New Vista Post-acute Care Center

F-F600

Findings:

1. A review of Resident 1's Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnoses including hemiplegia (complete or partial loss of muscle strength that affects only one side of the body) following cerebral infarction (stroke) affecting the left side, metabolic encephalopathy (condition of brain dysfunction), bipolar disease (a mental illness caused by unusual shifts in moods ranging from extreme highs to extreme low), depression (mental condition that causes persistent low mood), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing generalized body shaking) and hyperlipidemia (high cholesterol).

A review of Resident 1's Care Plan (CP) dated 3/13/2023 revised 6/2024 (n.d.) indicated Resident 1 had episodes of touching staff and residents. The CP goal indicated Resident 1 will have no injuries, misunderstandings or conflicts with staff and residents. The CP interventions indicated to monitor Resident 1's whereabouts and keep safe distance to ensure residents and staff avoid being in contact.

A review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 5/6/2024, indicated Resident 1's cognition (mental ability to make decisions for daily living) was intact. The MDS indicated Resident 1 was totally dependent (helper does all the effort) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair.

A review of Resident 1's Smoker's Risk assessment dated [DATE REDACTED] indicated Resident 1 had poor vision, limited mobility, needed redirection with safety awareness, and required supervision while smoking.

A review of Resident 1's Situation Background Assessment and Recommendation (SBAR a form used to communicate between the nursing team and the physician) dated 6/8/2024 timed at 2:05 p.m. indicated Resident 1 was bleeding from the left side of the forehead after fighting with Resident 2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 9 055473 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055473 B. Wing 06/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New Vista Post-Acute Care Center 1516 Sawtelle Blvd. Los Angeles, CA 90025

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of Resident 1's GACH Emergency Department Encounter note dated 6/8/2024, indicated Resident 1 was diagnosed with a contusion of the head and laceration of the scalp. Resident 1 underwent laceration Level of Harm - Actual harm repair with high pressured saline wash to cleanse the area, total length 1/2 centimeter (CM- Unit of measurement) in depth through the top layer of the skin. The note indicated the area was closed with Residents Affected - Few Dermabond (skin glue that holds wound edges together). The note indicated Resident 1 will require close follow-up in the next 2-3 days with primary physician otherwise to return to ER (emergency room ) with worsening of any symptoms. The note indicated Resident 1 was discharged back to the facility on [DATE REDACTED] evening.

A review of Resident 1's Interdisciplinary Team Conference Record (IDT- team members from different disciplines work together to review the root cause of the problem and develop a solution) dated 6/10/2024, indicated Resident 1 was informed of the facility zero tolerance rule for violence and instructed to notify staff

in the future if Resident 1 has any conflict with any other residents immediately and remove self from situation. The note also indicated Resident 1 was instructed to participate in activities.

A review of Resident 1's care plan titled, resident is at risk for injury and accident related to smoking, dated 6/14/2024, indicated interventions included to provide Resident 1 with physical supervision during scheduled smoking hours.

A review of Facility Designated Smoking Times indicated smoking hours as follows:

8:30 a.m. - 8:45 a.m.

10 a.m. - 10:15 a.m.

12:45 p.m. - 1 p.m.

2 p.m. - 2:15 p.m.

4 p.m. - 4:15 p.m.

6 p.m. - 6:15 p.m.

8 p.m. - 8:15 p.m.

