Other·March 28, 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 Department of Public Health during the investigation of one entity reported incident (ERI) during an Abbreviated standard survey. ERI number: CA00560624- 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 related to the original allegation was issued for entity reported incident number CA00560624.

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

F323 03/08/2018 (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: T8SU11 Facility ID: CA940000117 If continuation sheet 1 of 9 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: _______________ 055168 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOCAL POST-ACUTE CARE 7931 Sorensen Ave Whittier, CA 90606 (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 observation, interview, and record review, the facility failed to follow its policy and adhere to one of two-sampled resident's (Resident 1) plan of care, and ensure assistive devices were in safe and good working condition. The facility's staff transferred Resident 1 from the wheelchair to the bed, using a sling (a material used with loops or straps to support or raise a weight), hooked onto the Hoyer Lift (an assistive medical device used to transfer residents), in which the sling's strap broke, causing the resident to fall to the floor. This deficient practice resulted in Resident 1 sustaining a left forearm skin tear, having severe pain, left hip fracture (a break in the bone), six left rib fractures, which required an eight day hospital stay. These injuries had the potential for the resident to sustain further complications, such as bleeding, infections and/ or death. Findings: A review of Resident 1's Face Sheet indicated the resident was originally admitted to the facility on 8/12/11 and most recently readmitted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T8SU11 Facility ID: CA940000117 If continuation sheet 2 of 9 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: _______________ 055168 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOCAL POST-ACUTE CARE 7931 Sorensen Ave Whittier, CA 90606 (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 7/21/17. The resident's diagnoses included muscle weakness, acute embolism (a sudden blocking of an artery) and thrombosis of deep veins ([DVT] a blood clot in a deep vein) in the lower extremity, paraplegia (paralysis of the legs and lower body), and osteoarthritis ([OA] is when flexible tissue at the end of the bone wears down, causing inflammation) of the hip. A review of Resident 1's Admission Diagnoses/Status, dated 7/21/17, indicated the resident had diagnoses of seizure disorder (excessive and abnormal brain cell activity), right hip replacement (the damaged sections of the hip joint are replaced with an artificial joint often made from metal and plastic components), and left first, second, and fifth toe amputations (the surgical removal of all or part of a limb or extremity). A review of Resident 1's Admission Information Sheet, indicated the resident had a diagnosis of spinal stenosis (the narrowing of the spaces within the spine, causing pressure on the nerves that travel through the spine) in the lumbar region (the lower back, where the spine curves inward toward the abdomen). A review of Resident 1's "Initial History and Physical," dated 7/21/17, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and carescreening tool, dated 10/27/17, indicated Resident 1 was able to recall three of three words repeated to the resident, after cueing. The MDS indicated the resident reported the correct year, but was unable to report the correct month and day of the week. According to the MDS, the resident was completely dependent on one staff for physical assistance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T8SU11 Facility ID: CA940000117 If continuation sheet 3 of 9 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: _______________ 055168 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOCAL POST-ACUTE CARE 7931 Sorensen Ave Whittier, CA 90606 (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 bed mobility, dressing, eating, toilet use, and personal hygiene, and required two or more staff for physical assistance in transferring between surfaces. The MDS indicated Resident 1 had impairment on both sides of the upper extremity and was always incontinent of bowel and bladder (insufficient or involuntary control over urination or defecation [bowel movement]). A review of Resident 1's Care Plan titled, "At Risk for Headaches, Injuries, and Falls, due to Seizure Disorder, dated 7/24/17, indicated the staff's plan of approach to ensure the resident's safety. A review of Resident 1's Care Plan titled, At Risk for Fall or Injury, due to Impaired Vision, dated 7/24/17, indicated the staff's approach plan to keep the resident free from environmental hazards. A review of Resident 1's Care Plan titled, At Risk for Bleeding, Skin Discolorations, and Skin Tears, dated 7/24/17, indicated an approach plan to handle the resident gently and carefully at all times. A review of Resident 1's Care Plan titled, Impaired