Other·January 29, 2020

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 - Licensing and Certification during an ABBREVIATED survey for Facility Reported Incident: CA 00658985. Representing the Department of Public Health by Federal ID: 39617 R.N., HFEN. The abbreviated survey was limited to the specific incident investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for Facility Reported Incident: CA 00658985.

F656 SS=G Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 02/04/2020 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the 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: PLZ211 Facility ID: CA040000015 If continuation sheet 1 of 16 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: _______________ 555924 (X3) DATE SURVEY COMPLETED 01/22/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHEL LUTHERAN HOME, INC. 2280 Dockery Ave Selma, CA 93662 (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 right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to develop and implement a person-centered care plan for one of three sampled residents (Resident 1) when Resident 1 had a total of seven falls between 3/3/19 and 10/13/19 and facility did not develop an individualized fall prevention care plan and implement effective interventions after each fall to prevent additional falls. This failure led to Resident 1's seventh fall on 10/13/19 which resulted in a left femur [the bone of the thigh] fracture and being admitted to hospice care services (end of life care). Findings: During a review of the clinical record for Resident 1, the "Admission Record" dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZ211 Facility ID: CA040000015 If continuation sheet 2 of 16 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: _______________ 555924 (X3) DATE SURVEY COMPLETED 01/22/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHEL LUTHERAN HOME, INC. 2280 Dockery Ave Selma, CA 93662 (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 7/25/14, indicated Resident 1 had diagnosis of dementia [a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning], anxiety disorder [a worry about future events, and fear is a reaction to current events], agerelated physical debility [self-reported inability to walk due to impairments and limited mobility. It has been found in older adults with decreased strength to lower extremities], and history of falling. During a review of the clinical record for Resident 1, the "Medication Administration Record" dated October 2019, indicated Resident 1 had an order for clopidogrel bisulfate (blood thinning medication that causes side effects of easy bleeding/bruising and may take longer than usual for bleeding to stop with a cut or injury) 75 milligram (unit of measure), 1 tablet adminstered by mouth in the evening. During a review of the clinical record for Resident 1, the "Minimum Data Set" (MDS) assessment (an evaluation used to identify resident care needs) dated 7/22/19, indicated was severely cognitively impaired with a "Brief Interview for Mental Status" (BIMS) (an evaluation of attention, orientation and memory recall) score of 3 (0-7 severe cognitive impairment). The MDS assessment dated 7/22/19, indicated Resident 1 required oneperson extensive assistance with transferring to or from bed, chair, wheelchair, and standing position. Resident 1 required one person limited assistance with walking in room and corridor. During a review of the clinical record for Resident 1, the "Fall Risk Assessment" dated 11/1/18, indicated high risk for falls with a total score of 13 (total score of 10 or above FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZ211 Facility ID: CA040000015 If continuation sheet 3 of 16 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: _______________ 555924 (X3) DATE SURVEY COMPLETED 01/22/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHEL LUTHERAN HOME, INC. 2280 Dockery Ave Selma, CA 93662 (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 represents high risk). During an interview with the Licensed Vocational Nurse (LVN) on 10/15/19 at 1:47 p.m., she stated Resident 1 constantly tried to get up from the wheelchair and bed by herself. The LVN stated Resident 1 would want to go to bed and then go back into her wheelchair. The LVN stated her fall on 10/13/19 (Fall # 7) could have been avoided if a staff member was with Resident 1 supervising one on one but it had never been ordered. The LVN stated staff tried to check on Resident 1 frequently and she had an alarm on her bed and wheelchair but she was still falling because staff could not get to her on time. The LVN stated Resident 1 would not use her call light and would not ask staff for assistance because she was confused. During an interview with Certified Nursing Assistant (CNA) 2 on 10/15/19 at 2:10 p.m., she stated Resident 1 constantly tried to get up from her bed and wheelchair unassisted. CNA 2 stated Resident 1 would not use her call light and would attempt to stand up by herself. CNA 2 stated on 10/13/19 (Fall # 7) at 8:55 p.m., she sat with Resident 1 in the hallway when