Health inspection·April 5, 2024

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, interview and record review the facility failed to provide supervised and assisted ambulation to one of one sampled Residents, (1), at high risk for falls. This failure resulted in Resident 1 experiencing an unwitnessed fall that resulted in a broken bone in her left ankle. Findings: Resident 1 ' s admission Record indicated admission to the facility on 5/5/22, and included diagnoses of paranoid schizophrenia (a pattern of thoughts, feelings and behaviors that include suspicion of others), generalized muscle weakness, essential hypertension (high blood pressure often requiring medication that can have side effects increasing risk for falls) and cognitive communication deficit (difficulty with thinking and communication). A review of the Minimum Data Set (MDS) section GG dated 11/11/23 indicated Resident 1 required supervision or touching assistance (assistance from one person) for toileting hygiene, lower body dressing, chair and bed to chair transfer, walking 10 feet or more. The MDS indicated Resident 1 required set up or clean up assistance with toilet transfer. A review of facility Change of Condition (COC) note dated 1/26/23 indicated Resident 1 had an unwitnessed fall on her right knee on the physical therapy patio. A review of the facility COC note dated 2/28/23 indicated Resident 1 had a witnessed fall on the floor with her walker directly in front of her. A review of the facility COC note dated 3/14/23 indicated Resident 1 had an unwitnessed fall and was found on the left side of her bed with her head between her bed and the side dresser, Patient said she hit her head and has level seven out of ten pain in her right leg. A review of the facility COC noted dated 5/3/25 indicated Resident 1 had an unwitnessed fall and was found kneeling by her bedside. A review of the facility COC note dated 2/2/24 indicated Resident 1 had an unwitnessed fall and was found on the floor in front of toilet with her underwear on but pants around calves and stated I fell. ' An observation of Resident 1 ambulating in the hallway with a walker was conducted on 2/15/24 at 1:10 P.M. During the observation, Resident 1 did not have assistance or supervision from a staff member. Resident 1 was noted to walk with a limp on her left side. In an interview with the Director of Nursing (DON) conducted on 2/15/24 at 1:30 P.M., the DON stated at the time of the most recent fall (Resident 1) had a Brief Interview for Mental Status (BIMS) of Page 1 of 2 056062 056062 04/05/2024 Amaya Springs Health Care Center 8625 Lamar Street Spring Valley, CA 91977

F 0689 Level of Harm - Minimal harm or potential for actual harm 11 (moderate cognitive impairment). The DON stated, (Resident 1) was heard by a nurse asking for help in the bathroom. The nurse went in and saw the resident on the floor. A concurrent review of the Change of Condition (COC) note by Licensed Nurse (LN) 1 indicated, On 2/2/24 at approximately 9:20 P.M. the call light was on. Someone mumbled ' help me. ' Upon entry resident found on floor with pants down and underwear on. Resident stated, ' I fell. ' Residents Affected - Few In an interview with LN 2 conducted on 2/15/24 at 1:50 P.M., LN 2 stated, She needs set up and clean up assistance for toilet transfer and ability to get on and off commode. You can ' t see her room from the nurse ' s station. In a joint interview with LN 3 and the DON conducted on 2/15/24 at 2:15 P.M., LN 3 stated Resident 1 was not on a bowel and bladder program (a schedule for elimination of the bladder and bowel). The DON stated, Bowel and bladder training means a staff member goes to help the Resident use the restroom every two hours, after meals and before sleep at night. An interview with LN 3 was conducted on 3/13/24 at 1:10 P.M. LN 3 stated the most recent interventions in Resident 1 ' s fall care plan dated 5/5/23 included anticipate and meet resident needs. A toileting program is a way to anticipate a resident need. A review of the Physical Therapy evaluation dated 5/5/22 indicated Resident 1 could walk 10 feet with maximum assistance (assistance of 75% or more from one person), move from sitting to standing with maximum assistance, transfer to a toilet with maximum assistance, and that both of her legs were impaired. A review of Resident 1 ' s fall risk assessment dated [DATE], prior to the fall on 2/2/24, indicated her score was 12 which was noted as high risk r/t (related to) taking more narcotic (prescribed controlled substance for pain relief which may increase risk of falls)/ psychotropic (prescribed medication for some psychiatric diagnoses which may increase risk of falls) meds (medications). A review of the facility policy titled Fall Management Program revised March 13, 2021 indicated The Facility will implement a Fall Management Program that supports providing an environment free from fall hazards. A review of the facility policy titled Ambulation of a Resident revised January 1, 2012 indicated, Unless contraindicated, all assisted ambulation will utilize gait belts for resident and staff safety. Offer verbal encouragement and physical support. 056062 Page 2 of 2