Other·January 12, 2018

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 one entity reported incident (ERI) during an Abbreviated standard survey. ERI number: CA00543753 - Substantiated Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 36289 The inspection was limited to the specific ERI investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for entity reported incident number CA00543753.

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

F323 12/20/2017 (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 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: 2ZBT11 Facility ID: CA940000093 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: _______________ 055539 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARTESIA CHRISTIAN HOME INC. 11614 183rd St Artesia, CA 90701 (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 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 ensure a resident's plan of care and the facility's policy and procedure were implemented to prevent falls for one of two sampled residents (Resident 1). Resident 1, who had high risk for falls was left in the bathroom unsupervised and the resident got up from the toilet and fell, resulting in blunt head trauma (BHT) with a hematoma (a pool of blood between the brain and the brain's outermost covering ) and a right fractured (broken bone) hip. These deficient practices resulted in Resident 1 falling sustaining injuries with severe pain, requiring a transfer to a General Acute Care Hospital (GACH), undergoing a surgical repair of the right hip fracture and admittance for pain management for three days. Findings: A review of Resident 1's Face Sheet indicated the resident was originally admitted to the facility on 12/22/16 at 9:55 a.m., and readmitted on 7/15/17 at 6:30 p.m. The resident's diagnoses included Alzheimer's disease (a progressive disease that destroys FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2ZBT11 Facility ID: CA940000093 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: _______________ 055539 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARTESIA CHRISTIAN HOME INC. 11614 183rd St Artesia, CA 90701 (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 and other importance mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning), Vitamin D deficiency (insufficient amount of Vitamin D in the body, essential for strong bones), and history of falling. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and carescreening tool, dated 7/6/17, indicated Resident 1 did not have the ability to understand verbal content, or express ideas and wants. The MDS indicated the resident had short and long-term memory problems, inattention, and disorganized thinking. The MDS indicated Resident 1 had moderate cognitive impairment in making decisions regarding tasks of daily life, and the resident exhibited delusional (misconceptions or beliefs that are firmly held, contrary to reality) behaviors. The MDS indicated Resident 1 required extensive assistance of one personphysical assist with toileting and personal hygiene. According to the MDS, the resident had impairment to one side of the lower extremity, and was frequently incontinent (insufficient voluntary control over urination or defecation) of bowel and bladder. A review of Resident 1's "Fall Risk Evaluation, "dated 4/3/17, indicated the resident had a "fall risk score" of 19, which indicated scores of 10 or higher represented a high risk for falls. A review of Resident 1's Care Plan titled, "Falls," with an initiated date on 12/22/16, indicated the staff's plan of approach is to provide close supervision during the resident's bathroom use for safety. A review of Resident 1's Nursing Progress Note, dated 7/12/17, and timed at 7:10 a.m., indicated the resident had a fall incident in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2ZBT11 Facility ID: CA940000093 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: _______________ 055539 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARTESIA CHRISTIAN HOME INC. 11614 183rd St Artesia, CA 90701 (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 bathroom. The note indicated the resident was found lying on her right side, with both legs extended and her right arm underneath her head. The note indicated Resident 1 was left sitting in the toilet by the Certified Nursing Assistant (CNA), to respond to another resident's call light. The note indicated that Resident 1 attempted to get up from the toilet, lost her balance and fell, and the resident sustained a bump on the right side of her head, that measured two (2) centimeters (cm) in length by 2.5 cm in width. The note indicated when the resident was transferred back to bed, and complained of pain eight out of 10 (10 out of 10 indicates severe pain) in her right hip and leg, during passive range of motion ([PROM], is moving the resident's joint with no effort from the resident, by the assistance of a therapist or an equipment). A review of Resident 1's Nursing Progress Note, dated 7/12/17, and timed at 10:44 a.m., indicated at 8:30 a.m. on the same day, the resident remembered that she fell in the bathroom, complained of "very severe pain" on the right hip, and was "guarding" her leg. The note indicated the resident had severe pain after receiving Acetaminophen-Hydrocodone (a generic name for "Norco", a narcotic medication used to treat pain) 325 mg per 5 mg oral tablet, one tablet, at 6 a.m., for moderate pain, and could not move her hip and leg. The note indicated at 9:30 a.m., the same day, Resident 1 was screaming of pain while being assisted with a two-person assist in repositioning. The note indicated at 10:35 a.m. on 7/12/17, Resident 1 was transferred to the General Acute Care Hospital (GACH). