Health inspection·July 9, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a Morse Fall Scale (an assessment used to determine a resident's risk for falls) after a fall for one of three sampled residents (Resident 1). This failure had the potential to compromise the facility's ability to identify fall risk factors and implement interventions accordingly. