Other·July 12, 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 an investigation of an entity reported incident (ERI) and two complaint investigations. ERI No: CA00526824 : substantiated, refer to F 279 and F 323 Complaint No: CA00528497: substantiated, refer to F 279 and F 323 CA00526643: substantiated, refer to F 279 and

F 323 Representing the Department of Public Health: Evaluator ID No: 36575, RN, HFEN The inspection was limited to the specific ERI and complaints and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for ERI CA00526824 and complaint investigations CA00528497 and CA00526643.

F279 SS=D DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d);483.21(b)(1)

F279 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan. 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: 11FU11 Facility ID: CA940000044 If continuation sheet 1 of 16 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: _______________ 555112 (X3) DATE SURVEY COMPLETED 06/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (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 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c) (3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (iv)In consultation with the resident and the resident’s representative (s)(A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 11FU11 Facility ID: CA940000044 If continuation sheet 2 of 16 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: _______________ 555112 (X3) DATE SURVEY COMPLETED 06/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (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 community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to specify the frequency of visual checks on the care plan for one of two sampled residents (Resident 1), who was at risk for falls and had an actual fall on 12/20/16. The deficient practice had the potential for Resident 1 having more fall incidents. Findings: A review of Resident 1's record titled, "Face Sheet (admission record)," indicated Resident 1 was admitted to the facility on 7/16/12, and was re-admitted on 2/5/17, with diagnoses that included abnormalities of gait (the manner or style of walking) and mobility (the ability to move or be moved freely and easily), muscle wasting and atrophy (muscle loss that can cause inability to move certain body parts), Alzheimer's disease (a progressive disease of the brain that is characterized by symptoms like impairment of memory and eventually by disturbances in reasoning, planning, language, and understanding), dementia ( a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily functioning, and the most common behavioral disturbances of dementia include lack of interest or concern and agitation), hemiplegia (paralysis of one side of the body) following a stroke (interrupted blood flow to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 11FU11 Facility ID: CA940000044 If continuation sheet 3 of 16 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: _______________ 555112 (X3) DATE SURVEY COMPLETED 06/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (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 brain that results in brain cell death causing temporary or permanent disabilities); pseudobulbar affect (emotional instability due to a neurologic disorder characterized by involuntary crying or uncontrollable episodes of emotional displays), and osteoporosis (a condition that causes bones to become weak and brittle that a fall or even mild stresses can cause broken bones). A review of Resident 1's record titled, "Minimum Data Set ([MDS], a resident assessment and care screening tool), dated 1/11/17, indicated Resident 1 had severe cognitive (ability to reason and think) impairment. The MDS indicated Resident 1 required extensive assistance (resident performed part of the activity; staff provided support with bearing weight, at times full staff performance of activity) with one person physical assistance for the following activities of daily living ([ADLs], routine activities that individuals tend to perform every day without needing assistance): bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), locomotion on and off unit (how resident moves between locations in his/her room and off unit locations that is areas set aside for dining, activities or treatments. If in wheelchair, self-sufficiency once in wheelchair), dressing, eating, toilet use (how resident uses the toilet room, commode, bedpan; transfers on/off toilet; cleanses self after elimination; changes pad; and adjust clothes), and personal hygiene. The MDS indicated Resident 1's balance was not steady and was only able to stabilize with staff assistance for the following: moving from seated to standing position, walking, turning around, moving on and off toilet, and surfaceFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 11FU11 Facility ID: CA940000044 If continuation sheet 4 of 16 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: _______________ 555112 (X3) DATE SURVEY COMPLETED 06/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (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 to-surface transfer. The MDS indicated Resident 1 used a walker and wheelchair for mobility. A review of Resident 1's record titled, "Fall Risk Data Collection," dated 11/6/16, and 12/20/16, indicated Resident 1 was assessed as high risk for fall. A review of Resident 1's COC (Change of Condition)/ SBAR ([Situation, Background, Assessment, and Recommendation], a