2. A review of Resident 2's Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED]. Resident 2's diagnoses included Acquired absence of right leg above the knee, diabetes mellitus (DM- abnormal blood sugar), hyperlipidemia (high cholesterol), unspecified kidney failure (a condition in which the kidneys stop working and are not able to remove waste and extra water from

the blood or keep body chemicals in balance), depression, acute (sudden onset) embolism and thrombosis of deep vein (blood clot in an unspecified vein), acquired absence of right hip joint and hypertensive heart disease with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). The Face Sheet indicated Resident 2 was discharged home on 6/12/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 055473 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055473 B. Wing 06/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New Vista Post-Acute Care Center 1516 Sawtelle Blvd. Los Angeles, CA 90025

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of Resident 2's Minimum Data Set (MDS-a standardized assessment and care planning tool) dated, 4/21/2024 indicated Resident 2's cognition (mental ability to make decisions for daily living) was intact. Level of Harm - Actual harm Resident 2 was independent with toileting hygiene and transfers (moving between surfaces) from bed to chair. Residents Affected - Few

A review of the facility's investigation of a handwritten statement report from Resident 2, dated 6/8/2024, the statement indicated Resident 2 said that Resident 1 was trying to get a cigarette lit but no one would help and moved away. The statement indicated Resident 2 told Resident 1 to come back so that Resident 2 light

the cigarette for Resident 1 but Resident 1 flipped off (to show someone in an offensive way that you are annoyed with them) Resident 2. Resident 1 later returned with a cigarette asking Resident 2 for a light and Resident 2 took the cigarette from Resident 1 and threw it on the ground. Resident 1 went over to the housekeeping cart and grabbed a dust broom and hit Resident 2 with the dust broom [ROOM NUMBER]-5 (four to five) times on the head, shoulder, and hands. Resident 2 wrestled the dust broom away from Resident 1 and held it; then Resident 2 went back to the housekeeping cart and grabbed a dustpan and hit Resident 2 again. Resident 2 took the dustpan away from Resident 1 and hit Resident 1 on the forehead then Resident 1 stated ok. Resident 2's statement further indicated Licensed Vocational Nurse 1 (LVN 1) Showed up and took [Resident 1] away.

On 6/12/24, Resident 2's face sheet indicated the resident was discharged home.

During an interview on 6/24/2024 at 12:13 p.m., the Activity Director (AD) stated, We have designated smoking times and a list of residents that need supervision while smoking. The residents that requires supervision we keep their cigarettes and lighters locked in the office and give them out one at a time when a Residents wants to go and smoke. The Residents that are safe to smoke independently can come out on their own and they can keep their cigarettes and lighters. The AD stated Resident 1 required supervision while smoking to prevent fights with other residents because sometimes the residents don't understand what [Resident 1] is saying and when that happens [Resident 1] tends to get upset.

During the same interview on 6/24/2024 at 12:13 p.m., the AD stated, Only myself and my assistant have the key to the activity office where the cigarettes are kept. On the weekend we have a manager on duty that could be any department head and they will have the keys to the office. Nursing staff do not have access to

the activity office or any of the residents' cigarettes. I was not here for the fight between [Resident 1 and Resident 2] but my assistant was here. Unfortunately, my assistant at the time no longer works here. Supervision is provided by all staff through frequent visual checks. We did not have any dedicated staff to stay out here with residents that needed to be supervised so we would all watch from the dining room door because there is a direct line of sight to the smoking area in case myself or my assistant could not be outside.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 055473 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055473 B. Wing 06/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New Vista Post-Acute Care Center 1516 Sawtelle Blvd. Los Angeles, CA 90025

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During an interview on 6/24/2024 at 12:44 p.m., LVN 1 stated, On 6/8/2024 at approximately 2:00 p.m. I was walking around looking for one of my residents and passed by the sliding glass door to the smoking patio. I Level of Harm - Actual harm looked outside and saw [Resident 1] in the wheelchair (wc) from the back holding a broom in hand and Resident 2 in front holding a dustpan in the hand over the head as if to hit Resident 1, so I went outside Residents Affected - Few immediately. LVN 1 stated Resident 1 turned around in the wc and LVN 1 Resident 1 bleeding on the left side of forehead. LVN 1 stated, I did not see any other staff members out there. LVN 1 stated that LVN 1 wheeled Resident 1 to the west station and informed the charge nurse and supervisor who immediately rendered first aid to Resident 1 and called 911. LVN 1 stated Resident 2 did not smoke and would go out to

