Health inspection·March 14, 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 interview and record review, the facility failed to ensure the Fall Morse Scale was completed accurately for one of two sampled residents (Resident 1). The failure to accurately assess residents ' fall risk has the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions for falls. Findings: Review of Resident 1 ' s medical record indicated he was readmitted to the facility on [DATE] with diagnoses including anoxic brain damage (caused by a complete lack of oxygen to the brain), epilepsy (a brain condition that causes recurring seizures [a sudden, uncontrolled burst of electrical activity in the brain]), and metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood that may lead to personality changes). Review of Resident 1 ' s Interdisciplinary Team Progress Notes (IDT), dated 9/14/23 , indicated Resident 1 had an unwitnessed fall on 9/13/23. Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool), dated 9/8/23, indicated his brief interview for mental status (BIMS, a tool used to screen and identify a resident ' s cognition [thinking ability]) was 15 (13-15 means intact cognition). Review of Resident 1 ' s morse fall scale assessment, dated 9/3/23, indicated Resident 1 had a history of falls; and that, his fall score was 40 (a score of 25 -44 means a moderate risk for falls). Review of Resident 1 ' s morse fall scale assessment, dated 9/29/23, indicated, no history of fall, and his fall score was 25. Review of Resident 1 ' s morse fall scale assessment, dated 11/15/23, indicated, no history of fall, and his fall score was 25. During a concurrent interview and record review with the director of nursing (DON) on 11/21/23 at 12:53 p.m., she verified the morse fall scale assessments were done for all residents every quarter, and post fall and as needed. The DON confirmed staff did not complete Resident 1 ' s morse fall scale assessments accurately on 9/29/2023 and 11/15/2023. The DON stated staff should have completed these assessments accurately to capture Resident 1 ' s history of falls. During a concurrent interview and record review with the Minimum Data Set (MDS, resident ' s (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: 056376 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 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)