Health inspection·April 9, 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 two of four sampled residents (Resident 1 and Resident 2) were free of accident hazards, when care provided was not consistent with care plan intervention and facility fall management policy. This failure resulted in delay of care for an unwitnessed fall of Resident 1, which potentially caused Resident 1's hip fracture, and had the potential for Resident 1 and Resident 2 to have repeat falls. Findings: During a review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated, Resident 1 was admitted to the facility September 2019 with multiple diagnoses which included dementia (a progressive state of decline in mental abilities). During a review of Resident 1's care plan, initiated 11/29/22, the care plan indicated, . [Resident 1] is at risk for falls .goal .resident will be free of falls .resident will not sustain any injury if fall happens again .interventions .follow facility fall protocol . During a review of Resident 1's fall risk evaluation, dated 2/26/25, the fall risk evaluation was not fully completed and did not have a fall risk score. During a review of Resident 1's Progress Note, dated 3/25/25, the Progress Note indicated, . Patient is having acute pain on his right hip .it looks like patient might have a femur (thigh bone) fracture .no report of falls was noted .Patient .might have fell .will send him to ER for further evaluation . During a review of Resident 1's Progress Noted, dated 3/26/25, the Progress Note indicated, .Spoke to [NAME] RN from Sutter .he stated that resident will be admitted for right femoral neck (bone that connects hip joint to thigh bone) fracture . During a review of a facility document, dated 4/1/25, the facility document indicated, .Based on interviews among staff members, it was revealed that the resident was found on the floor at the hallway sometime about 2 weeks ago . During a review of Resident 1's fall risk evaluation, dated 4/3/25, the fall risk evaluation was Page 1 of 3 056139 056139 04/09/2025 Roseville Point Health & Wellness Center 600 Sunrise Avenue Roseville, CA 95661

F 0689 not fully completed, did not have a fall risk score, and was not signed. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/9/25 at 10:34 a.m., with Licensed Nurse 1 (LN 1), LN 1 stated she worked on the day that Resident 1 fell, approximately 2-3 weeks ago. LN 1 further stated, the day Resident 1 fell, he was found on the hallway floor by a Certified Nursing Assistant (CNA) during the evening shift. LN 1 further stated she assisted with helping Resident 1 get back in his wheelchair. LN 1 further stated she did not do an assessment of the resident or notify the physician. Residents Affected - Few During a review of Resident 1's Progress Notes from 2/26/25 through 3/24/25, there were no documented evidence of falls including any post fall assessments or post fall follow up. During an interview on 4/9/25 at 11:44 a.m. with Director of Nursing (DON), the DON acknowledged facility protocol was not followed when Resident 1's unwitnessed fall was not documented or reported, which led to delay in care and risk for repeat falls. During a review of the facility's policy and procedure (P&P) titled, Fall Management Program, revised 3/13/21, the P&P indicated, .As part of the admission Assessment, the licensed nurse will complete a fall risk evaluation .a licensed nurse will conduct a new fall risk evaluation .post fall and as needed .Following every resident fall, the licensed nurse will perform a post-fall evaluation and update .for an unwitnessed fall .the license nurse will complete neurological checks for 72 hours following the fall incident .the attending physician will be informed .the licensed nurse will notify the Director of Nursing .Administrator regarding the fall incident as soon as possible .within 15-20 minutes after the fall, the licensed nurse will initiate a Post-Fall Huddle .the license nurse will immediately update the care plan with recommendations .the IDT (Interdisciplinary Team) will investigate the fall . During a review of Resident 2's face sheet, the face sheet indicated, Resident 2 was admitted to the facility March 2025 with multiple diagnoses which included Pulmonary Embolism (blood clot in the lung). During a review of Resident 2's care plan, initiated 3/23/25, the care plan indicated, .Risk for Falls .Goal .Resident Will Be Free of Falls Interventions .initiate fall risk precautions . During a review of Resident 2's progress note, dated 3/23/25, the progress note indicated Resident 2 fell in the bathroom. During a review of Resident 2's progress note, dated 3/26/25, the progress note indicated Resident 2 fell out of his bed. The facility was unable to provide a facility fall risk precaution document when asked. During a concurrent observation and interview on 4/9/25 at 11:04 a.m. with LN 2, in Resident 2's bedroom, Resident 2 was lying in bed. Resident 2's bed was not in the lowest position and the fall mat was not next to the bed. LN 2 confirmed Resident 2 was a fall risk. LN 2 further stated fall precautions should have been in place for resident including bed in lowest position and fall mat next to bed. LN 2 further stated there was a risk for injury when fall precautions were not observed. During an interview on 4/9/25 at 11:44 a.m. with DON, DON stated the expectation was for fall precautions to be followed to prevent risk of falls and injury. 056139 Page 2 of 3 056139 04/09/2025 Roseville Point Health & Wellness Center 600 Sunrise Avenue Roseville, CA 95661

F 0689 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P, titled Fall Management Program revised 3/13/21, the P&P indicated, .purpose .to provide residents a safe environment that minimizes complications associated with falls .policy .providing an environment free from fall hazards . Residents Affected - Few 056139 Page 3 of 3