Health 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 Page 1 of 2 055739 055739 07/02/2025 Salinas Valley Post Acute 637 East Romie Lane Salinas, CA 93901

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Condition Evaluation, dated 5/19/25, indicated Resident 1 had an unwitnessed fall. The section titled Resident Representative Notification indicated notification was done on 5/19/25 at 4:00 p.m., and Resident 1 was self-responsible. A review of Resident 1's face sheet (a document summarizing key information about a resident) indicated Resident 1's son was the responsible party (RP, a person designated to make health care decisions for a resident). During an interview and concurrent record review with the DON on 7/2/25 at 2:00 p.m., he stated Resident 1 was not identified as being self-responsible and confirmed the son was listed as the RP. The DON confirmed the son was not notified of Resident 1's falls on 5/2/25 and 5/19/25, and stated the son should have been informed of the falls. Review of the facility's policy titled Change in a Resident's Condition or Status, revised February 2021, indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. Review of the facility's policy titled Care Plans - comprehensive Person Centered, dated 2001, indicated the interdisciplinary team develops and implements a comprehensive, person-centered care plan for each resident. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the residents' condition. 055739 Page 2 of 2