Health inspection·August 17, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, the facility failed to ensure one of three sampled resident ' s (Resident 1) brief was changed with two people helping to turn Resident 1 in the bed. Residents Affected - Few This failure resulted in Resident 1 falling off the bed and suffering a right femur fracture (broken right upper leg bone). Findings: During a review of Resident 1 ' s Minimum Data Set (MDS - an assessment tool used to plan care for the resident), dated, 1/4/2022, MDS indicated two people were required to move Resident 1 to and from lying position, to turn side to side, and to position body in the bed. During a concurrent observation and interview on 4/12/2023, at 10:37 a.m. in Resident 1 ' s room with Certified Nursing Assistant (CNA) 1, CNA 1 stated, CNA 1 was changing Resident 1 ' s brief on 3/21/2022, when Resident 1 fell off the bed. CNA 1 stated, Resident 1 was in her bed with side rails up at the head of the bed only. CNA 1 stated, CNA 1 was standing on one side of the bed. CNA 1 stated, she assisted Resident 1 to roll up on her side, while Resident 1 was holding the side rail with her hand, resulting in Resident 1 facing the siderail with her back facing CNA 1. CNA 1 stated, Resident 1 let go of the side rail, slid off the bed on the side opposite where CNA 1 was standing, and fell onto the floor. CNA 1 stated, CNA 1 was changing Resident 1 ' s brief by herself 1 demonstrated how CNA 1 stood on one side of the bed and turned Resident 1 up onto her side, while Resident 1 held the side rail. CNA 1 stated Resident 1 ' s legs started sliding off the bed when Resident 1 let go of the side rail. CNA 1 stated, CNA 1 grabbed Resident 1, but was unable to prevent her sliding off the bed onto the floor. CNA 1 stated, CNA 1 was regularly assigned to Resident 1 and had always changed Resident 1 ' s brief by herself. CNA 1 stated, Resident 1 was sleepier than usual that day. CNA 1 stated, CNA 1 told the charge nurse Resident 1 was sleepier than usual that day. During an interview on 4/12/2023, at 10:55 a.m., with Registered Nurse (RN) 1, RN 1 stated, RN 1 assessed Resident 1 after she fell on 3/21/2022, and found Resident 1 to be alert, oriented and in no pain. RN 1 stated, RN 1 worked day shift the day Resident 1 fell. RN 1 stated, RN 1 told the evening shift staff that Resident 1 had fallen. During an interview by telephone on 4/25/2023, at 2:27 p.m., with LVN 1, LVN 1 stated, she cared for Resident1 on the evening shift on 3/12/2022. LVN 1 stated, LVN 1 had been informed by the day shift nurse that Resident 1 had fallen out of bed earlier that day. LVN 1 stated, LVN 1 observed Resident 1 ' s level of alertness was down. LVN 1 stated, 911 was called and Resident 1 was sent out to the Page 1 of 2 055434 055434 08/17/2023 Hayward Gardens Post Acute 1628 B Street Hayward, CA 94541

F 0689 acute care hospital. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1 ' s Progress Notes (NP), dated 3/21/22, at 9:45 p.m., the PN indicated, Resident 1 was unable to answer simple questions and therefore, was transferred to the acute care hospital. Residents Affected - Few During a review of Resident 1 ' s History and Physical (H & P) from the acute care hospital, dated 3/22/2022, the H & P indicated, Resident 1 came from skilled nursing facility after a witnessed fall on 3/21/2022, at 2:00 p.m. H & P indicated, Resident 1 was in septic shock, had an abnormal urinalysis (test of urine), and was very sleepy. H & P indicated Resident 1 was admitted to the hospital. During a review of Resident 1 ' s Orthopaedic Consultation Note, from the acute care hospital, undated, indicated Resident 1 had a fall on 3/21/2023, at Resident 1 ' s care facility, complained of right hip pain two days later and was found to have a right proximal femur fracture. During an interview on 5/15/2023, at 3:14 p.m., with RN 1, RN 1 stated, CNA 1 had been regularly assigned to Resident 1. During a concurrent interview and record review on 5/15/2023, at 2:58 p.m., with the Assistant Director of Nursing (ADON), ADON stated, ADON reviewed the MDS, dated , 1/4/2022. ADON stated, the MDS indicated, Resident 1 required a two person assist when being moved in the bed, such as when Resident 1 was turned. ADON stated, Resident 1 required a two person assist when staff changed Resident 1 ' s brief, because Resident 1 had to be turned up on her side to change the brief. 055434 Page 2 of 2