the patio to draw or just to get some air. LVN 1 stated on 6/8/2024 in the patio, Resident 2 told LVN 1 that Resident 1 had a cigarette and was asking for a lighter. LVN 1 stated Resident 1 then got upset when Resident 2 told Resident 1 that Resident 2 did not have a lighter. LVN 1 stated Resident 1 turned around and wheeled away in a wc. LVN 1 stated Resident 2 then called Resident 1 back to help find a lighter and Resident 1 flipped the middle finger at Resident 2. LVN 1 stated Resident 1 returned and asked Resident 2 again for a lighter. LVN 1 stated Resident 2 took the cigarette from Resident 1 and threw the cigarette on the ground. LVN 1 stated Resident 1 went over to the housekeeping cart and grabbed a dust broom and hit Resident 2 with the dust broom [ROOM NUMBER]-5 (four to five) times on the head, shoulder, and hands. Resident 2 wrestled the dust broom away from Resident 1 and held it; then Resident 1 went back to the housekeeping cart and grabbed a dustpan and hit Resident 2 again. Resident 2 took the dustpan away from Resident 1 and hit Resident 1 on the forehead and that is when I walked outside. LVN 1 stated, I do think we could have done a better job in terms of more frequent rounds when residents are outside smoking. LVN 1 stated, we don't have anyone designated to sit out there so it's up to all of us collectively watch the residents. I'm not sure what [Resident 1] needed when smoking but I would have guessed [Resident 1] needed to be supervised.

During an interview on 6/24/2024 at 1:15 p.m., LVN 2 stated LVN 2 was the charge nurse on 6/8/2024. LVN 2 stated Resident 1 smokes and requires supervision when smoking. LVN 2 stated Resident 1 was alert and oriented to person, place, and time. LVN 2 stated Resident 2 was at risk for injury if unsupervised when smoking. LVN 2 stated the Activities Department provides cigarettes to residents. LVN 2 stated Resident 1 would go directly to Activities Department to get the cigarettes and lighter. LVN 2 stated Activities Department would let the nurses know that Resident 1 was smoking. LVN 2 stated, No one from the activity department told me that [Resident 1] was outside smoking that day, 6/8/2024. LVN 2 stated that on 6/8/2024 at around 2:00 p.m., LVN 1 wheeled Resident 1 in wc to the nurses' station and observed Resident 1 bleeding on the forehead. LVN 2 stated LVN 2 applied ice pack, called 911, and informed Resident 1's doctor and Residents 1's family. LVN 2 stated the facility transferred Resident 1 to the GACH on 6/8/2024.

During an interview on 6/24/2024 at 3 p.m., the Administrator (Adm) stated, Yes, this incident [fight between Resident 1 and Resident 2) could have been avoided if there was supervision during the time and if staff members would have been aware of the smoking times.

A review of the facility's policy and procedures (P&P) titled, Smoking Policy and Procedures reviewed on 7/14/2023, indicated, The facility shall inform all residents of their right to smoke in the designated smoking patio. The designated smoking patio is located outside of the dining room .

2. The facility shall follow a smoking schedule and assign a designated smoking staff to oversee smoking activity during specified hours. The smoking schedule shall be posted in the designated smoking area.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 055473 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055473 B. Wing 06/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New Vista Post-Acute Care Center 1516 Sawtelle Blvd. Los Angeles, CA 90025

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 3. The facility shall assess residents expressing a desire to smoke for safety and appropriateness to smoke using the Smoking Assessment within 72 hours (about 3 clays) upon admission, quarterly in conjunction with Level of Harm - Actual harm their quarterly care plan review and as needed.

Residents Affected - Few 4. The facility shall collect the smoking materials of residents identified to be unable to smoke independently or unsupervised based on the Smoking Assessment.