tool to help improve communication between healthcare staff), dated 12/20/16 at 12:20 a.m., indicated Resident 1 was observed restless in the wheelchair and was calling out for no apparent reason. The COC/SBAR indicated Resident 1 was placed in the lobby across from the nursing station and Resident 1 continued to pull on the seat belt. The COC/SBAR indicated Resident 1 was administered Ativan (a medication used to treat anxiety) but Resident 1 continued to yell out and reach down at socks and pull at her gown with the seat belt. The COC/SBAR indicated Resident 1 was found on the floor next to the wheelchair. The COC/SBAR indicated Resident 1's seat belt remained intact and the wheelchair alarm was crumpled from friction. A review of Resident 1's Post-Fall Assessment, dated 12/20/16, indicated Resident 1 had a fall from the wheelchair with non-release seat belt after least restrictive measures had been provided and ineffective. The interdisciplinary team ([IDT], a group of health care professionals from diverse fields who work together in establishing a plan and goals for the achievement of a resident's maximum potential) recommendations included to continue visual checks as previously done at least every one hour and as needed and continue current interventions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 11FU11 Facility ID: CA940000044 If continuation sheet 5 of 16 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: _______________ 555112 (X3) DATE SURVEY COMPLETED 06/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (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 On 3/29/17 at 1:50 p.m., during an interview and concurrent review of Resident 1's Post-Fall Assessment, dated 12/20/16, DON stated the IDT recommendations for Resident 1 were to continue visual checks as previously done at least every one hour and as needed and continue current interventions. The DON stated there were no documentation in Resident 1's record that staff were providing visual checks every one hour and as needed for Resident 1. On 3/29/17 at 1:50 p.m., during an interview and concurrent review of Resident 1's care plan for actual fall, dated 12/20/16, DON stated the care plan indicated a facility intervention of visual checks. The DON stated the care plan should have specified the frequency of the visual checks. The DON stated the purpose of a care plan was to address a resident problem, indicate a resident goal, and to indicate facility interventions to minimize the problem. The DON stated the purpose of a care plan was to make sure that the resident was being taken cared. The DON stated the care plan should be evaluated for effectiveness quarterly and as needed basis such as upon a change of condition. The DON stated the care plan should be revised or updated by revising or adding interventions related to the resident's problem. A review of the facility's policy and procedures titled, "Care Planning," dated 3/1/14, indicated the facility was responsible for ensuring a comprehensive care plan was developed for each resident. The policy indicated the facility was responsible for providing person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 11FU11 Facility ID: CA940000044 If continuation sheet 6 of 16 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: _______________ 555112 (X3) DATE SURVEY COMPLETED 06/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F323 FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 SS=G PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide the following care and services to one of two sampled residents (Resident 1): 1. Review and revise Resident 1's care plan interventions for effectiveness after a fall in accordance with facility policy and procedures. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 11FU11 Facility ID: CA940000044 If continuation sheet 7 of 16 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: _______________ 555112 (X3) DATE SURVEY COMPLETED 06/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (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 2. Provide staff supervision in accordance with Resident 1's care plan. Resident 1, who had history of falling (4/24/16, 6/22/16, 8/5/16, 11/6/16, and 12/20/16), was placed in a wheelchair with a self-release belt (an intervention that was identified not effective) and was taken to the nursing station for close monitoring on 3/5/17, at 4:40 a.m. Resident 1 was left unsupervised in the nursing station and fell. This deficient practice resulted in Resident 1 being transferred to the hospital on 3/5/17, and was diagnosed to have subdural hematoma (pooling of blood around the brain that is mainly due to head trauma) and left hip fracture (a break in the upper part of the thighbone where it forms the hip joint). Findings: A review of Resident 1's record titled, "Face Sheet (admission record)," indicated Resident 1 was admitted to the facility on 7/16/12, and was re-admitted on 2/5/17, with diagnoses that included abnormalities of gait (the manner or style of walking) and mobility (the ability to move or be moved freely and easily), muscle wasting and atrophy (muscle loss that can cause inability to move certain body parts), Alzheimer's disease (a progressive disease of the brain), dementia (a group of symptoms affecting memory, thinking, and social abilities), hemiplegia (paralysis of one side of the body) following a stroke (interrupted blood flow to the brain that results in brain cell death causing temporary or permanent disabilities); pseudobulbar affect (emotional instability due to a neurologic disorder), and osteoporosis (a condition that causes bones to become weak and brittle). