Other·November 13, 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 HealthLicensing and Certification during a Standard Abbreviated Survey. Facility reported incident (FRI): CA 00641800Substantiated Representing the Department: 38585-HFEN The inspection was limited to the investigation of the FRI and does not reflect the findings of a full inspection of the facility.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §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 provide adequate supervision and assistance device to ensure safety from falls for one of two sampled residents, (Resident 1). Resident 1 was assessed as a high risk for fall with history of 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: 3H1L11 Facility ID: CA050000047 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: _______________ 055826 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY OAKS POST ACUTE 830 E Chapel St Santa Maria, CA 93454 (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 constantly leaning forward and was ordered by the physician to use lap buddy (a breakaway lap cushion that helps with positioning if a person tends to lean forward and is in danger of falling out of the wheelchair) while in wheelchair for safety. A certified nursing assistant (CNA 1) left resident unattended while the resident was seated in the wheelchair without the lap buddy on . As a result, Resident 1 fell forward from the wheelchair, sustained laceration on the left forehead and a skull fracture, requiring a transfer to the emergency room. Findings: During an observation on 6/27/19, at 9:00 A.M., Resident 1, was sitting in a wheelchair at bedside, with lap buddy on, wearing pants and blouse, two nursing staff were assisting Resident 1 back to bed. Resident 1 had light brown and light green colored bruises on left cheek bone area. The resident was not inteviewable. During a review of the clinical record for Resident 1, the document titled, "Client Diagnoses Report", dated 5/21/2019, indicated the Admitting Diagnoses were: Repeated Falls, Alzheimer's disease (neurological disorder in which the death of brain cells cause memory loss and cognitive decline) with late onset, 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), Restlessness and Agitation. Review of the the Minimum Data Set (MDS) (assessment of healthcare and functional needs and abilities), dated 6/4/19, indicated Resident 1 had short term and long term memory problems, and moderately impaired FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H1L11 Facility ID: CA050000047 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: _______________ 055826 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY OAKS POST ACUTE 830 E Chapel St Santa Maria, CA 93454 (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 cognitive skills (decisions poor; cues/supervision required). Resident 1 required extensive assistance (resident involved in activity and staff provide weight-bearing assistance) with one person physical assist for transfers and walking. Resident 1's balance is not steady and only able to stabilize with staff assistance. Review of Fall Risk Assessment dated 5/21/19 indicated Resident 1 was a high risk of falls, with a score of "13". The assessment showed a score from 8-16 was a high risk for falls related to the following risk factors: History of falls in the past 180 days, neuromuscular dysfunction (affects muscles and their direct nervous system control), balance deficit/unsteady gait, impaired judgment, wandering behavior, use of psychotropic (medication that affect a person's mental state), and narcotic (a drug, that in moderate doses dulls the senses, relieves pain, and induces profound sleep) medications, visual deficit (decreased ability to see to a degree that causes problems), bladder/bowel dysfunction (problems with urinating and passing stool), and required an assistive device to ambulate/transfer. Resident 1 has dementia and poor safety awareness, fell at home sustaining a fractured right hip, and does not use the call light due to dementia. Review of the document titled, "[facility name] Resident Care Plan" for falls, initiated on 5/23/19, indicated Resident 1 had poor safety judgement, was constantly leaning forward, and was unable to use a call light due to dementia, had a fall at home resulting in right hip fracture. Approaches in order to prevent injury from fall included the use of lap buddy (a breakaway lap cushion that aides in the prevention of falls) and not to leave Resident 1 unattended. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H1L11 Facility ID: CA050000047 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: _______________ 055826 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY OAKS POST ACUTE 830 E Chapel St Santa Maria, CA 93454 (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 Review of the document titled "Physician Orders", dated 5/28/19, indicated an order to use lap buddy while Resident 1 is in wheelchair for safety measure due to resident's constantly leaning forward. Review of document titled "CNA Documentation" dated 6/13/19, at 5:27 A.M. revealed, CNA 1 put Resident 1 in her wheelchair, went to get lap buddy and resident fell flat on her face. A review of a licensed nurse (LN 1) note, dated 6/13/19, at 8:52 A.M., indicated, at 5:55 am, Resident 1 was in room when CNA (CNA 1) Resident 1 in the wheelchair, when CNA turned to grab the lap buddy, Resident 1 fell forward, hit her face on the floor, cutting her forehead open. Resident 1 was bleeding and 911 was called for transfer to the emergency room. During an observation and concurrent interview with CNA 1, on 9/18/19, at 7:45 A.M., while at the resident's room where the fall incident occurred, CNA 1 demonstrated how the fall incident, on 6/13/19 occurred. CNA 1 demonstrated and explained that the alarm kept going off and Resident 1 was trying to get out of bed on left side. CNA 1 put Resident 1 in wheelchair with the wheelchair facing head of bed and then rolled the wheelchair back a couple of feet and turned to head out of the room. CNA 1 then realized, "Oh, yes, the lap buddy, and turned to go get it." The lap buddy was on neighbor's bed side table. The distance was measured from resident's location to the lap buddy was six feet and 4 inches away. CNA 1 indicated she then took about four to five steps to get the lap buddy, heard a "thump", and resident fell on the floor. During an interview with the Director of Nursing (DON), on 6/27/19, at 9:30 A.M., the DON FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H1L11 Facility ID: CA050000047 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: _______________ 055826 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY OAKS POST ACUTE 830 E Chapel St Santa Maria, CA 93454 (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 stated, "We do a fall assessment upon admission and that is what triggers fall precautions, then we update it with any changes. Resident 1 was on Fall Precautions." The DON further stated, "CNA 1 had gotten Resident 1 up in a wheelchair, turned to reach for the lap buddy, I don't even think CNA 1 took a step, but the resident (Resident 1), fell forward. CNA 1 should have had the lap buddy ready and with her to use." Review of Resident 1's hospital emergency room report, dated 6/13/19, indicated Resident 1 sustained a head injury and facial laceration (tissue tear) on her left forehead. Resident 1 received six stitches to the forehead laceration. A review of the Computerized Tomography (an X-ray image made using a form of tomography (technique for displaying a representation of a cross section through the human body using Xrays or ultrasound) in which a computer controls the motion of the X-ray source and detectors, processes the data, and produces an image) report, dated 6/13/19, indicated Resident 1 sustained a fracture of the right occipital condyle (undersurface protuberances of the main bone of the back and lower part of the skull). The facility policy and procedure titled, "Fall Risk Assessment", dated March 2018, indicated in part, "..7. The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition..9. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H1L11 Facility ID: CA050000047 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: _______________ 055826 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY OAKS POST ACUTE 830 E Chapel St Santa Maria, CA 93454 (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 are not modifiable.." The facility policy and procedure titled, "FallsClinical Protocol", dated March 2018, indicated in part, "Monitoring and Follow-Up" and, "..4. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling ( instead of, or in addition to those that have already been identified) and also reconsider the current interventions.." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H1L11 Facility ID: CA050000047 If continuation sheet 6 of 6