5. The facility shall store smoking supplies in the medication carts.

6. The designated smoking staff shall ensure that all smoking materials are available during the posted smoking schedule .

9. The designated smoking staff shall gather smoking supplies at the end of the smoking period and return them to the medication cart for safekeeping.

The same P&P indicated, The facility shall make provisions to accommodate the smoking policy during inclement. The facility shall hold an IDT conference with residents who are non-compliant with the facility's smoking policy and procedure to explain the risks of unsafe smoking behavior.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 055473

F-F689

Findings:

A review of Resident 1's Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED]. Resident 1's diagnoses included hemiplegia (complete or partial loss of muscle strength that affects only one side of the body) following cerebral infarction (stroke) affecting the left side. Metabolic encephalopathy (condition of brain dysfunction), bipolar disease (a mental illness caused by unusual shifts in moods ranging from extreme highs to extreme low). Depression (mental condition that causes persistent low mood), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing generalized body shaking) and hyperlipidemia (high cholesterol).

A review of Resident 1's Care Plan dated 3/13/2023 revised 6/2024 (n.d.) indicated Resident 1 had episodes of touching staff and residents. The goal indicated Resident 1 will have no injuries, misunderstandings or conflicts with staff and residents. The interventions included indicated to monitor Resident 1's whereabouts and keep safe distance to ensure residents and staff avoid being in contact.

A review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 5/6/2024, indicated Resident 1's cognition (mental ability to make decisions for daily living) was intact. The MDS indicated Resident 1 was totally dependent (helper does all the effort) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair.

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.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 9 055473 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055473 B. Wing 06/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New Vista Post-Acute Care Center 1516 Sawtelle Blvd. Los Angeles, CA 90025

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 A review of Resident 1's Smoker's Risk assessment dated [DATE REDACTED] indicated Resident 1 had poor vision, limited mobility, needed redirection with safety awareness, and required supervision while smoking. Level of Harm - Actual harm

A review of Resident 1's Situation Background Assessment and Recommendation (SBAR- a form used to Residents Affected - Few communicate between the nursing team and the physician) dated 6/8/2024 timed at 2:05 p.m., indicated Resident 1 was bleeding from the left side of the forehead after fighting with Resident 2.

A review of Resident 1's GACH Emergency Department Encounter note dated 6/8/2024, indicated Resident 1 was diagnosed with a contusion of the head and laceration of the scalp. The noted indicated Resident 1 underwent laceration repair with high pressured saline wash to cleanse the area, total length 1/2 centimeter (cm- unit of measurement) in depth through the top layer of the skin. The noted indicated the area was closed with Dermabond (skin glue that holds wound edges together). The noted indicated Resident 1 was discharged back to the facility on [DATE REDACTED] evening.

A review of Resident 1's Interdisciplinary Team Conference Record (IDT- team members from different disciplines work together to review the root cause of the problem and develop a solution) dated 6/10/2024, indicated Resident 1 was informed of the facility zero tolerance rule for violence and instructed to notify staff

in the future if Resident 1 has any conflict with any other residents immediately and remove self from situation. The note also indicated Resident 1 was instructed to participate in activities.

A review of Facility Designated Smoking Times indicated smoking hours as follows:

8:30 a.m. - 8:45 a.m.

10 a.m. - 10:15 a.m.

12:45 p.m. - 1 p.m.

2 p.m. - 2:15 p.m.

4 p.m. - 4:15 p.m.

6 p.m. - 6:15 p.m.

8 p.m. - 8:15 p.m.