she heard a yell coming from the hallway. CNA 2 stated Resident 1 stood up from her wheelchair unassisted and fell. CNA 2 stated Resident 1 should have been on one on one supervision to prevent the fall on 10/13/19 but it had never been ordered or done. During an interview with CNA 1 on 10/15/19 at 2:46 p.m., she stated Resident 1 would not use the call light because she was confused. CNA 1 stated she would encourage Resident 1 to ask for help but Resident 1 did not understand the importance of using her call light. CNA 1 stated Resident 1 would get up without asking for help and her bed or wheelchair alarm would go off and staff would then go assist Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZ211 Facility ID: CA040000015 If continuation sheet 4 of 16 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: _______________ 555924 (X3) DATE SURVEY COMPLETED 01/22/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHEL LUTHERAN HOME, INC. 2280 Dockery Ave Selma, CA 93662 (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 1. CNA 1 stated she had to ask Resident 1 if she needed assistance because Resident 1 would not ask for assistance to get up from her bed or wheelchair unless staff asked her. CNA 1 stated Resident 1 required one-person physical assist to and from bed, wheelchair and toilet. CNA 1 stated Resident 1 was able to ambulate with a gait belt (a device put on a patient who has mobility issues, may be used to aid in the safe movement of a patient, from a standing position to a wheelchair) but was unable to walk independently. CNA 1 stated Resident 1 should have been on one on one supervision because she would constantly get up from her wheelchair and bed unassisted. During a concurrent interview and record review with the Director of Nursing (DON) on 10/15/19 at 1 p.m., she stated on 7/15/19 (Fall # 3) Resident 1 attempted to ambulate in her room unassisted and fell. The care plan intervention following the fall indicated, "Keep call light within reach while in room." The DON stated Resident 1 had a BIMS score of three and was severely cognitively impaired. The DON stated Resident 1 had poor safety awareness and did not think she could fall if she got up by herself. The DON stated Resident 1 did not use her call light and would not ask for help. During a concurrent interview and record review with the DON on 10/15/19 at 1 p.m., she stated on 9/8/19 (Fall # 4) Resident 1 attempted to get up from her wheelchair unattended and the wheelchair was unlocked. The DON stated the wheelchair rolled back when Resident 1 sat back down and fell on her bottom. The care plan intervention following the fall was, "Antiroll brake for wheelchair when available." The DON stated the antiroll brake was never ordered by the Administrator (ADM). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZ211 Facility ID: CA040000015 If continuation sheet 5 of 16 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: _______________ 555924 (X3) DATE SURVEY COMPLETED 01/22/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHEL LUTHERAN HOME, INC. 2280 Dockery Ave Selma, CA 93662 (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 During a concurrent interview and record review with the ADM on 10/15/19 at 2:57 p.m., Resident 1's care plan dated 9/9/19, indicated, "Antiroll brakes for wheelchair when available." The ADM stated the intervention for the fall on 9/8/19 (Fall # 4) was never implemented because he did not remember he had to order the antiroll brakes for Resident 1. The ADM stated Resident 1 should have been on one on one because she was constantly trying to get out of her wheelchair and bed to prevent further falls. During a concurrent interview and record review with the DON on 10/15/19 at 1 p.m., she stated on 9/27/19 (Fall # 5) Resident 1 stood up from her wheelchair unassisted to pull her pants up and fell forward. The care plan intervention following the fall was, "Resident encouraged to sit in regular chair when sitting outside her room." The DON stated Resident 1 did not like sitting in a regular chair and was put back in her wheelchair without implementing a different intervention. During a concurrent interview and record review with the DON on 10/15/19 at 1 p.m., she stated on 9/27/19 (Fall # 6) Resident 1 attempted an unassisted transfer from her bed and fell. The DON stated Interdisciplinary Team (IDT) determined Resident 1's falls were unavoidable and did not implement any new interventions. The DON stated Resident 1 was impulsive and was monitored by staff for impulsive behaviors, "Getting up unassisted/walking unassisted" every shift. During a concurrent interview and record review with the DON on 10/16/19 at 4:25 p.m., she stated on 3/3/19 (Fall # 1) Resident 1 was sitting in her wheelchair by the nurse's station and attempted to ambulate back to her bed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZ211 Facility ID: CA040000015 If continuation sheet 6 of 16 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: _______________ 555924 (X3) DATE SURVEY COMPLETED 01/22/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHEL