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
interviews and record reviews, the facility failed to follow their own policy when Resident 1 was transferred
from bed to wheelchair without the use of a gait belt (assistance safety device).
This failure resulted in Resident 1 ' s injury of chipped fracture to his right tibia (shin bone).
Findings.
A review of the Facility ' s undated admission Record indicated, Resident 1 was admitted on [DATE] with
diagnoses that included Repeated Falls, Cognitive Communication Deficit and Retention of Urine
Unspecified.
An interview on 4/23/24 at 10:55 A.M., with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1
stated she was supposed to be watching lights and provide assistance to residents when needed. CNA 1
stated if a resident wants to be left alone, CNA 1 will leave them alone but would be watching from a
distance.
A phone interview on 4/29/24 at 4:13 P.M., with CNA 2 was conducted. CNA 2 stated, she worked with
Resident 1 that night of 3/15/24. CNA 2 stated at around 5:45 A.M., she asked Resident 1 if he wanted to
go to the bathroom and Resident 1 agreed. CNA 2 transferred Resident 1 from the bed to his wheelchair
with the use of a [NAME] steady (manual lift). After being transferred, Resident 1 slid from the wheelchair
while being assisted by CNA 2 to the floor. CNA 2 stated she did not have a gait belt on him since he
required minimal (the assisting person or device are required to perform 25 % of the work or a mobility
task) assistance. CNA 2 acknowledged she should always have her gait belt with her to use with Resident 1
' s transfers.
An interview on 4/23/24 at 11:20 A.M., with the Assistant Director of Nursing (ADON) was conducted. The
ADON stated Resident 1 required moderate (the assisting person or device are required to perform 50% of
the work or mobility task) assistance with transfers as assessed by the Physical Therapist. The ADON
stated the staff needs to always have the gait belt with them during transfers and ambulating residents in
the facility.
A phone interview on 4/29/2024 at 4:34 P.M., with the Director of Nursing (DON) was conducted. The DON
stated the staff should always have their gait belts in their possession. The DON stated Resident 1 was a
partial 1 per rehab assessment, and Resident 1 required moderate assistance with transfers and
ambulation.
(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:
055632
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
055632
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Grossmont Post Acute Care
8787 Center Drive
LA Mesa, CA 91942
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
A phone interview with family member (FM)1 on 4/24/24 at 9:04 A.M., was conducted. FM1 stated, the
Administrator (ADM) told and confirmed that her husband did not have a gait belt on him when he fell and
that he was assisted to the floor when he slid from his wheelchair. FM1 stated the facility stated it was a
witnessed fall. FM1 stated her husband had a history of falls and had injured his right leg previously and
then again at the facility as a result of the fall.
Residents Affected - Few
A record review of Resident 1 ' s MDS (minimum data set- tool assessment ) dated, 3/8/24 indicated,
Resident 1 ' s cognition was severely impaired or a score of 5 (0-7 indicated severe cognitive impairment;
8-12 indicated moderate cognitive impairment; 13-15 indicated cognition is intact).
A record review of the Physical Therapy Treatment Encounter notes dated, 3/13/2024 indicated, Resident 1
required moderate assistance of 1 person during sit to stand and transfers from chair/bed and to chair
transfers and uses a front wheel walker as an assistive device.
A record review of the Emergency Department visit at the Acute hospital on 3/15/24 indicated, final result
impression of the x-rays of Resident 1 ' s tibia and fibula (calf bone) indicated Non-displaced acute medial
tibial plateau fracture with associated
A record review of the Facility ' s undated Gait Belt Policy indicated .#3 cnas/nas are required to have
always assigned gait belt in their possession . #4 gait belts should be used when transferring and
ambulating residents if and indicated .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055632
If continuation sheet
Page 2 of 2