2. A review of Resident 2's Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED]. Resident 2's diagnoses included Acquired absence of right leg above the knee, diabetes mellitus (DM- abnormal blood sugar), hyperlipidemia (high cholesterol), unspecified kidney failure (a condition in which the kidneys stop working and are not able to remove waste and extra water from

the blood or keep body chemicals in balance), depression, acute (sudden onset) embolism and thrombosis of deep vein (blood clot in an unspecified vein), acquired absence of right hip joint and hypertensive heart disease with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). The Face Sheet indicated Resident 2 was discharged home on 6/12/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 9 055473 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055473 B. Wing 06/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New Vista Post-Acute Care Center 1516 Sawtelle Blvd. Los Angeles, CA 90025

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 A review of Resident 2's MDS-a dated, 4/21/2024 indicated Resident 1's cognition was intact. Resident 2 was independent with toileting hygiene and transfers (moving between surfaces) from bed to chair. Level of Harm - Actual harm

A review of the facility's investigation of a handwritten statement report from Resident 2, dated 6/8/2024, the Residents Affected - Few statement indicated Resident 2 said that Resident 1 was trying to get a cigarette lit but no one would help and moved away. The statement indicated Resident 2 told Resident 1 come back so that Resident 2 light the cigarette for Resident 1, but Resident 1 flipped off (gave the middle finger) Resident 2. Resident 1 later returned with a cigarette asking Resident 2 for a light and Resident 2 took the cigarette from Resident 1 and threw it on the ground. Resident 1 went over to the housekeeping cart and grabbed a dust broom and hit Resident 2 with the dust broom [ROOM NUMBER]-5 (four to five) times on the head, shoulder, and hands. Resident 2 wrestled the dust broom away from Resident 1 and held it; then Resident 2 went back to the housekeeping cart and grabbed a dustpan and hit Resident 2 again. Resident 2 took the dustpan away from Resident 1 and hit Resident 1 on the forehead then Resident 1 stated ok. Resident 2's statement further indicated Licensed Vocational Nurse 1 (LVN 1) Showed up and took [Resident 1] away.

During an interview on 6/24/2024 at 12:13 p.m., the Activities Director (AD) stated, We have designated smoking times and a list of residents that need supervision while smoking. The residents that require supervision we keep their cigarettes and lighters locked in the office and give them out one at a time when a Residents wants to go and smoke. The Residents that are safe to smoke independently can come out on their own and they can keep their cigarettes and lighters. The AD stated Resident 1 required supervision while smoking to prevent Resident 1 from fighting with other residents because sometimes the residents don't understand what [Resident 1] is saying and when that happens [Resident 1] tends to get upset.

During an interview on 6/24/2024 at 12:20 p.m., the AD stated, Only myself and my assistant have the key to

the activity office where the cigarettes are kept. On the weekend we have a manager on duty that could be any department head and they will have the keys to the office. Nursing staff do not have access to the activity office or any of the residents' cigarettes. I was not here for the fight between (Resident 1 and Resident 2) but my assistant was here. Unfortunately, my assistant at the time no longer works here. Supervision is provided by all staff through frequent visual checks. We did not have any dedicated staff to stay out here with residents that needed to be supervised so we would all watch from the dining room door because there is a direct line of sight to the smoking area in case myself or my assistant could not be outside.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 9 055473 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055473 B. Wing 06/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New Vista Post-Acute Care Center 1516 Sawtelle Blvd. Los Angeles, CA 90025

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 During an interview on 6/24/2024 at 12:44 p.m., LVN 1 stated, On 6/8/2024 at approximately 2:00 p.m. I was walking around looking for one of my residents and passed by the sliding glass door to the smoking patio. I Level of Harm - Actual harm looked outside and saw [Resident 1] in the wheelchair (wc) from the back holding a broom in hand and Resident 2 in front holding a dustpan in the hand over the head as if to hit Resident 1, so I went outside Residents Affected - Few immediately. LVN 1 stated Resident 1 turned around in the wc and LVN 1 saw Resident 1 bleeding on the left side of forehead. LVN 1 stated, I did not see any other staff members out there. LVN 1 stated LVN 1 wheeled Resident 1 to the west station and informed the charge nurse and supervisor who immediately rendered first aid to Resident 1 and called 911. LVN 1 stated Resident 2 did not smoke and would go out to

