Health inspection·October 1, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 10/1/24 at 12:25 p.m. in the hallway, Resident 1 walked down the main hallway while holding Certified Nursing Assistant (CNA) 1 ' s hand. Resident 1 would not engage in conversation. A closed skin tear and abrasion were observed on the back of her right elbow. During a concurrent observation and interview on 10/1/24 at 12:26 p.m. with CNA 1, in Resident 1 ' s room, CNA 1 helped Resident 1 sit down on the edge of her bed. CNA 1 stated Resident 1 was able to walk unassisted unless she was tired. CNA 1 stated she was the CNA caring for Resident 1 on the day of the fall. CNA 1 stated she and Resident 1 were in the dining room during breakfast on 9/25/24. CNA 1 stated she was assisting another resident and when Resident 1 finished breakfast, she walked out of the dining room by herself. CNA 1 stated Resident 1 should have supervision when she walked because she tended to go into unsafe areas of the building such as other resident ' s rooms or unsupervised areas. CNA 1 stated if Resident 1 was sleepy, she would stop where she was and put herself on the floor which increased the risk of her being injured. CNA 1 stated Resident 1 was not supervised after she left the dining room and was found on the floor by a staff member. During an interview on 10/1/24 at 1:17 p.m. with CNA 2, CNA 2 stated she was the hallway safety monitor. CNA 2 stated Resident 1 frequently walked alone, unsupervised. CNA 2 stated if Resident 1 was tired she needed supervision because she had a history of putting herself on the ground. CNA 2 stated, we keep an eye on her when she is tired. CNA 2 stated Resident 1 was a high fall risk and was on the Red Sneaker Program. During a review of the facility ' s Red Sneaker Program, undated, the program indicated, . High Risk for Falls . [Resident 1 ' s name] . Criteria for Inclusion in the Red Sneaker Program . Resident has had a fall in the last 90 days . Resident has a Fall Risk Assessment Score of above 10 . Focus on residents who are High Risk for Falls that may be attempting to ambulate independently . During a concurrent interview and record review on 10/1/24 at 1:37 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s General Note, dated 9/25/24, at 2:40 p.m., written by LVN 1, the note indicated, . informed that resident is on the floor, resident was noted to by [be] lying on her right side with both hands under her head . eye closed . Head to toe assessment completed . skin tear noted to the right elbow . LVN 1 stated she was the charge nurse at the time of Resident 1 ' s fall. LVN 1 stated she was told Resident 1 was found on the floor in front of the business office and the fall was not witnessed. LVN 1 stated the fall was not witnessed by staff. LVN 1 stated Resident 1 would normally ambulate around the facility without supervision or assistance but was known to be a high fall risk and was on the Red Sneaker Program. LVN 1 stated when Resident 1 was tired, her gait was less steady, so she needed supervision for safety. LVN 1 stated Resident 1 was normally sleepy in the morning around breakfast time, so she should have had supervision at the time of the fall. Resident 1 ' s SBAR dated 9/25/24, written by LVN 1, the SBAR indicated, . Resident fell in Hallway . Fall Risk Factors: History of falls Impaired safety awareness/judgement . Injury Skin Tear . Unwitnessed Fall . Resident 1 ' s MDS Section GG (functional abilities) was reviewed. The Section GG indicated, . I. Walk 10 feet [code 04-Supervision or touching assistance] . J. Walk 50 feet with two turns [code 04-Supervision or touching assistance] . K. Walk 150 feet [code 04-Supervision or touching assistance] . LVN 1 stated the MDS indicated Resident 1 required supervision or touch assistance to ambulate safely. LVN 1 reviewed Resident 1 ' s fall risk scores of 16 on 9/4/24 and 13 on 9/25/24. LVN 1 stated the scores indicated Resident 1 was at high risk for falls. LVN 1 stated Resident 1 ' s falls were because she ambulated unsupervised when she was tired. During a concurrent interview and record review on 10/1/24 at 2:43 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 1 ' s MDS section GG was reviewed. The MDSC stated Resident 1 ' s fall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056281 If continuation sheet Page 2 of 3 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 056281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Care Center 925 North Cornelia Fresno, CA 93706 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 9/25/24 was unwitnessed. The MDSC stated the MDS indicated Resident 1 needed supervision or touch assistance when ambulating. The MDSC stated Resident 1 required redirection when ambulating for safety. The MDSC stated Resident 1 had a history of lowering herself onto the floor when she was tired. During an interview on 10/1/24 at 3:12 p.m. with the Director of Nursing (DON), the DON stated Resident 1 required supervision when ambulating. The DON stated supervision meant watching the resident to make sure she was not going into unsafe areas such as other resident ' s rooms. The DON stated Resident 1 ' s fall on 9/25/24 was unwitnessed. The DON stated Resident 1 ' s fall would have been witnessed if she had been supervised. The DON reviewed Resident 1 ' s fall risk score and stated Resident 1 was at high risk for falls. The DON stated Resident 1 had poor safety awareness and had behaviors of putting herself on the floor when tired. The DON stated it was her expectation for staff to supervise Resident 1 when walking. During an interview on 10/1/24 at 3:38 p.m. with the Administrator (ADM), the ADM stated Resident 1 ' s needs for supervision would vary. The ADM stated Resident 1 had a history of falling and putting herself on the floor when tired. The ADM declined to answer if Resident 1 was supervised when she had the unwitnessed fall on 9/25/24. During a review of Resident 1 ' s fall risk care plan dated 8/17/24, the care plan indicated, At risk for injury or fall related injury due to resident has impaired safety awareness . Redirect as indicated . Safety cueing as indicated . Staff to anticipated needs in timely manner . Staff to frequently check resident?s [sic] whereabouts for safety . During a review of Resident 1 ' s care plan for fall dated 9/25/24, the care plan indicated, . At risk for delayed injury related to actual fall on 9/25/24 . Encourage rest period . Manage resident fall risk through facility Red Sneaker Program . During a review of the facility ' s policy and procedure (P&P) titled, Safety and Supervision of Residents, undated, the P&P indicated, . Our facility strives to make the environment as free from accident hazards as possible . Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents . The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices . Implementing interventions to reduce accident risks . Ensuring that interventions are implemented . Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident ' s assessed needs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056281 If continuation sheet Page 3 of 3