indicated Resident 1 had a new onset of decreased functional mobility, reduced static (stationary) and dynamic (in motion) balance, and reduced ability to ambulate safely. The background assessment indicated Resident 1 had a high fall risk and poor static and dynamic standing balance (maximum assistance). The PT Discharge Summary, dated 3/19/19, indicated Resident 1 had a poor static standing balance and needed moderate assistance (required 26 percent [%] to 75 % assist from staff). A review of the physician's order, dated 5/14/19, indicated Occupational Therapist (OT) to evaluate and treat Resident 1. A review of Resident 1's OT Evaluation and Plan of Treatment form, dated 5/14/19, indicated Resident 1 had a decline in grooming, hygiene, dressing, and toilet transfer, due to decreased strength on both upper extremities and decreased sitting/standing balance, resulting in reduced safety and an increased need for assistance. The background assessment indicated that Resident 1 had a high fall risk with poor standing balance, requiring maximum assistance (76 % to 99 % assist from staff) during ADLs. The functional skills assessment indicated total dependence on lower body dressing. A review of Resident 1's OT Discharge Summary, dated 5/20/19, indicated Resident 1 had poor standing balance during ADLs and was dependent (maximum assistance) on staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MSM711 Facility ID: CA970000095 If continuation sheet 4 of 8 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: _______________ 055288 (X3) DATE SURVEY COMPLETED 07/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUTUMN HILLS HEALTH CARE CENTER 430 N Glendale Ave Glendale, CA 91206 (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 with lower body dressing. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR), dated 5/20/19 at 10 a.m., indicated Resident 1 had a fall in the shower room. CNA 1 assisted Resident 1 to stand up with a front wheel walker (FWW) against the wall for stability. CNA 1 was behind Resident 1 to pull up the incontinent brief. Resident 1's legs gave out, and CNA 1 was not able to pull Resident 1 back to the wheelchair. Resident 1 kneeled on the floor and hit her head in the wall. The physician notified, at 10:10 a.m., ordered x-rays (pictures of the inside of the body) of Resident 1's lower extremities. A review of the x-ray results, dated 5/20/19, indicated Resident 1 had left and right knee fractures with associated joint effusion (water in the joint). Resident 1 had a fracture involving left proximal tibia (the inner, long bone of the leg) and fibula (the outer, smaller bone of the leg) with mild displacement (the bone snapped into two or more parts and moved so that the two ends are not lined up straight). Resident 1 also had a complete oblique fracture (a broken bone in which the bone breaks at an angle) involving right distal femur (bone of the thigh) with mild displacement. A review of Resident 1's Progress Notes, dated 5/20/19 at 2:55 p.m., indicated the physician was informed of the x-ray results and ordered to transfer Resident 1 to GACH 1. A review of the facility's Investigation Report, Interview Record, dated 5/20/19 timed at 4:45 p.m., indicated CNA 1 gave a shower to Resident 1 around 10 a.m., then tried to put the incontinent brief by having Resident 1 stand up and hold the FWW. Resident 1 successfully and easily stood up from the shower chair, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MSM711 Facility ID: CA970000095 If continuation sheet 5 of 8 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: _______________ 055288 (X3) DATE SURVEY COMPLETED 07/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUTUMN HILLS HEALTH CARE CENTER 430 N Glendale Ave Glendale, CA 91206 (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 while CNA 1 was trying to put the brief on, Resident 1's legs gave up. CNA 1 was not able to hold Resident 1. Resident 1 kneeled on the floor and hit her head on the wall. A review of the GACH 1 History and Physical examination, dated 5/21/19, indicated Resident 1 had bilateral knee fractures, mildly displaced fracture of the distal right femur, and mild posterior (back) displacement of the distal fracture fragment and comminuted (crushed into numerous pieces) mildly impacted fractures of the left proximal tibia and proximal fibula. Resident 1 was admitted to be evaluated by a physician in orthopedic surgery (the branch of surgery concerned with conditions involving the musculoskeletal system [bones, muscles, and their associated tissues such as tendons and ligaments]). A review of the GACH 1 Discharge Summary, dated 5/30/19, indicated Resident 