Inspection·July 2, 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 interview and record review, the facility failed to ensure fall management was implemented for one of three sampled residents (Resident 1) when: 1. Resident 1 was not monitored after 5 falls;2. No interdisciplinary team meeting was conducted after 3 falls;3. No care plan was developed after one fall; and4. Resident 1's Responsible Party was not notified after 2 falls. These failures had the potential for Resident 1 to develop ill effects from a fall, to result in future falls and injury, and for Resident 1's responsible party being uninformed and unaware of his condition.A review of Resident 1's clinical record indicated he was admitted on [DATE] and had diagnoses including unspecified fall, muscle weakness, abnormalities of gait and mobility, and cellulitis (bacterial infection of the skin) of the left lower limb. A review of Resident 1's admission Fall Risk Observation/Assessment, dated 3/12/25, indicated his fall risk score was 16 which indicated a high risk for falls. Review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] and was discharged on 6/2/25. Resident 1 had 5 unwitnessed falls during his stay in the facility. Review of Resident 1's clinical record indicated he had unwitnessed falls on 4/1/25, 5/2/25, 5/19/25, 5/24/25, and 5/29/25. There was no documentation in the progress notes that licensed nurses were monitoring Resident 1 every shift after these falls for any ill effects from the falls for a 72 period. During an interview and concurrent record review with the director of nursing (DON) on 7/2/25 at 2:00 p.m., he stated licensed nurses should monitor a resident for 72 hours after a fall and record the resident's post-fall status in the progress notes every shift. The DON confirmed documentation by licensed nurses every shift for 72 hours was not done after Resident 1's 5 falls on the above dates. Review of Resident 1's clinical record indicated three of Resident 1's 5 falls, on 5/19/25, 5/24/25, 5/29/25, had no documented evidence that the facility's interdisciplinary team (IDT, team members from different departments involved in a resident's care) met to discuss Resident 1's falls. During an interview and concurrent record review with the DON on 7/2/25 at 2:00 p.m., he stated the IDT should meet after every fall to discuss the cause of the fall and to develop a plan to prevent further falls, and revise and/or update the care plan based on the IDT's decision. The DON confirmed there was no evidence the IDT met after Resident 1's 3 falls on 5/19/25, 5/24/25. and 5/29/25. Review of Resident 1's clinical record indicated Resident 1 had an unwitnessed fall on 4/1/25. This was the first fall in the facility since Resident 1's admission on [DATE]. There was no care plan developed for Resident 1's actual fall on 4/1/25. During an interview and concurrent record review with the DON on 7/2/25 at 2:00 p.m., he confirmed there was no care plan developed for Resident 1's fall on 4/1/25. The DON stated there should be a care plan created after a fall with interventions identified to prevent further falls. A review of Resident 1's Change of Condition Evaluation, dated 5/2/25, indicated Resident 1 had an unwitnessed fall. The section titled Resident Representative Notification indicated notification was done on 5/2/25 at 2:00 p.m., and Resident 1 was self-responsible party. Another Change of (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: 055739 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 055739 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Salinas Valley Post Acute 637 East Romie Lane Salinas, CA 93901 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)