Other·January 9, 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 Entity Reported Incident. Entity Reported Incident #: CA00489193 Substantiated. Representing the Department of Public Health: Evaluator ID #: 36205 RN, HFEN The inspection was limited to the specific entity reported incident investigation and does not represent the findings of a full inspection of the facility.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(h)

F323 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and 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 identify and evaluate accident risks and hazards, and did not implement / 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: YP7Z11 Facility ID: CA970000099 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: _______________ 555432 (X3) DATE SURVEY COMPLETED 08/23/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOLHEIM SENIOR COMMUNITY 2236 Merton Ave Los Angeles, CA 90041 (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 monitor interventions when necessary for one of three sampled residents (Resident 1). For Resident 1, who was assessed as high fall risk, the facility did not provide supervision and did not ensure the resident's personal alarm (used to alert staff) was functioning, per the plan of care. These deficient practices resulted in Resident 1 suffering a fall with injuries, which included a hip fracture and transfer to the general acute care hospital (GACH). Findings: A review of the clinical record indicated Resident 1 was admitted to the facility, on 12/18/10, with diagnoses which included unstable angina (chest pain), shortness of breath, and low back pain. The Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 2/24/16, indicated Resident 1 required limited assistance with transfers with one person assist, and for bed mobility, Resident 1 required supervision. A review of Resident 1's Fall Risk Assessment, dated 2/18/16, indicated a score of 10 or more represented a high fall risk and Resident 1 scored 11. The fall risk assessment indicated Resident 1 had intermittent confusion and required the use of a wheelchair as assistive device for gait or balance. During an interview, on 5/26/16, at 11:45 a.m., the assistant director of nursing (ADON) stated Resident 1 was a fall risk and had history of falling in the past. The ADON stated Resident 1 had an order for personal alarm while in wheelchair, but she did not know why the alarm did not go off when Resident 1 stood from the wheelchair to walk. The ADON stated she did FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YP7Z11 Facility ID: CA970000099 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: _______________ 555432 (X3) DATE SURVEY COMPLETED 08/23/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOLHEIM SENIOR COMMUNITY 2236 Merton Ave Los Angeles, CA 90041 (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 not know if Resident 1's personal alarm was working or if it was with the resident at that time of incident. The ADON stated Resident 1's personal alarm was used to prevent falling and would produce a sound or alarm that would alert the staff to assist or help the resident when the resident gets up from the wheelchair. A review of Resident 1's care plan for orientation / safety / fall prevention, dated 11/18/15, indicated Resident 1 was at risk for increasing confusion due to dementia and anxiety and was at risk for fall related to history of falls. The care plan approach or intervention indicated personal alarm while in wheelchair and bed, frequent checks for proper wheelchair positioning and repositioning as needed. Further review of Resident 1's care plan indicated a history of falls on 3/19/16, 4/5/16, and 5/18/16. A review of the physician's order, dated 3/21/16, indicated Resident 1 was to receive a personal alarm while in bed or wheelchair for safety and fall prevention. A review of Resident 1's assessment for the use of personal protective safety device, dated 3/21/16, indicated she was alert with confusion and the safety recommendation for prevention of fall included use of personal alarm in bed, and use of personal alarm in wheelchair. On 5/26/16, at 1:40 p.m., an interview was conducted with the rehabilitation nursing attendant (RNA 1) who stated Resident 1 was observed walking in the hallway without any staff assistance. RNA 1 stated she saw Resident 1 looked very tired, then fell and hit the floor with her left hip. RNA 1 stated she did not see or hear any personal alarm. During an interview, on 5/26/16, at 3:15 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YP7Z11 Facility ID: CA970000099 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: _______________ 555432 (X3) DATE SURVEY COMPLETED 08/23/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOLHEIM SENIOR COMMUNITY 2236 Merton Ave Los Angeles, CA 90041 (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 the registered nurse (RN) supervisor stated a staff should be assisting Resident 1 while walking and he did not know why no one saw Resident 1 walking from the front lobby to the hallway. The RN supervisor stated Resident 1 should not be left alone walking, since she used the wheelchair for ambulation. A review of the facility's interdisciplinary notes, dated 5/18/16, indicated status post fall incident, Resident 1 was observed lying on the floor on her left side along the hallway without her wheelchair, and Norco (contains narcotic and non-narcotic pain reliever) was given to Resident 1 for pain, rated at 8 out of 10 (10 indicating most severe pain). The interdisciplinary notes indicated Resident 1 was unable to move her left leg due to pain. A review of the physician's order, dated 5/18/16, indicated Resident 1 was to receive a Stat (urgent) x-ray of left hip, femur (thigh bone), pelvis (large bony structure near the base of the spine to which the legs are attached) secondary to left hip fall. A review of the physician's order, dated 5/18/16, indicated Resident 1 was to receive a neuro check (series of thorough assessments to make sure all injuries sustained from the fall are documented and treated appropriately), and was transferred to the GACH emergency department for further evaluation. A review of Resident 1's Radiology Report, dated 5/18/16, indicated there was a left intertrochanteric fracture (type of hip fracture) with impaction and varus angulation (deformity in which an anatomical part is turned inward toward the midline of the body to an abnormal degree). On 6/1/16, at 11:20 a.m., an interview was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YP7Z11 Facility ID: CA970000099 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: _______________ 555432 (X3) DATE SURVEY COMPLETED 08/23/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOLHEIM SENIOR COMMUNITY 2236 Merton Ave Los Angeles, CA 90041 (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 conducted with director of nursing (DON) who stated she did not see the personal alarm with Resident 1 when she had the fall on 5/18/16. The DON stated and confirmed no one was in the area to observe and supervise Resident 1 walking in the hallways. During an interview, on 6/1/16, at 11:20 a.m., the DON stated the facility did not have a written guideline on fall prevention and management, and the facility did not have written guidelines on the use of personal alarm. The DON stated, "We don't have a written policy/guide on how the procedure is done. We cover everything about fall reduction and the use of personal alarm but it is not written in a policy form. We should put this in a guide format for the staff to use." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YP7Z11 Facility ID: CA970000099 If continuation sheet 5 of 5