Activities of Daily Living ([ADL] are routine self-care activities such as bathing, dressing, eating) Function: Resident Requires Assist with ADLs, dated 7/24/17, indicated an approach plan for a two-person assist in transferring the resident using a Hoyer Lift. A review of Resident 1's "CNA-ADL Tracking Form," for the month of 11/2017, indicated the resident was totally dependent (full staff performance) on two or more persons for physical assist in transfers. A review of Resident 1's "Multidisciplinary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T8SU11 Facility ID: CA940000117 If continuation sheet 4 of 9 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: _______________ 055168 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOCAL POST-ACUTE CARE 7931 Sorensen Ave Whittier, CA 90606 (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 Progress Record," dated 11/9/17 and timed at 1:30 p.m., indicated while Resident 1 was being transferred from the bed to the wheelchair, using a Hoyer Lift, one of the straps of the sling broke, and "suddenly" a second strap on the left side of the sling broke as well. The record indicated the resident fell to the floor, landing between the legs of the Hoyer Lift, hitting her left shoulder, and complained of severe pain to her back. The record indicated the resident sustained a skin tear to the left forearm. A review of a SBAR (Situation, Background, Assessment, and Recommendation [used to facilitate prompt and appropriate communication]) Communication Form, dated 11/9/17, indicated after Resident 1 had a fall during a transfer from the bed to the wheelchair using the Hoyer Lift, the resident had pain to the left shoulder, chest, and between the shoulders, with grimacing (a facial expression, indicating pain, disgust, or disapproval) behavior and moaning. A review of Resident 1's "Discharge Summary," dated 11/9/17, indicated the resident was transferred to general acute care hospital (GACH) for a fall during a Hoyer Lift transfer, after complaining of pain 10/10 (10 indicates the worse pain). A review of the facility's Investigation Form, of an interview with the Maintenance Supervisor (MS), dated 11/9/17, indicated the MS found one sling that looked questionable, which was the one that broke. The investigation indicated that the MS was unsure why the sling had not been discarded before. A review of Resident 1's GACH Record from the Emergency Department (ED), dated 11/9/17, and timed 2:48 p.m., indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T8SU11 Facility ID: CA940000117 If continuation sheet 5 of 9 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: _______________ 055168 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOCAL POST-ACUTE CARE 7931 Sorensen Ave Whittier, CA 90606 (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 hit the bed and the floor, when the sling broke. The ED record indicated Resident 1 was complaining of severe pain to her head, back, left sided chest, and left hip, and was worse with movement or touch. The record indicated Resident 1 was in distress due to complaining of pain everywhere, and was placed on a "C-Collar (a cervical collar, also known a neck brace, a medical device used to support the neck)." The record resident received four (4) milligrams (mg) of Morphine Sulfate (pain reliever narcotic), every 10 minutes, intravenously ([IV], administered into the vein), for pain. A review of Resident 1's Admission History and Physical from the GACH Record, dated 11/9/17, indicated the stitching of the Hoyer Lift's sling "gave way" and the resident fell against the legs of the Hoyer Lift. The record indicated the resident had six fractures of the left ribs posteriorly and a left hip fracture, with severe pain. The record indicated the resident was admitted to the GACH for pain control and possible surgical intervention of the left hip. A review of Resident 1's Radiological (X-ray) Report from the GACH, dated 11/9/17, and timed at 3:13 p.m., indicated the resident had an impacted fracture ( a type of fracture, in which one fragment of the bone goes into the other broken end of the bone) at the left sub capital femur (the neck of the hip bone). The report also indicated Resident 1 had acute fractures at the left lateral third, lateral fourth, posterior fifth, posterior sixth, posterior seventh, and posterior eighth ribs, with various displacement. A review of the facility's Policy and Procedure (P/P) titled, "Use of Mechanical (Hoyer) Lift," with a revision date of 11/2017, indicated equipment (mechanical lift and sling) was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T8SU11 Facility ID: CA940000117 If continuation sheet 6 of 9 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: _______________ 055168 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOCAL POST-ACUTE CARE 7931 Sorensen Ave Whittier, CA 90606 (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 assessed and prepared for use. The P/P indicated the Certified Nursing Assistants (CNA) would assess the lift slings before each use to ensure slings were in good working condition to protect the safety and well-being