LUTHERAN HOME, INC. 2280 Dockery Ave Selma, CA 93662 (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 unassisted and fell next to her bed. The care plan intervention indicated, "Encourage Resident to call for assistance." The DON stated Resident 1 had a BIMS score of three and was severely cognitively impaired. The DON stated Resident 1 had poor safety awareness and did not think she could fall if she got up by herself. The DON stated Resident 1 would not ask for help. During a review of the clinical record for Resident 1, the "Discharge Instructions" from the hospital dated 10/14/19-10/16/19, indicated, "Orthopedic [the correction of deformities of bones or muscles] is a moderate risk surgery and pt [patient] is a high risk pt [patient] given history of multivessel coronary artery disease [arteries that supply blood to heart muscle become hardened and narrowed]. Patient is very well-known to cardiologist [Doctor that opens chest and performs heart surgery] [Doctors name]. I discussed patient's case with [Doctors name] over phone [sp] patient is a high risk patient for orthopedic surgical intervention given patient's multivessel coronary artery disease in setting of advance age/dementia and that he would not recommend patient undergoing surgery ... palliative team was consulted. They discussed with family. Ultimately decision was made to change her to hospice care ..." During a review of the clinical record for Resident 1, the "Facility Communication Sheet/Telephone Order Form" from hospice dated 10/16/19, indicated, " ...Situation: New admission for [Hospice Name] DX: CAD [Coronary Artery Disease-arteries that supply blood to heart muscle become hardened and narrowed]. Background: Recent L [left] hip fx [fracture], not a surgical candidate Assessment: Patient in pain, agitated Recommendations: Pain and anxiety management ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZ211 Facility ID: CA040000015 If continuation sheet 7 of 16 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: _______________ 555924 (X3) DATE SURVEY COMPLETED 01/22/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHEL LUTHERAN HOME, INC. 2280 Dockery Ave Selma, CA 93662 (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 facility policy and procedure titled,"Interdisciplinary Team Guidelines, Care Planning" dated 7/2019, indicated, "It is the policy of this facility to include appropriate members of the IDT in the care planning process to effectuate, as appropriate, person centered care... Baseline care plans are developed within 48 hours of admission and must address effective and person centered in accordance with acceptable professional standards. These care plans shall include resident's strengths, goals, life history and preferences..." The facility policy and procedure titled, "Fall/Accident Mitigation and Intervention" dated 7/19, indicated, "It is the policy of this facility to minimize the risk of falls or accidents, and minimize the risk of serious injury associated with falls or accidents ...2. Resident at risk for falls shall have a care plan that identifies the risk factors for that individual resident and appropriate intervention based on the risk factors... 6. The facility nursing staff and/or the IDT shall update the resident's plan of care accordingly to reduce the risk of further occurrences of a fall or other event..."

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 02/05/2020 §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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZ211 Facility ID: CA040000015 If continuation sheet 8 of 16 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: _______________ 555924 (X3) DATE SURVEY COMPLETED 01/22/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHEL LUTHERAN HOME, INC. 2280 Dockery Ave Selma, CA 93662 (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 This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to provide supervision and assistance for Resident 1 when preventative measures were not implemented, a " ...one on one ..." (one staff member to one resident) was not addressed by Interdisciplinary Team (IDT) (a facility group compose of a physician, registered nurse, social worker and additional appointed facility staff) and antiroll brakes for Resident 1's wheelchair were not provided as indicated in Resident 1's care plan. This failure led to Resident 1 falling six times from 3/3/19 to 10/13/19. Resident 1 suffered a fall on 10/13/19 when she attempted to stand up on her own without staff supervision. Resident 1 was transferred to the Acute Care Hospital (ACH) on 10/14/19. Resident 1 was diagnosed with a left femur [the bone of the thigh] fracture on 10/14/19 and returned to the facility on 10/16/19 with hospice care services (end of life care). Findings: During a review of the clinical record for Resident 1, the "Admission Record" dated 7/25/14, indicated resident had diagnosis of dementia [a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning], anxiety disorder [a worry about future events, and fear is a reaction to