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.
(continued on next page)
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
055299
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055299
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Loma Linda Post Acute
25383 Cole Street
Loma Linda, CA 92354
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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.
Event ID:
Facility ID:
055299
If continuation sheet
Page 2 of 2
