Health inspection·March 18, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow Resident 1's plan of care of having two-person assistance when one-person assistance provided during care. As a result, Resident 1 had a witnessed fall and sustained a traumatic hematoma of the forehead (closed wound with blood collection following the fall. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting right dominant (complete weakness of one side of the body and weakness on one part of the body following a stroke), dysphagia (difficulty of swallowing) following a stroke and epilepsy per the facility admission Record. A review of Resident 1's physician history and physical examination (H&P) on 1/23/24 indicated Resident 1 did not have the capacity to understand and make decisions. A review of the fall risk evaluation indicated: 10/25/2025 indicated a score of 24 which meant a high risk of fall 1/30/25 indicated a score of 24 which meant a high risk of fall. A review of interdisciplinary team review and recommendations (IDT) on 1/22/2025 indicated on 1//20/2025 around 9:46 P.M. during night shift, Resident 1 had a witnessed fall from bed. According to the assigned certified nurse assistant (CNA), when Resident 1 was being changed and when turning her to the left side, Resident 1 rolled out of bed. Therapy and IDT recommendations included two- person assist for patient care. A review of the care plan related to activities of daily living (ADL) self-care needs on 10/24/2022 indicated Resident 1 required one staff to provide bathing, showering, dressing, eating, personal hygiene, oral care and toilet use, while Resident 2 required two-person assist on bed mobility, transfer and toileting hygiene. A review of the hospital notes on 1/20/2025 indicated diagnoses fall, initial encounter and traumatic hematoma of forehead, initial encounter. CT scan (computed tomography, imaging device) indicated large frontal scalp soft tissue hematoma. Page 1 of 2 055114 055114 03/18/2025 Arbor Hills Nursing Center 7800 Parkway Drive LA Mesa, CA 91942

F 0689 A review of the MDS (a federally required assessment tool) indicated Section GG: Level of Harm - Minimal harm or potential for actual harm 7/25/2024: Resident 1 was coded with impairment of one side for upper and lower extremities, depended on most ADLs. Residents Affected - Few 10/25/2024: Resident 1 was coded impairment on side for upper extremity and impairment of both sides for lower extremities and depended on most ADLs. 1/20/2025: Resident 1 was coded impairment on side for upper extremity and impairment of both sides for lower extremities and depended on most ADLs. On 2/5/2025 at 12::39 P.M., an observation and interview were conducted with Resident 1 and Director of Nursing (DON) present. Resident 1 was observed in bed with bruising and rounded mass on the forehead. The DON stated Resident 1 was send out to the hospital and came back with a skin tear in the forehead and bruising around both eyes, left nasal and upper lip area, going to the neck and later showed in the shoulder. On 2/5/2025 at 12:50 P.M., an interview was conducted with CNA 1. CNA 1 stated she was providing care with Resident 1 during the evening shift. CNA 1 stated she was providing care by herself with no other CNA. CNA 1 stated Resident 1 was falling, and she was trying to stop the fall but Resident 1 fell. CNA 1 stated Resident 1 was a two-person assistance and should have called another person to assist. On 2/25/2025 at 1:40 P.M., an interview was conducted with LN 1. LN 1 stated Resident 1's fall incident happened on 1/20/2025. LN1 stated she received message to go Resident 1's room. LN 1 stated CNA 1 was providing care to Resident 1 and Resident 1 rolled out of bed in the left side of her bed. LN 1 stated when she came into the room, Resident 1 was on the floor, LN 1 stated Resident 1 required two -person assist when providing care. LN 1 stated CNA 1 should have asked another person to assist because Resident 1 was a total assist with right sided weakness. On 2/25/2025 at 1:38 P.M., an interview and record review were conducted with LN 2. LN 2 stated MDS Section GG on 10/25/2024, Resident 1 was dependent transfer, bed mobility was total care and was coded two-person assistance. LN 2 stated MDS Section GG described dependent as helper did all of the effort and resident did none of the effort to complete the activity or the assistance of two or more helpers was required to resident to complete the activity. On 2/5/2025 at 2:28 P.M., an interview and record review were conducted with the DON and LN 2. The DON stated her expectation was staff to follow Resident 1's plan of care. Per the facility policy entitled Activities of Daily Living (ADL), revision date March 2028, indicated .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) . 055114 Page 2 of 2