Health inspection·October 31, 2023

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 observation, interviews and record reviews, the facility failed to provide safety reminders, guidance, and assistance to one of four residents (Resident 1) before he tripped on a transition strip on the floor and fell while walking at the lobby of the facility. This failure resulted in Resident 1 sustaining a closed or incomplete fracture of the neck of the right thigh bone, pain, and hospitalization. Findings: A review of records indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of asthma, cognitive (natural skills including attention, memory, processing speed, reasoning, planning, problem solving, and multitasking) communication deficit, anxiety disorder, and major depressive disorder, among other conditions. Resident 1 ' s Minimum data set (MDS – federally mandated process for clinical assessment of each resident in Medicare and Medicaid certified nursing homes of their functional capabilities and help nursing home staff identify health problems) dated 6/3/23, indicated he had short term memory problem and required limited assistance (staff providing guided maneuvering of limbs or other non-weight-bearing assistance) while walking the corridors, moving between his room and adjacent corridor on the same floor, or moving to and from distant areas on the floor. A review of the Resident 1 ' s care plan dated 1/16/21, indicated interventions to prevent falls included providing the resident/family/caregivers safety reminders and a safe environment with even floors, etc. A review of facility documents titled: 1) SBAR Communication Form and progress Note V-3 (pneumonic for Situation-Background-Assessment-Recommendation a framework for communication between members of the health care team about a patient's condition) dated 6/3/23 indicated Resident 1 had a witnessed fall on 6/3/23, and; 2) Progress Notes dated 6/3/23 titled: Post Fall indicated Resident 1 was sent to the acute hospital for a closed or incomplete fracture of the neck of the right thigh bone. During an interview on 6/14/23, at 1:03 p.m., Licensed Nurse A (LN A) stated Resident 1 fell on 6/3/23, around 3:30 p.m. during change of shift. LN A stated she was inside the admission office when she heard a commotion at the lobby and when she went to check was informed by another Licensed Nurse and the Receptionist about Resident 1 ' s fall. LN A stated she had briefly assessed Resident 1 before he was moved using a Hoyer lift (a portable total body lift or a patient lift used to allow a person to be lifted and transferred with a minimum of physical effort) and returned to his room. LN A stated Resident 1 was alert and oriented, lying flat on his back, his right leg was slightly over his left leg, refused to bend his legs because his back hurt and denied he had hit his head during the fall. LN A stated Resident 1 was using his walker independently. Page 1 of 2 055919 055919 10/31/2023 Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/14/23, at 1:18 p.m., Unlicensed Staff B (ULS B) stated Resident 1 was walking and was maneuvering his walker to go over the transition strip on the floor near the receptionist counter at the lobby. ULS B stated the slider on Resident 1 ' s walker got stuck on the lip of the transition strip between wood floor to tile, and Resident 1 fell backward to the right still holding on to his walker. ULS B stated she ran to Resident 1, told him not to move while she called for assistance. ULS B stated Resident 1 was forgetful, asking why he was in pain several times. A review of Activities of Daily Living (ADL) record of Resident 1 between 5/27 to 6/3/23, titled: Follow-up Question Report 5/28/23 - 6/3/23, indicated, Resident 1 required limited 1-person physical assistance on: 5/28/23 at 2:19 p.m., 5/31/23 at 8:14 a.m., 5/31/23 at 2:18 p.m., 6/2/23 at 10:37 a.m., 6/2/23 at 2:16 p.m., and 6/3/23 at 10:53 a.m. during the 7-day look back period. A review of the facility ' s policy titled: Falls-Clinical Protocol revised 9/2021, indicated under the subheading Treatment/Management: based on resident assessment, the staff and physician will identify pertinent interventions o try to prevent falls and to address risks of serious consequences of falling. A review of facility policy titled Fall risk assessment, revised 12/2007, indicated under policy interpretation and implementation: the staff with the support of the Attending Physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, ADL capabilities and identify environmental factors that may contribute to falling and will collaborate and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. The policy did not specifically discuss implementation of interventions, such as adequate supervision consistent with a resident ' s needs and ADL capabilities, goals, care plan and current professional standards of practice to eliminate the risk, if possible, and, if not, reduce the risk of an accident. 055919 Page 2 of 2