the patio to draw or just to get some air. LVN 1 stated on 6/8/2024 in the patio, Resident 2 told LVN 1 that Resident 1 had a cigarette and was asking for a lighter. LVN 1 stated Resident 1 turned around and wheeled away in a wc. LVN 1 stated Resident 2 then called Resident 1 back to help find a lighter and Resident 1 flipped the middle finger at Resident 2. LVN 1 stated Resident 1 returned and asked Resident 2 again for a lighter. LVN 1 stated Resident 2 took the cigarette from Resident 1 and threw the cigarette on the ground. LVN 1 stated Resident 1 went over to the housekeeping cart, grabbed a dust broom, and hit Resident 2 with

the dust broom [ROOM NUMBER]-5 (four to five) times on the head, shoulder, and hands. Resident 2 wrestled the dust broom away from Resident 1 and held it; then Resident 1 went back to the housekeeping cart and grabbed a dustpan and hit Resident 2 again. Resident 2 took the dustpan away from Resident 1 and hit Resident 1 on the forehead and that is when I walked outside. LVN 1 stated, I do think we could have done a better job in terms of more frequent rounds when residents are outside smoking. LVN 1 stated we don't have anyone designated to sit out there so it's up to all of us to collectively watch the residents. I'm not sure what [Resident 1] needed when smoking but I would have guessed [Resident 1] needed to be supervised.

During an interview on 6/24/2024 at 1:15 p.m., LVN 2 stated LVN 2 was the charge nurse on 6/8/2024. LVN 2 stated Resident 1 smoked and required supervision when smoking. LVN 2 stated Resident 1 was alert and oriented to person, place, and time. LVN 2 stated Resident 2 was at risk for injury if unsupervised when smoking. LVN 2 stated the Activities Department provides cigarettes to residents. LVN 2 stated Resident 1 would go directly to Activities Department to get cigarettes and a lighter. LVN 2 stated the Activities Department would let the nurses know that Resident 1 was smoking. LVN 2 stated, No one from the Activities Department told me that [Resident 1] was outside smoking that day, 6/8/2024. LVN 2 stated on 6/8/2024 at around 2:00 p.m., LVN 1 wheeled Resident 1 in wc to the nurses' station and observed Resident 1 bleeding on the forehead. LVN 2 stated LVN 2 applied ice pack, called 911, and informed Resident 1's doctor and Residents 1's family. LVN 2 stated the facility transferred Resident 1 to the GACH on 6/8/2024.

During an interview on 6/24/2024 at 3:00 p.m., the Administrator (Adm) stated, Yes, this incident (between Resident 1 and Resident 2) could have been avoided if there was supervision during the time and if staff members would have been aware of the smoking times.

A review of facility's P&P titled Abuse Prevention/Investigation/Reporting and Resolution, effected 11/28/2026, indicated, The facility will protect the rights, safety, and wellbeing of each resident (regardless of physical and mental condition), for whom we provide care and treatment against any and all forms of physical . abuse, . or any treatment that would result in physical harm, pain, mental suffering . The P&P further indicated Physical abuse includes assault . and hitting .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 9 055473 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055473 B. Wing 06/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New Vista Post-Acute Care Center 1516 Sawtelle Blvd. Los Angeles, CA 90025

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42342 Residents Affected - Few Based on interview, and record review the facility failed to provide supervision while smoking for one of three sampled residents (Resident 1).

This deficient practice resulted in a fight between Resident 1 and Resident 2 on 6/8/2024. Resident 2 hit Resident 1 on the forehead. Resident 1 sustained a laceration (cut) to the forehead and was transferred to

the general acute care hospital (GACH) on 6/8/2024. GACH diagnosed Resident 1 with contusion (a bruise [This happens when small blood vessels get torn and leak blood under the skin], a result of a direct blow or

an impact) of the head.

Cross Reference