1's family decided for no surgery and placed resident on hospice care (a terminally ill person who's expected to have six months or less to live). During observation and concurrent interview, on 6/10/19, at 9:10 a.m., Resident 1 was laying on the bed, had redness on the middle of the forehead, had immobilizers (a device to prevent or restrict movement) on both lower extremities, and swollen knees and legs. Resident 1 could not recall the fall incident. During an interview, on 6/10/19 at 11:05 a.m., CNA 1 stated no one witnessed the incident, and she was the only one assisting Resident 1. CNA 1 stated nobody (licensed nurses and/or rehabilitation services) informed her that Resident 1 was not able to stand up on her own. CNA 1 stated she did not receive training from the rehabilitation services. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MSM711 Facility ID: CA970000095 If continuation sheet 6 of 8 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: _______________ 055288 (X3) DATE SURVEY COMPLETED 07/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUTUMN HILLS HEALTH CARE CENTER 430 N Glendale Ave Glendale, CA 91206 (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 During a record review of Resident 1's medical records and concurrent interview, on 6/10/19 at 3:10 p.m., PT 1 reviewed her documentation on 2/13/19 and 3/19/19. PT 1 stated Resident 1 had poor standing balance and required moderate assistance. PT 1 stated Resident 1 had weakness on both lower extremities. PT 1 stated staff should hold her while standing and use a gait belt for support. PT 1 stated Resident 1 should not stand up with a walker during dressing. PT 1 reviewed Resident 1's medical records, and the medical records had no documented evidence that resident's progress for the rehabilitation program was routinely discussed to caregivers by ongoing education and training. During an interview, on 6/10/19, at 4:20 p.m., Director of Staff Development (DSD) stated Resident 1 should have two-person assist in during care. DSD was unable to provide documentation that CNAs were informed of Resident 1's needs. During an interview, on 6/17/19 at 8:35 a.m., OT 1 stated he assessed and evaluated Resident 1, on 5/14/19, due to reported decline in ADL participation and regression in physical strength. OT 1 stated Resident 1 had poor standing balance during ADLs, required maximum assistance, and dependent on lower body (LB) dressing. OT 1 stated maximum assistance means 76 % to 99% physical assist from staff and dependent means staff doing everything for the resident. OT 1 stated Resident 1 was unable to stand up on her own and tendency to buckle while doing rehabilitation activity with him. OT 1 stated he used gait belt and exerted almost 100% to hold Resident 1 during rehabilitation activity to prevent a fall. OT 1 stated Resident 1 does not have much strength to grasp, and Resident 1 should not stand up in the walker during FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MSM711 Facility ID: CA970000095 If continuation sheet 7 of 8 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: _______________ 055288 (X3) DATE SURVEY COMPLETED 07/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUTUMN HILLS HEALTH CARE CENTER 430 N Glendale Ave Glendale, CA 91206 (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 dressing, unless there were two persons assisting Resident 1. OT 1 stated the safest way to do LB dressing was on lying position for safety of the resident and staff. A review of the facility's policy and procedure titled, "Rehabilitation Admission and Discharge," dated 4/2005, indicated throughout the skilled rehabilitation program, the resident's progress should be routinely discussed. Throughout therapy, ongoing education, and caregiver training should be provided and documented to prepare for the targeted discharge disposition. A review of the facility's policy and procedure titled, "Dressing and Grooming Education," dated 3/2000, indicated putting on or taking off trousers, if the resident cannot stand without support, the resident should lie down on the bed or if standing balance is poor, instruct resident to lie down in the bed. A review of facility's policy and procedure titled, "Fall Prevention," dated 12/1/05, indicated a fall prevention program will be developed for each patient that will provide patient care staff with creative, functional strategies to prevent fall and undue injuries from such incidents, while recognizing the patients' rights and their needs to maintain their highest level of functioning. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MSM711 Facility ID: CA970000095 If continuation sheet 8 of 8