Other·December 26, 2018

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 one complaint during an abbreviated standard survey. Complaint number: CA00605587. Representing the Department : Health Facilities Evaluator Nurse #39672. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was written for complaint number CA00605587.

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 interview and record review, the facility failed to ensure one of three sampled residents, Resident 1, with a history of multiple falls, was closely monitored and supervised to 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: QJPV11 Facility ID: CA940000014 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: _______________ 056104 (X3) DATE SURVEY COMPLETED 11/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSE VILLA HEALTHCARE CENTER 9028 Rose St Bellflower, CA 90706 (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 prevent repeated falls and serious injury. This deficient practice resulted in Resident 1 having an unwitnessed fall while taking a shower unassisted, sustaining a right ankle fracture (broken bone) and requiring admission to General Acute Care Hospital 1 (GACH 1) for a right ankle surgery. Findings: A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility on 12/4/16 with diagnoses including dyspnea (difficulty breathing), end-stage renal disease (chronic irreversible kidney failure), muscle weakness, abnormalities of gait (walking) and mobility, and type 2 diabetes (long-term metabolic disorder that is characterized by high blood sugar, insulin resistance). A review of Resident 1's care plan dated 2/28/18, revised 6/1/18 indicated Resident 1 was at risk for falls related to hospitalization, aging process and with episode of taking showers without informing staff on his own. The care plan for Resident 1 indicated interventions to include reinforce teaching regarding safety, calling for assistance, as needed. A review of the Minimum Data Set (MDS standardized assessment and care-screening tool) dated 8/7/18, indicated Resident 1 was able to remember and make decisions. Resident 1 required physical help in part of the bathing activity and required supervision with setting up support for bed mobility, transfer, walk in the room and corridors, eating and toilet use. Resident 1 required limited assistance with one-person physical assist with dressing and personal hygiene. Resident 1 used walker and wheelchair for mobility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QJPV11 Facility ID: CA940000014 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: _______________ 056104 (X3) DATE SURVEY COMPLETED 11/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSE VILLA HEALTHCARE CENTER 9028 Rose St Bellflower, CA 90706 (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 a Fall Risk Assessment dated 8/12/18 indicated Resident 1 was at high risk for falls with a history of falls in the past three months, had balance problems while standing/walking, decreased muscular coordination/jerking movements, changes in gait pattern when walking and required the use of assistive devices. A care plan developed on 8/27/18, for Resident 1's ADL self-performance deficit related to decreased balance, decreased right upper extremity range of motion (ROM), increased pain on right shoulder, back and hip, indicated in the approaches to provide Resident 1 with assistance as needed. A review of the nursing Progress Notes indicated Resident 1 had unwitnessed falls on 5/23/18 and on 8/12/18. On 8/12/18, the documentation indicated Resident 1 used the toilet by himself and when tried to reach the toilet paper, he lost his balance and fell on the floor. A review of nursing Progress Note dated 9/25/18, timed at 10:30 a.m. indicated Registered Nurse 1 (RN 1) was called by a nursing staff after hearing Resident 1 yelling for help. RN 1 found Resident 1 sitting on the shower floor with the shower chair in front of him. Resident 1 stated he stood up from the shower chair and slipped off the floor. Resident 1 tried to prevent the fall by holding on to the wall but failed and on his right side hitting his right ankle. Resident 1 complained of pain rated 8/10 (pain rating scale from zero indicating no pain and 10 the worst possible pain) to his right leg. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QJPV11 Facility ID: CA940000014 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: _______________ 056104 (X3) DATE SURVEY COMPLETED 11/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSE VILLA HEALTHCARE CENTER 9028 Rose St Bellflower, CA 90706 (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 was transferred the same day of the fall, 9/25/18, to GACH 1. Further review of the clinical record disclosed there were no additional interventions the interdisciplinary team had identified to address that the resident continued to go to the shower room by himself. There was no system in place to prevent the resident to go to the shower room unattended. A review of GACH 1's x-ray (taking images pictures of the inside of the body) results for two views of the right ankle, dated 9/26/18 indicated the Resident 1 had an acute trimalleolar fracture (is a three-part break) of the ankle. A review of a GACH 1's Physician's Discharge Summary, dated 9/27/18 indicated Resident 1 was admitted on 9/25/18 and discharged on 9/27/18 back to the facility after undergoing surgery to repair the right ankle fracture. On 9/28/18, at 10:30 a.m., during an interview, the facility's Director of Nursing (DON) confirmed Resident 1 fell in the shower room on 9/25/18. DON was unable to provide documented evidence of a system in place that the facility used to safely monitor the resident from going to the bathroom unassisted to prevent repeated falls and serious injury. On 10/30/18, at 3:15 p.m., during an interview, Resident 1 stated on the morning of the fall (9/25/18), the resident asked a Certified Nursing Assistant, if he could take a shower. Resident 1 stated he could not remember the CNA's name but was told to go ahead and take a shower and they would be in to assist. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QJPV11 Facility ID: CA940000014 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: _______________ 056104 (X3) DATE SURVEY COMPLETED 11/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSE VILLA HEALTHCARE CENTER 9028 Rose St Bellflower, CA 90706 (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 According to Resident 1, staff never showed up. Resident 1 stated he usually takes a shower by himself and unassisted. On 11/14/18, at 3:50 p.m., during an interview, MDS 1 stated on 9/25/18, she was in her office, which was across from the shower room and she heard yelling. MDS 1 stated she went to the shower room and found Resident 1 on the floor in the shower by himself and she notified RN 1 of the incident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QJPV11 Facility ID: CA940000014 If continuation sheet 5 of 5