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2ZBT11 Facility ID: CA940000093 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: _______________ 055539 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARTESIA CHRISTIAN HOME INC. 11614 183rd St Artesia, CA 90701 (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 Nursing Progress Note, dated 7/15/17, and timed at 6:30 p.m., indicated the resident returned to the facility, after being admitted in the GACH for three days. Resident 1 underwent an Open Reduction and Internal Fixation ([ORIF], a twopart surgery used to repair broken bones in which the bone is first reduced or put back into place and then an internal fixation device (such as screws, plates, rods, or pin) is placed on the bone to hold it together) of the right hip. The note indicated the resident had an incision to the right hip, measuring 5.5 cm in length, and an incision to the right lateral thigh, with measurements of 2.5 cm and 1.2 cm. The note indicated Resident 1 sustained a skin tear on the right shin and right middle finger, and had scattered discoloration to the bilateral upper extremities. A review of Resident 1's Physician Order Report, dated 6/27/17 to 7/27/17, indicated to apply pressure pad alarm (pressure sensitive devices used to notify caregivers when residents move from their beds, chairs, or wheelchairs) at all times when in the wheelchair, and to monitor the resident getting out of the wheelchair without assistance. A review of Resident 1's GACH record, dated 7/12/17, and timed at 11:08 a.m., indicated the resident had an unwitnessed fall in the bathroom after attempting to get up from the toilet, and sustained a small hematoma to the right back of the head, and had right hip pain. The record indicated Emergency Medical Services (EMS) noted a "bump" to the parietal (situated near the side and top of the skull) region of Resident 1's head. The record indicated that per the resident's family member, the resident had a history of having a repaired left hip fracture. A review of the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2ZBT11 Facility ID: CA940000093 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: _______________ 055539 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARTESIA CHRISTIAN HOME INC. 11614 183rd St Artesia, CA 90701 (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 laboratory results dated 7/12/17, and timed at 11:40 a.m., indicated the resident's calcium levels was 8.4 milligrams (mg) per deciliter (dL), (Normal Reference Range [NRR] is 8.5 to 10.2 mg/dL). The record indicated the resident's radiographic (x-ray) result of 8.4 mg/dL, was positive for an acute right sided intertrochanteric (the proximal or upper part of the femur or thighbone) hip fracture without dislocation, osteopenia (low bone density), and evidence of a previous ORIF of a left intertrochanteric fracture. The record indicated Resident 1 would require surgery. A review of Resident 1's "Wound Care Note," from the GACH, dated 7/13/17, and timed at 3:11 p.m., indicated the resident had a "small linear laceration (a deep cut or tear in the skin or flesh) with soft eschar (dead tissue)" on the resident's right shin (bony front part of the lower leg). A review of Resident 1's "Medication Administration Report," from the GACH, dated 7/15/17, indicated the resident received Norco, on 7/15/17 at 4:21 p.m. The report indicated the resident received Morphine Sulfate (a stronger narcotic pain medication), 2 mg intravenously (administered into the vein), every four hours prn severe pain, on 7/15/17 at 3:41 a.m. On 7/27/17 at 3:30 p.m., during an interview, Resident 1 stated she had a "simple surgery" because she "fell out of a tree." On 7/27/17 at 4:50 p.m., during an interview, the Director of Nursing (DON) stated Resident 1 required assistance for bathroom use. The DON stated staff are expected not to leave Resident 1 unattended in the bathroom. The DON stated if an assigned resident needed assistance, and the CNA was in the middle of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2ZBT11 Facility ID: CA940000093 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: _______________ 055539 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARTESIA CHRISTIAN HOME INC. 11614 183rd St Artesia, CA 90701 (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 providing care for another resident, the CNA should ask for help from a colleague or another staff member. On 12/12/17 at 11:20 a.m., during a telephone interview, Licensed Vocational Nurse 1 (LVN 1) stated, "I didn't understand why she (CNA 1) left her (Resident 1)." LVN 1 stated there are specific instructions not to leave Resident 1 unattended. LVN 1 stated the staff are to finish completing care with the resident, and ensure safety before doing another task. LVN 1 stated Resident 1 required "close supervision." LVN 1 stated CNA 1 should have asked her colleagues for assistance and yell, "help." On 12/12/17 at 1 p.m., during a telephone interview, CNA 1 stated, "I made a poor decision to leave her (Resident 1)." CNA 1 stated she found Resident 1 laying on her right side on the bathroom floor and the resident had hit her head. CNA 1 stated the resident does not use the call light, and requires constant visual monitoring, because she has behaviors of getting out of her bed or wheelchair without assistance. CNA 1 stated she should have called for help while she was with Resident 1 and another resident's call light was activated. A review of the facility's undated Policy and Procedure titled, "Promoting Safety," indicated to ensure that assistance and supervision was provided as written in the care plan, especially using supervision (close, visual, and oversight) while in the bathroom. A review of the facility's Policy and Procedure (P/P) titled, "Accident Prevention Program for Residents," revision dated 11/2/11, indicated implementation to provide supervision based on the individual resident's needs and identified risks in the resident's environment. The P/P indicated "close supervision" was defined as a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2ZBT11 Facility ID: CA940000093 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: _______________ 055539 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARTESIA CHRISTIAN HOME INC. 11614 183rd St Artesia, CA 90701 (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 CNA remaining in the bathroom, while the resident was on the toilet. The P/P also indicated close supervision would be care planned as "do not leave resident unattended in the bathroom." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2ZBT11 Facility ID: CA940000093 If continuation sheet 8 of 8