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. (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: 055919 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 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)