current events], agerelated physical debility [self-reported inability to walk due to impairments and limited mobility and a history of falls]. During a review of the clinical record for Resident 1, the "Medication Administration Record" dated October 2019, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZ211 Facility ID: CA040000015 If continuation sheet 9 of 16 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: _______________ 555924 (X3) DATE SURVEY COMPLETED 01/22/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHEL LUTHERAN HOME, INC. 2280 Dockery Ave Selma, CA 93662 (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 had an order for clopidogrel bisulfate (blood thinning medication that causes side effects of easy bleeding/bruising and may take longer than usual for bleeding to stop with a cut or injury) 75 milligram (unit of measure), 1 tablet administered by mouth in the evening. During a review of the professional reference titled, "Drugs and Supplements Clopidogrel (Oral Route)." Mayo Clinic, Mayo Foundation for Medical Education and Research (MFMER), dated 10/1/19, indicated, "While you are using this medicine, if you have any kind of bleeding, it may take longer than usual to stop, especially if you hurt yourself. Stay away from ... situations where you could be bruised, cut, or injured ...This medicine may increase your chance of bleeding or bruising. Check with your doctor right away if you notice any unusual bleeding or bruising; black, tarry stools; blood in the urine or stools; or pinpoint red spots on your skin." During a review of the clinical record for Resident 1, the "Minimum Data Set" (MDS) assessment (an evaluation used to identify resident care needs) dated 7/22/19, indicated Resident 1 was severely cognitively impaired with a "Brief Interview for Mental Status" (BIMS) (an evaluation of attention, orientation and memory recall) score of 3 (0-7 severe cognitive impairment). The MDS assessment dated 7/22/19, indicated Resident 1 required one-person extensive assistance with transfers to or from bed, chair, wheelchair, and standing position. Resident 1 required one person limited assistance with walking in room and corridor. During a concurrent interview and record review, on 12/19/19, at 2:17 p.m., with the Director of Nursing (DON), Resident 1's "Fall Risk Assessment" dated 8/6/18 was reviewed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZ211 Facility ID: CA040000015 If continuation sheet 10 of 16 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: _______________ 555924 (X3) DATE SURVEY COMPLETED 01/22/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHEL LUTHERAN HOME, INC. 2280 Dockery Ave Selma, CA 93662 (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 fall risk assessment on 8/6/18 indicated a high risk for falls with a total score of 11 (Total score of 10 or above represents high risk). The fall risk assessment on 11/1/18 indicated a high risk for falls with a total score of 13. The DON stated there was no other fall risk assessments done after 11/1/18 for Resident 1. The DON stated residents were determined fall risk on admission and if the resident falls once at the facility then they are automatically considered a high fall risk. The DON stated fall risk assessments are not completed quarterly or with every fall. During an interview with the Licensed Vocational Nurse (LVN) on 10/15/19, at 1:47 p.m., she stated Resident 1 constantly tried to get up from the wheelchair and bed by herself. The LVN stated Resident 1 would want to go to bed and then go back into her wheelchair. The LVN stated her fall on 10/13/19 (Fall # 7) could have been avoided if a staff member was with Resident 1 supervising on a one on one basis but it had never been ordered or done. The LVN stated staff tried to check on Resident 1 frequently and she had a bed and wheelchair alarm but she was still falling because staff could not get to her on time. The LVN stated Resident 1 would not use her call light and would not ask staff for assistance because she was confused. During an interview with Certified Nursing Assistant (CNA) 2 on 10/15/19, at 2:10 p.m., she stated Resident 1 constantly tried to get up from her bed and wheelchair unassisted. CNA 2 stated Resident 1 would not use her call light and would attempt to stand up by herself. CNA 2 stated on 10/13/19 (Fall # 7) at 8:55 p.m., she sat with Resident 1 in the hallway while she completed her documentation. CNA 2 stated she went to answer another resident's call light and left Resident 1 unsupervised FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZ211 Facility ID: CA040000015 If continuation sheet 11 of 16 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: _______________ 555924 (X3) DATE SURVEY COMPLETED 01/22/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHEL LUTHERAN HOME, INC. 2280 Dockery Ave Selma, CA 93662 (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 sitting in her wheelchair in the hallway. CNA 2 stated she heard a yell coming from the hallway. CNA 2 stated when she stepped out to the hallway she observed