Other·June 26, 2019

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 California Department of Public Health during an abbreviated survey for the investigation of complaint #CA00620336. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 26987 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 07/02/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure 1 resident's (Resident 1) environment remained free from accident hazards for a census of 92 when: 1) Resident 1 was not provided an appropriate size bed to prevent falls; 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: 7EMF11 Facility ID: CA030000067 If continuation sheet 1 of 6 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: _______________ 056073 (X3) DATE SURVEY COMPLETED 06/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SACRAMENTO POST-ACUTE 5255 Hemlock Street Sacramento, CA 95841 (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 2) Resident 1 was not provided assistive devices (side rails/bed rails) as indicated by the Nursing Quarterly Assessment to reduce risk of falls; and, 3) Resident 1 was not provided adequate supervision with the use of two person assistance per the Care Plan instructions for Activities of Daily Living (ADLs). These failures resulted in Resident 1 experiencing an avoidable fall with a head injury which included, a left periorbital (around the left eye area) soft tissue swelling and a mild subdural hematoma (collection of blood outside of the brain but within the skull). Findings: Resident 1 was admitted to the facility in 2016 with diagnoses including, chronic respiratory failure, dependence on supplemental oxygen, gastrostomy (a tube surgically placed into the stomach to provide nutrition), and a persistent vegetative state (a condition in which a medical patient is completely unresponsive to psychological and physical stimuli and displays no sign of higher brain function). Review of Resident 1's Care Plans indicated, a Fall Care Plan dated 10/23/16, indicated, "...Keep bed in the lowest position with brakes locked." Review of Resident 1's Annual Minimum Data Set (MDS-an assessment tool) dated 1/15/18 indicated Resident 1 was assessed as in a persistent vegetative state/ no discernable consciousness under the Comatose section B0100. Resident 1 had a feeding tube for nutrition, a tracheostomy tube (a tube in the trachea to allow direct access to the breathing tube) for oxygen dependence, incontinent of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7EMF11 Facility ID: CA030000067 If continuation sheet 2 of 6 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: _______________ 056073 (X3) DATE SURVEY COMPLETED 06/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SACRAMENTO POST-ACUTE 5255 Hemlock Street Sacramento, CA 95841 (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 bowel and bladder, and was unresponsive. She required total dependence on two persons for physical assistance for bed mobility, toilet use, and personal hygiene. Resident 1's spouse was the responsible party for decision-making. Review of an Activities of Daily Living (ADL) Care Plan dated 10/2/18, indicated, "...Requires: Total Dependence 2 person...assist for bed mobility, transfers from the bed to a chair, and personal hygiene needs." Review of a Nursing Quarterly Assessment for Resident 1 dated 10/18/18 indicated there were no falls in the past 3 months and Resident 1 was considered to be "At Risk-[for falls]Continue to Care Plan. Individualized Interventions to Reduce Risk of Falls: Assistive Devices (e.g. Side/Bed Rail...)." A Nurse's Note dated 1/14/19 at 23:43 [11:43 p.m.] indicated, "At approximately 2312 [11:12 p.m.], CNA reported that patient [Resident 1] had a witnessed fall to the floor during ADL [Activities of Daily Living] care. CNA stated that patient was lying on her R [right] side when she had a forceful cough causing herself to slip off the mattress. Upon assessment, patients LOC [level of consciousness] and ROM [range of motion] appear stable to baseline. No skin breakdown, or facial grimace. Swelling and mild redness noted to L [left] eyebrow, from contact with hard surface..." Resident 1 was transferred out to acute care hospital for an evaluation. Review of a document dated 1/14/19 and completed on 1/22/19 titled Event Report indicated, "Fall Summary, Fall to the floor. Location of the fall, Resident room. Activity during or just prior to the fall, other-during Activity of Daily Living (ADL) care. Was the fall FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7EMF11 Facility ID: CA030000067 If continuation sheet 3 of 6 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: _______________ 056073 (X3) DATE SURVEY COMPLETED 06/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SACRAMENTO POST-ACUTE 5255 Hemlock Street Sacramento, CA 95841 (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 witnessed? Yes (By whom?)