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 11FU11 Facility ID: CA940000044 If continuation sheet 8 of 16 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: _______________ 555112 (X3) DATE SURVEY COMPLETED 06/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (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 record titled, "Minimum Data Set ([MDS], a resident assessment and care screening tool), dated 1/11/17, indicated Resident 1 had severe cognitive (ability to reason and think) impairment. The MDS indicated Resident 1 required extensive assistance (resident performed part of the activity; staff provided support with bearing weight, at times full staff performance of activity) with one person physical assistance for the following activities of daily living ([ADLs], routine activities that individuals tend to perform every day without needing assistance): bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), transfers (how resident moves between surfaces), locomotion on and off unit (how resident moves between locations), dressing, eating, toilet use (how resident uses the toilet room), and personal hygiene. The MDS indicated Resident 1's balance was not steady and was only able to stabilize with staff assistance. The MDS indicated Resident 1 used a walker and wheelchair for mobility. A review of Resident 1's record titled, "Fall Risk Data Collection," dated 1/16/17, indicated Resident 1 was assessed as high risk for fall. The Fall Risk Data Collection indicated Resident 1 was assessed high risk for fall on 4/13/16, 4/24/16, 6/22/16, 8/5/16, 10/10/16, 11/6/16, and 12/20/16. A review of Resident 1's record titled, "History and Physical Examination," dated 2/7/17, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's record titled, "Progress Note," dated 2/21/17, the psychiatrist indicated Resident 1 had shown confusion, disorganization, disorientation, and a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 11FU11 Facility ID: CA940000044 If continuation sheet 9 of 16 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: _______________ 555112 (X3) DATE SURVEY COMPLETED 06/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (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 noticeable decline in cognitive functions. The progress note indicated Resident 1 continued to be restless, constantly fidgeting and unable to keep still. The progress note indicated Resident 1's self-care skills were impaired and the resident required cues and assistance to perform self-care skills, and that Resident 1 was dependent on others. A review of Resident 1's record titled, "COC (Change of Condition)/ SBAR ([Situation, Background, Assessment, and Recommendation], a tool to help improve communication between healthcare staff), dated 4/24/16 at 7:30 p.m., indicated Resident 1 was in her wheelchair, took off self-release belt, and dropped to her knees. A review of Resident 1's record titled, "Post-Fall Assessment," dated 4/25/16, indicated another resident witnessed Resident 1's fall on 4/24/16 in the hallway. The interdisciplinary team ([IDT], a group of health care professionals from diverse fields who work together in establishing a plan and goals for the achievement of a resident's maximum potential) recommendations included to refer Resident 1 to physical therapy for evaluation, remind Resident 1 not to get up unassisted and to ask for assistance (MDS indicated Resident 1 had severe cognitive impairment), continue the use of the wheelchair alarm (an alarm used for fall prevention and safety) and self-release belt (a belt that the resident was able to remove or release) to remind Resident 1 not to get up unassisted; provide frequent visual checks; and continue to attend and anticipate resident's needs promptly. A review of Resident 1's COC/SBAR, dated 6/22/16 at 8:30 p.m., indicated the wheelchair alarm was heard from Resident 1's room. Resident 1 was found on the floor lying on her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 11FU11 Facility ID: CA940000044 If continuation sheet 10 of 16 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: _______________ 555112 (X3) DATE SURVEY COMPLETED 06/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (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 back. Resident 1 sustained redness on the left lower back. A review of Resident 1's Post-Fall Assessment, dated 6/23/16, indicated Resident 1 was last seen with self-release belt and alarm in wheelchair. The Post-Fall Assessment indicated Resident 1 was able to release the self-release belt and attempted to stand up, lost her balance, and fell. The IDT recommendations included to continue physical therapy, provide frequent visual checks, continue the use of the wheelchair and bed alarms and self-release belt, remind Resident 1 not to get up unassisted and instruct Resident 1 to use wheelchair brakes. A review of Resident 1's COC/SBAR, dated 8/5/16 at 8:55 p.m., indicated a Certified Nurse Assistant (CNA X) was fixing Resident 1's bed while Resident 1 was in her wheelchair inside her room. CNA X heard the wheelchair alarm and then saw Resident 1 on the floor with blood coming out from the right nostril. The COC/SBAR indicated Resident 1 was agitated and 9-1-1 (emergency number) was called. A review of Resident 1's Post-Fall