Casa Bonita Convalescent Hospital
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
effectiveness.During an interview on 9/10/2025 at 12:49 PM with the PTD, the PTD stated Resident 1's physical therapy goals had not changed from 7/2025 to 9/2025 and [the facility worked with] Resident 1 on bed mobility and strengthening exercises the entire time. The PTD stated there were slight differences in emphasis depending on Resident 1's progress but the big picture remained constant.During a concurrent
interview and record review on 9/10/2025 at 3:18 PM with the Administrator (ADM), Resident 1's untitled CPs, dated 5/8/2025 and dated 8/29/2025, the CP indicated Resident 1 had altered behavior patterns related to attempting to get out of bed unassisted and expected behavior related to movement to floor mat were reviewed. The ADM stated Resident 1's fall prevention interventions listed in the CPs were standard interventions and the facility had done everything possible without resorting to restraints (devices or equipment used to a person's body to restrict their freedom of movement or normal access to their body).
The ADM stated a sitter was provided to preserve Resident 1's dignity. When asked if the facility had assessed causative factors of Resident 1's behavior as indicated in the CPs, the ADM stated the ADM was not aware of causative factors and if causative factors were a listed intervention, it [the CPs] should have been followed. The ADM stated the facility treated the falls but did not look into the possible causes of the falls and did not know if Resident 1 had increased impulsive behavior leading to further falls.During a concurrent interview and record review on 9/10/2025 at 3:18 PM with the ADM, the facility's P&P titled, Falls and Fall Risk, Managing, dated 3/2018, was reviewed. The P&P indicated under Resident-Centered Approaches to Managing Falls and Fall Risk, 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident with a history of falls. The ADM stated Resident 1's fall prevention care plan indicated standard fall prevention interventions used for any resident that was at high risk for falls. The P&P further indicated under Monitoring Subsequent Falls and Fall Risk: 1. the staff will observe each resident's response to interventions intended to reduce falling or the risks of falling. The ADM stated the current interventions in place were effective because Resident 1 would have otherwise fallen more often. The ADM stated the facility did not have documented evidence to indicate fall prevention interventions were evaluated for effectiveness and the facility did not do the depth of evaluation that was perhaps needed.During a review of
the facility's undated P&P titled, Falling Star Program, the P&P indicated recommendations to ensure a successful program included: evaluation for appropriate useful interventions for fall reduction.
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CASA BONITA CONVALESCENT HOSPITAL in SAN DIMAS, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAN DIMAS, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CASA BONITA CONVALESCENT HOSPITAL or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.