Health inspection·October 14, 2024

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 ensure adequate supervision was provided to prevent avoidable accidents for one of three sampled residents (Resident1). When Resident 1 fell out of bed. This failure contributed to Resident 1 sustaining multiple discoloration to left eye, left forearm and left knee. Findings: During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: cardiac arrest (unexpected loss of heart function), pneumonia (infection in lungs), type 2 diabetes (body has trouble controlling blood sugar), hypertension (high blood pressure). During a concurrent interview and record review of Resident 1 ' s Medical Record with the Director of Nursing (DON) reviewed and verified the following: 1. Acute hospital transfer documents dated August 15, 2024: Poor safety awareness .Rehab Potential and Diagnosis: Tremors, falls/alarms, life vest, treatment diagnosis for Physical Therapy: decrease independence with functional mobility. 2. Fall Risk assessment dated [DATE]=3 (low risk) 3. Change Of Condition (COC) Fall dated September 06, 2024. 4. COC for Bruises September 06, 2024. Re-eval Fall Risk Assessment September 06, 2024=13 (high risk). 5. Careplan- At risk for falls related to impaired mobility muscle weakness, impaired safety awareness, impulsiveness initiated September 04, 2024 .Will be free of serious injury do to fall through the review date .September 06, 2024 Resident was found sitting on the floor at foot of bed .bed alarm while in bed initiated September 10, 2024, floor mats initiated September 08, 2024, room assignment close to nurse station initiated September 06, 2024 .Skull, left knee and left forearm Xray on September 08, 2024. During an interview on September 24, 2024, with Resident 2 (R2) R2 states, Resident 1 had bruising all along the side of leg and arm, all along the left side, I heard he fell in another room. There Page 1 of 2 055129 055129 10/14/2024 Grand Terrace Health Care Center 12000 Mount Vernon Ave Grand Terrace, CA 92313

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were no mats on the floor when he was moved to this room, the sister was the one that told them to place the mats on the floor after he fell .he was in and out of clarity. I would use call light at night, and they would take a long time, he wound take off his oxygen .he needed more hands on and supervision because of his clarity. When I see that he needed a nurse, I would call them, and push the call light. The bruising was bad, I was not in the other room when he fell, but in this room, he was really bruised up, and like I said the sister was the one telling them to place the floor mats. During concurrent interview and record review on September 24, 2024, with the Director of Nursing (DON) of medical records, skin assessments, DON states, Resident 1 fell September 04.2024, I think they found this resident at foot of bed family and doctor notified. Doctor came September 06, 2024, at 4PM for to H&P at this point he had bruising to eyelid, he wrote for Xray, but I don ' t know what happened. The bruising to eyelid was small. We moved him closer to nurse station, the floor mats were started September 08, 2024, our immediate intervention was to move closer to nursing station. He was sent out due to low oxygen and chest pain. During a review of the facility ' s policy and procedure titled, Fall Management System revised [no date], the policy and procedure indicated, This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assisted devices and functional programs as appropriate to prevent accidents. 055129 Page 2 of 2