Assessment, dated 8/5/16, indicated Resident 1 was able to release the self-release belt. The IDT recommendations included to continue safety belt as a fall prevention intervention, provide frequent visual checks, and to continue the use of the wheelchair and bed alarms. A review of Resident 1's COC/SBAR, dated 11/6/16 at 2:50 p.m., indicated Resident 1 was found on the floor, lying on her right side and the wheelchair alarm was going off and the safety belt was off. The COC/SBAR indicated Resident 1 sustained a bump on the right side of the forehead with reddened discoloration. The COC/SBAR indicated Resident 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 11FU11 Facility ID: CA940000044 If continuation sheet 11 of 16 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: _______________ 555112 (X3) DATE SURVEY COMPLETED 06/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (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 transferred to the emergency room for evaluation due to the fall. A review of Resident 1's Post-Fall Assessment, dated 11/7/16, indicated Resident 1 was in the hallway, witnessed getting up from the wheelchair unassisted and falling. The PostFall Assessment indicated Resident 1 had episodes of forgetfulness and confusion, and noted at various times removing the safety seat belt (self-release belt). The IDT recommendations included visual checks every hour for 72 hours for Resident 1. A review of Resident 1's record titled, "Physician and Telephone Orders," dated 11/7/16, indicated to discontinue self-release belt and put non-release seat belt for safety secondary to diagnosis of Alzheimer's disease, may release every two hours and PRN (whenever necessary for ADLs and skin evaluation. A review of Resident 1's COC/SBAR, dated 12/20/16 at 12:20 a.m., indicated Resident 1 was observed restless in the wheelchair and was calling out for no apparent reason. The COC/SBAR indicated Resident 1 was placed in the lobby across from the nursing station and Resident 1 continued to pull on the seat belt. The COC/SBAR indicated Resident 1 was administered Ativan (a medication used to treat anxiety) but Resident 1 "continued to yell out and reach down at socks and pull at her gown with the seat belt." "RN (not identified) continued on to check rooms down heading to the outside patio when flagged down by a Certified Nurse Assistant CNA (not identified) to alert RN patient on floor." The COC/SBAR indicated Resident 1 was found on the floor next to the wheelchair. The COC/SBAR indicated Resident 1's seat belt remained intact and the wheelchair alarm was crumpled from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 11FU11 Facility ID: CA940000044 If continuation sheet 12 of 16 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: _______________ 555112 (X3) DATE SURVEY COMPLETED 06/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (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 friction. A review of Resident 1's Post-Fall Assessment, dated 12/20/16, indicated Resident 1 had a fall from the wheelchair with non-release seat belt after least restrictive measures had been provided and ineffective. The IDT recommendations included to continue visual checks as previously done at least every one hour and as needed and continue to current interventions. A review of Resident 1's COC/SBAR, dated 3/5/17 at 4:45 a.m., the Licensed Vocational Nurse (LVN) 1 documented that on 3/5/17 at 4:20 a.m., Resident 1 was observed trying to slide herself from the bed onto the floor mats. At 4:40 a.m., Resident 1 was trying to slide herself onto the floor mats and the bed alarm keeps going off. LVN 1 placed Resident 1 in her wheelchair for close monitoring at the nursing station. The self-release seat belt and wheelchair alarm was applied for Resident 1 in the wheelchair. LVN 1 was asked to assist with another resident in the room. LVN 1 then heard the alarm sound in the room and ran to check Resident 1 who was observed on the floor beside her wheelchair. LVN 1 stated that Resident 1 knew how to take off the seat belt. Resident 1 sustained a cut to the left eyebrow that was bleeding. At 5 a.m., Resident 1's physician was notified of the fall with order to transfer to the hospital for evaluation and treatment. At 6:50 a.m., Resident 1 left the facility by ambulance. During review of Resident 1's records in regard to the fall incidents on 3/29/17 at 1:50 p.m., the Director of Nursing (DON) stated Resident 1 was known to take off the self-release belt and the resident would stand up without staff assistance. The DON stated the facility implemented the self-release belt to prevent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 11FU11 Facility ID: CA940000044 If continuation sheet 13 of 16 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: _______________ 555112 (X3) DATE SURVEY COMPLETED 06/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (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 falls but Resident 1 continued to have fall incidents. The DON stated another facility intervention was to provide visual checks for Resident 1. The DON stated there were no documentation that staff were providing visual checks for Resident 1. The DON stated Resident 1's care plan should have specified the frequency of the visual checks. The DON stated the care plan interventions should have been evaluated for effectiveness. The DON stated the care plan interventions should have been reviewed and revised to address