Resident 1 on the floor. CNA 2 stated Resident 1's fall (Fall # 7) could have been avoided with a " ...one on one ..." supervision but it had never been done. CNA 2 stated she was not instructed by the LVN to supervise Resident 1 on a " ...one on one ..." During an interview with CNA 1 on 10/15/19, at 2:46 p.m., she stated Resident 1 would not use the call light because she was confused. CNA 1 stated she would encourage Resident 1 to ask for help but Resident 1 did not understand the importance of using her call light. CNA 1 stated she had to ask Resident 1 if she needed assistance because Resident 1 would not ask for assistance to get up from her bed or wheelchair unless staff asked her. CNA 1 stated Resident 1 required one-person physical assist to and from bed, wheelchair and toilet. CNA 1 stated Resident 1 was able to ambulate with a gait belt (a device put on a patient who has mobility issues, may be used to aid in the safe movement of a patient, from a standing position to a wheelchair) but was unable to walk independently. CNA 1 stated Resident 1 should have been on " ...one on one ..." supervision because she would constantly get up from her wheelchair and bed unassisted. During a concurrent interview and record review on 10/15/19, at 1 p.m., with the Director of Nursing (DON), Resident 1's "Care Plan" dated 7/17/19 was reviewed. The DON stated on 7/15/19 (Fall # 3) Resident 1 attempted to ambulate in her room unassisted and fell. The care plan intervention following the fall indicated, "Keep call light within reach while in room." The DON stated Resident 1 had a BIMS score of three and was severely cognitively FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZ211 Facility ID: CA040000015 If continuation sheet 12 of 16 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: _______________ 555924 (X3) DATE SURVEY COMPLETED 01/22/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHEL LUTHERAN HOME, INC. 2280 Dockery Ave Selma, CA 93662 (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 impaired. The DON stated Resident 1 had poor safety awareness and she [Resident 1]did not think she could fall if she got up by herself. The DON stated Resident 1 did not use her call light and would not ask for help. During a concurrent interview and record review on 10/15/19, at 1 p.m., with the DON, Resident 1's "Care Plan" dated 9/9/19 was reviewed. The DON stated on 9/8/19 (Fall # 4) Resident 1 attempted to get up from her wheelchair unattended and the wheelchair was unlocked. The DON stated the wheelchair rolled back when Resident 1 sat back down and fell on her bottom. The care plan intervention dated 9/9/19 following the fall was, "Antiroll brake for wheelchair when available." The DON stated the antiroll brakes were not ordered by the Administrator (ADM). During a concurrent interview and record review on 10/15/19, at 2:57 p.m., with the ADM, Resident 1's "Care Plan" dated 9/9/19 was reviewed. Resident 1's care plan dated 9/9/19, indicated, "Antiroll brakes for wheelchair when available." The ADM stated the intervention for the fall on 9/8/19 (Fall # 4) was never implemented because he did not remember he had to order the antiroll brakes for Resident 1. The ADM stated Resident 1 should have been on " ...one on one ..." because she was constantly trying to get out of her wheelchair and bed to prevent further falls. During a concurrent interview and record review on 10/15/19, at 1 p.m., with the DON, Resident 1's "Care Plan" dated 9/27/19 was reviewed. The DON stated on 9/27/19 (Fall # 5) Resident 1 stood up from her wheelchair unassisted to pull her pants up and fell forward. The care plan intervention following the fall dated 9/27/19 was, "Resident encouraged to sit in regular chair when sitting outside her room." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZ211 Facility ID: CA040000015 If continuation sheet 13 of 16 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: _______________ 555924 (X3) DATE SURVEY COMPLETED 01/22/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHEL LUTHERAN HOME, INC. 2280 Dockery Ave Selma, CA 93662 (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 DON stated Resident 1 did not like sitting in a regular chair and was put back in her wheelchair without implementing a different intervention. During a concurrent interview and record review on 10/15/19, at 1 p.m., with the DON, Resident 1's "Care Plan" dated 9/30/19 was reviewed. The DON stated on 9/27/19 (Fall # 6) Resident 1 attempted an unassisted transfer from her bed and fell. The DON stated the IDT (Interdisciplinary Team-a group composed of a nurse, social worker, activity staff, dietary staff and other facility appointed staff) determined Resident 1's falls were unavoidable and did not implement any new interventions. During a concurrent interview and record review on 10/16/19, at 4:25 p.m., with the DON, Resident 1's "IDT Post Fall Investigation Review" dated 9/30/19 was reviewed. The "IDT Post Fall Investigation Review" indicated, "IDT has determined falls are unavoidable - many interventions in place. Goal is to