Health inspection·May 29, 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 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 being sent out to acute hospital for evaluation. 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: pulmonary edema (excess fluid in lungs), abnormalities of gait and mobility, hypertension (high blood pressure), acute and chronic respiratory failure (lungs cannot exchange oxygen properly), colon cancer (cancer in rectum). 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. Fall risk assessment on admission March 28, 3025, High Risk=18. 2. Careplan: Falls: Resident is at risk for falls with or without injury related to altered balance while standing and/or walking, unsteady gait, UNWITNESSED-FALL Date Initiated: 04/16/2025, Created on: 03/28/2025. 3. Change of Condition Fall April 16, 2025: Sleeping when round was made alert with forgetfulness and confusion, needs assistance with Activities of Daily Living (ADL). At 1:30AM, Certified Nursing Assistant (CAN) assigned reposition resident and resident go back to sleep. 3:30AM resident changed she had a Bowel movement (BM) and around 4AM resident calling for help noted on the floor in her back in between her room door. Body assessment done, vital signs and neuro check initiated, no visual injury noted. During an interview on May 08, 2025, with Director of Nursing (DON) DON states, I explained to resident son about the rails, we have the grab bars upper bars. It's considered a restraint, I was notified after the fall about family requesting bedrails. After fall, I told the Resident son we will place her at nurse station. Bed was at lowest position, we were constantly and reminding her to use call light. She was not ambulatory. When she did have a fall, we did a (COC) and sent her out for eval. I offered interventions of room change near nurse station, we had already care planed it. I would do a medication review as well. The nurse station is in middle, this resident was not by nurse station but it was in a busy hallway. Page 1 of 2 055299 055299 05/29/2025 Loma Linda Post Acute 25383 Cole Street Loma Linda, CA 92354

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's policy and procedure titled, Fall and Fall Risk Managing revised [March 2018], the policy and procedure 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. During a review of the facility's policy and procedure titled, Falls- Clinical Protocol revised [March 2018], the policy and procedure indicated, The physician will help identify individuals with a history of falls and risk factors for falling. a. Staff will ask the resident and the caregiver or family about a history of falling. b. The staff and physician will document in the medical record a history of one or more recent falls (for example, within 90 days). c. While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. The physician will help identify individuals with a history of falls and risk factors for falling. a. Staff will ask the resident and the caregiver or family about a history of falling. b. The staff and physician will document in the medical record a history of one or more recent falls (for example, within 90 days). c. While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. 055299 Page 2 of 2