Resident 1's problem. On 5/5/17 at 7:07 a.m., during a telephone interview, LVN 1 stated on 3/5/17, at 4:20 a.m., Resident 1's bed alarm was making a lot of sound. Resident 1 was observed moving a lot in bed, with both legs hanging off the bed, trying to slide herself off the bed. LVN 1 stated that she decided to place Resident 1 on the wheelchair with the self-release belt and alarm in the wheelchair. LVN 1 stated she then took Resident 1 in the nursing station by the hallway so that LVN 1 could closely monitor Resident 1 to prevent fall. LVN 1 stated that Resident 1 knew how to unhook self- release belt on her own and was fast in releasing the self-release belt. LVN 1 stated CNA 2 asked LVN 1 to assist with Randon Sampled Resident (RSR) 1 in RSR 1's room. LVN 1 stated she left Resident 1 in the wheelchair at the nursing station without staff supervision. LVN 1 stated she heard the alarm sound while she was in RSR 1's room. LVN 1stated she ran out of RSR 1's room and saw Resident 1 on the floor next to the wheelchair. LVN 1 stated there was no staff present during the time of Resident 1's fall. LVN 1 stated she felt the self-release belt was enough to prevent the fall. LVN 1 stated Resident 1 could have been placed on one to one staff supervision (one resident by one staff member who remains with the resident at all FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 11FU11 Facility ID: CA940000044 If continuation sheet 14 of 16 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: _______________ 555112 (X3) DATE SURVEY COMPLETED 06/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (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 times) to prevent the fall. LVN 1 stated Resident 1 sustained a cut to the left eyebrow area with minimal bleeding and small amount of blood in her mouth due to possibility that Resident 1 may have hit her head on the floor from the fall. On 5/8/17 at 12:08 p.m., during an interview and concurrent review of Resident 1's COC/SBAR, dated 3/5/17, DON stated LVN 1 left Resident 1 at the nursing station to assist RSR 1 and Resident 1 had a fall. DON stated, "The staff (LVN 1) should not have turned her back on the resident (Resident 1) and should not have left the resident because the resident was quick to release the self release belt." The DON stated, "The resident's (Resident 1) fall could have been avoided if the resident was supervised and the staff (LVN 1) did not leave the resident." A review of the facility's policy and procedures titled, "Care Planning," revised 3/1/14, indicated the care plan will be periodically reviewed and revised by the IDT at intervals that included when there was a change of condition. According to the facility's policy and procedures titled, "Fall Management Program," dated 6/1/15, the facility was responsible for providing a safe environment that minimizes complications associated with falls. A review of Resident 1's hospital admission records dated 3/5/17, at 11:23 a.m., indicated Resident 1 arrived in the emergency room (ER) and was seen at 7:17 a.m. The ER record indicated, "Critical care (involves close, constant attention by a team of speciallytrained health care providers) was provided to prevent clinically significant and life-threatening deterioration of the patient's condition." The ER FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 11FU11 Facility ID: CA940000044 If continuation sheet 15 of 16 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: _______________ 555112 (X3) DATE SURVEY COMPLETED 06/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL RANCHO VISTA HEALTH CARE CENTER 8925 Mines Ave Pico Rivera, CA 90660 (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 record indicated Resident 1 was to be admitted to the intensive care unit ([ICU], a special department that provides intensive treatment medicine) due to subdural hemorrhage. A review of Resident 1's hospital diagnostic test result, dated 3/5/17, indicated computerized axial tomography ([CT scan], xray equipment that helps reveal internal injuries and bleeding quickly) of the head with findings of left subdural bleed, subdural hematoma (a collection of blood outside the brain that causes increased pressure on the brain that can be life-threatening), subarachnoid hemorrhage (bleeding in the space that surrounds the brain), and fracture in the anterior wall of the left maxillary sinus (area of the facial bone). A review of Resident 1's hospital diagnostic test result, dated 3/7/17, indicated CT scan of the pelvis (joint area of hip and thigh bone) with findings of fracture (broken bone) of the left femur (thigh bone) with angulation (abnormal position of fractured bones). A review of Resident 1's hospital record titled, "Discharge Summary," dated 3/19/17, indicated, "Option of surgery was considered for left hip surgery, because of the patient's condition it was thought she is high risk, so family did not want to go through surgery and opted for palliative and hospice (a multidisciplinary approach to specialized medical care) care services." The Discharge Summary indicated Resident 1's final diagnoses included: history of fall with subdural hematoma, history of left hip fracture, and advanced dementia. The Discharge Summary indicated Resident 1's prognosis (the likely course of disease or ailment or the outcome of one's chance of survival) was poor. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 11FU11 Facility ID: CA940000044 If continuation sheet 16 of 16