- CNA..." Review of the Emergency Department Note, dated 1/15/19 at 0107 [1:07 a.m.] indicated, "[Resident 1] with a history of persistent vegetative state, on trach collar but not vent [ventilator] dependent, who presents s/p [status post] fall from tonight around 2300 [11 p.m.]. Per EMS [Emergency Medical Service], patient was being turned on her side and then coughed and fell out of bed and hit her head and now has swelling to her left eyebrow. Staff at the SNF [Skilled Nursing Facility] report she cried immediately when she hit the ground. Symptoms are moderate in severity." An Interdisciplinary Team (IDT) Note dated 1/16/19 indicated, "[Resident 1] sustained a witnessed fall to the floor during ADL care... completed CT (computed tomography-an X-ray image made using a form of tomography in which a computer controls the motion of the Xray source and detectors, processes the data, and produces the image) scan 2x [two times] with findings of left periorbital (around the left eye area) soft tissue swelling and mild subdural hematoma (collection of blood outside the brain)... at risk for fall/injury... Other interventions IDT recommends: ...2 person assist during ADL/pericare and wider bed." In an interview with the Licensed Nurse 1 (LN 1) on 1/24/19 at 6:10 a.m., the LN 1 stated she was the charge nurse on the night shift. The LN 1 was aware of Resident 1's fall on 1/14/19. The LN 1 stated the bed was too narrow for the size of [Resident 1]. The LN 1 further stated, "We made a mistake. There should have been two people assisting with care." During an observation on 1/24/19 at 6:12 a.m., Resident 1 was in bed with the bed positioned low and fall mats on the floor on each side of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7EMF11 Facility ID: CA030000067 If continuation sheet 4 of 6 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: _______________ 056073 (X3) DATE SURVEY COMPLETED 06/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SACRAMENTO POST-ACUTE 5255 Hemlock Street Sacramento, CA 95841 (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 bed. The feeding tube was connected and the pump was on. The trachea dressing was clean and in place with the oxygen on. Resident 1 was addressed by name and there was no response. Resident 1 was staring at the ceiling with no eye contact. An interview was conducted on 1/24/19 at 6:23 a.m. with the Certified Nursing Assistant 1 (CNA 1). The CNA 1 confirmed she was the direct care provider for Resident 1 on 1/14/19. The CNA 1 stated she used a draw sheet to slide Resident 1 toward her before rolling Resident 1 onto her side to change the brief and provide personal care. The CNA 1 stated the bed was too narrow for the size of [Resident 1]. The CNA 1 described the size of the resident and stated, "it was difficult to provide care because the resident was as wide as the bed." The CNA 1 stated, "even if you pulled the resident toward you and then turned her, she fit so tightly in the bed there was no room." The CNA 1 stated Resident 1 started to cough and rolled off of the bed. The CNA 1 confirmed the bed was in the standard position, no fall mats were on the floor, and no side rails were used during the care being provided. The CNA 1 further confirmed she was working by herself to provide personal care to Resident 1. An interview was conducted with the LN 2 on 1/24/19 at 6:58 a.m. The LN 2 stated a mechanical lift was used to get Resident 1 back into the bed after the fall. The LN 2 stated the bed for Resident 1 was too narrow for the size of the resident. The LN 2 confirmed there were no side rails used, no fall mats on the floor, no assistance from other staff, and the bed was in the standard position, slightly elevated while care was being provided. The LN 2 concluded the interview by saying, "The fall could have been prevented for [Resident 1]." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7EMF11 Facility ID: CA030000067 If continuation sheet 5 of 6 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: _______________ 056073 (X3) DATE SURVEY COMPLETED 06/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SACRAMENTO POST-ACUTE 5255 Hemlock Street Sacramento, CA 95841 (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 facility policy revised December 2007 and titled "Falls and Fall Risk, Managing" indicated, "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling." A facility policy revised October 2010 and titled Assessing Falls and Their Causes indicated, "...Preparation: Review the resident's care plan to assess for any special needs of the resident...Relevant environmental issues should be addressed promptly..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7EMF11 Facility ID: CA030000067 If continuation sheet 6 of 6