decrease major injury." The DON stated, the IDT had not requested an order from the physician for every 15 minute checks, every 30 minute checks and a " ...one on one ..." because close monitoring or supervision would not have kept Resident 1 from falling because her room was located in front of the nurse's station and multiples falls were observed form the nurses station. During a concurrent interview and record review on 1/6/19, at 9:39 a.m., with the Director of Staff Development (DSD), Resident 1's "IDT Post Fall Investigation Review" dated 9/30/19 was reviewed. The DSD stated, the IDT had implemented many interventions to keep Resident 1 safe from a major injury and could not come up with any other interventions. The DON stated, a " ...one on one ..." was not an option discussed with the IDT because the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZ211 Facility ID: CA040000015 If continuation sheet 14 of 16 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: _______________ 555924 (X3) DATE SURVEY COMPLETED 01/22/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHEL LUTHERAN HOME, INC. 2280 Dockery Ave Selma, CA 93662 (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 facility did not have staff available to provide one on one supervision. The DSD stated, a " ...one on one ..." would have prevented Resident 1 from obtaining a major injury. During a concurrent interview and record review on 10/16/19, at 4:25 p.m., with the DON, Resident 1's "Care Plan" dated 3/3/19 was reviewed. The DON stated on 3/3/19 (Fall # 1) Resident 1 was sitting in her wheelchair by the nurse's station and attempted to ambulate back to her bed unassisted and fell next to her bed. The care plan intervention indicated, "Encourage Resident to call for assistance." The DON stated Resident 1 had a BIMS score of three and was severely cognitively impaired. The DON stated Resident 1 had poor safety awareness and did not think she could fall if she got up by herself. The DON stated Resident 1 would not ask for help. During a review of the clinical record for Resident 1, the "Discharge Instructions" from the hospital dated 10/14/19 to 10/16/19, indicated, "Orthopedic [the correction of deformities of bones or muscles] is a moderate risk surgery and [patient] is a high risk [patient] given history of multivessel coronary artery disease [arteries that supply blood to heart muscle become hardened and narrowed]. Patient is very well-known to cardiologist [Doctor that opens chest and performs heart surgery] [Doctors name]. I discussed patient's case with [Doctors name] over phone a per him patient is a high risk patient for orthopedic surgical intervention given patient's multivessel coronary artery disease in setting of advance age/dementia and that he would not recommend patient undergoing surgery ... palliative team was consulted. They discussed with family. Ultimately decision was made to change her to hospice care ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZ211 Facility ID: CA040000015 If continuation sheet 15 of 16 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: _______________ 555924 (X3) DATE SURVEY COMPLETED 01/22/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHEL LUTHERAN HOME, INC. 2280 Dockery Ave Selma, CA 93662 (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 During a review of the clinical record for Resident 1, the "Facility Communication Sheet/Telephone Order Form" from hospice dated 10/16/19, indicated, " ...Situation: New admission for [Hospice Name] DX [diagnosis]: CAD [Coronary Artery Disease-arteries that supply blood to heart muscle become hardened and narrowed]. Background: Recent L [left] hip [fracture], not a surgical candidate Assessment: Patient in pain, agitated Recommendations: Pain and anxiety management ..." During a review of the facility policy and procedure titled, "Interdisciplinary Team Guidelines, Care Planning" dated July 2019, indicated, "It is the policy of this facility to include appropriate members of the IDT in the care planning process to effectuate, as appropriate, person centered care... Baseline care plans are developed within 48 hours of admission and must address effective and person centered in accordance with acceptable professional standards. These care plans shall include resident's strengths, goals, life history and preferences..." During a review of the facility policy and procedure titled, "Fall/Accident Mitigation and Intervention" dated July 2019, indicated, "It is the policy of this facility to minimize the risk of falls or accidents, and minimize the risk of serious injury associated with falls or accidents ...2. Resident at risk for falls shall have a care plan that identifies the risk factors for that individual resident and appropriate intervention based on the risk factors... 6. The facility nursing staff and/or the IDT shall update the resident's plan of care accordingly to reduce the risk of further occurrences of a fall or other event..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PLZ211 Facility ID: CA040000015 If continuation sheet 16 of 16