Health inspection·July 8, 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 interview and record review, the facility failed to provide care that allowed one of three residents (1) to remain safe when Resident 1 was a bariatric resident and only one certified nursing assistant (CNA) working with her. This failure resulted in Resident 1 fell off her bed and to the floor. Findings: Review of Resident 1's admission Record indicated she was admitted to the facility on [DATE] with severe obesity diagnosis. Review of Resident 1's Minimum Data Set (MDS, a clinical assessment tool), dated 3/8/24, indicated her range of motion was impaired on one side for her upper and lower extremity, and she needed maximal assistance for rolling left and right in her bed. Review of Resident 1's Change of Condition Report, dated 3/4/24, at 7:51 a.m., indicated on 3/4/24, at 7:15 a.m., when one CNA was repositioning Resident 1 in bed during a change, Resident 1 rolled off the bed and onto the floor. During an interview with assistant director of nursing A (ADON A) on 7/8/24, at 3:40 p.m., she stated the CNA worked with Resident 1 by herself. The CNA turned Resident 1 to the side to cleanse the back of her body. Resident 1's leg slid off the bed, and Resident 1 fell to the floor. ADON A stated the CNA should not work with Resident 1 alone because Resident 1 was a bariatric resident. The facility always educated staff that two persons were needed when working with a bariatric resident. ADON A stated the CNA should have called another CNA to work with her on Resident 1. Review of the facility's policy, Care and Treatment of Bariatric Residents, dated 6/1/23, indicated Bariatric residents have special needs. This facility will provide the necessary care and treatment that allows the bariatric resident to remain safe . 5. Care will be provided with the number of staff needed to ensure safety of the resident and the staff. Based on interview and record review, the facility failed to provide care that allowed one of three residents (1) to remain safe when Resident 1 was a bariatric resident and only one certified nursing assistant (CNA) working with her. This failure resulted in Resident 1 fell off her bed and to the floor. Findings: Page 1 of 2 055316 055316 07/08/2024 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 1's admission Record indicated she was admitted to the facility on [DATE] with severe obesity diagnosis. Review of Resident 1's Minimum Data Set (MDS, a clinical assessment tool), dated 3/8/24, indicated her range of motion was impaired on one side for her upper and lower extremity, and she needed maximal assistance for rolling left and right in her bed. Review of Resident 1's Change of Condition Report, dated 3/4/24, at 7:51 a.m., indicated on 3/4/24, at 7:15 a.m., when one CNA was repositioning Resident 1 in bed during a change, Resident 1 rolled off the bed and onto the floor. During an interview with assistant director of nursing A (ADON A) on 7/8/24, at 3:40 p.m., she stated the CNA worked with Resident 1 by herself. The CNA turned Resident 1 to the side to cleanse the back of her body. Resident 1's leg slid off the bed, and Resident 1 fell to the floor. ADON A stated the CNA should not work with Resident 1 alone because Resident 1 was a bariatric resident. The facility always educated staff that two persons were needed when working with a bariatric resident. ADON A stated the CNA should have called another CNA to work with her on Resident 1. Review of the facility's policy, Care and Treatment of Bariatric Residents, dated 6/1/23, indicated Bariatric residents have special needs. This facility will provide the necessary care and treatment that allows the bariatric resident to remain safe . 5. Care will be provided with the number of staff needed to ensure safety of the resident and the staff. 055316 Page 2 of 2