of residents. The P/P indicated slings that look suspicious would be replaced immediately by the MS or Director of Nursing Services (DON). The P/P indicated the MS would ensure the slings were in good working condition. A review of the mechanical lift's "Owner's Manual," dated 2017, indicated a "Warning" to visibly inspect the sling prior to each use to ensure the sling was the correct type, size and design to handle lifting. The Manual indicated to ensure the sling was not damaged, torn, worn, discolored, or past its useful life. The Manual indicated to lift the resident one to two inches over the bed or chair, stop and check that all straps, sling fabric and loops are secure. The Manual indicated to ensure not exceeding sling or lift maximum weight, and that the wrong sling size could cause residents to fall out. On 11/14/17 at 12:10 p.m., during an observation and interview, the MS stated that CNAs are required to check the condition of the slings prior to resident use. The Hoyer Lift was observed with a sign on top of its leg, indicating to visually inspect the sling prior to use. The MS presented the sling with the torn strap used by Resident 1 during the time of the fall. The sling was observed with four straps of the sling, with blue, green and purple loops encased within a black strap. The black straps were observed stitched at the base, connected to the sling's material. The black straps on the left top and bottom of the sling was removed, with partial frayed straps remained. The black straps at the right top and bottom of the sling were observed worn out, and partially torn. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T8SU11 Facility ID: CA940000117 If continuation sheet 7 of 9 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: _______________ 055168 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOCAL POST-ACUTE CARE 7931 Sorensen Ave Whittier, CA 90606 (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 blue, right top strap (within the black strap) was observed partially torn. The MS stated the old bag of slings, including the damaged sling shown would be replaced with new slings. On 11/14/17 at 12:40 p.m., during an observation and interview, CNA 1 stated that staff are expected to inspect the straps of the sling prior to use. CNA 1 stated she assisted with the transfer during the resident's fall from the lift. CNA 1 stated she was at the foot of Resident 1, guiding the transfer, while CNA 2 was maneuvering the Hoyer Lift. CNA 1 stated within seconds, two straps of the sling broke while the Hoyer Lift was moving. CNA 1 stated that the resident fell on the floor landing on her left side and sustained a skin tear. CNA 1 stated the sling used for the resident was stored and obtained from the facility's laundry room. On 11/14/17 at 1:33 p.m., during an interview, CNA 2 stated that while Resident 1 was on the sling, the green strap located to the left of the sling, covering the top portion of her body was hooked onto the Hoyer Lift, but suddenly broke, and the purple strap located to the left of the sling, covering the resident's lower part of her body, hooked onto the Hoyer Lift ripped immediately after. CNA 2 stated she was behind the Hoyer Lift and could not prevent Resident 1 from falling. CNA 2 stated the resident fell to the floor, and landed on her left shoulder and left thigh. CNA 2 stated the resident was very fragile, and completely dependent on staff for ADLs care. CNA 2 stated prior to applying the sling on the resident, she and CNA 1 checked the purple and green straps of the sling and they looked "ok" at the time. CNA 2 stated she could not recall if they inspected the condition of the upper and lower black straps of the sling. CNA 2 stated that all straps, especially the black FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T8SU11 Facility ID: CA940000117 If continuation sheet 8 of 9 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: _______________ 055168 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOCAL POST-ACUTE CARE 7931 Sorensen Ave Whittier, CA 90606 (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 straps that are connected to the sling, should be inspected prior to putting the sling on the resident. On 11/14/17 at 1:42 p.m., during an observation and interview, the Director of Staff Development (DSD), stated that staff are expected to examine the Hoyer Lift and the slings prior to resident use. The DSD stated if the slings and straps appeared defective or worn out, the sling must be reported and given to the nurse supervisor and the MS for immediate replacement. On 11/14/17 at 1:57 p.m., during an interview and record review, the MS stated that checking the straps of the slings are essential to ensure the resident was safe and securely held by the Hoyer Lift. On 11/14/17 at 3:20 p.m., during and interview, the Director of Nursing (DON), stated there was no record to indicate the sling and the straps of the sling were inspected routinely prior to Resident 1's fall incident on 11/9/17. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T8SU11 Facility ID: CA940000117 If continuation sheet 9 of 9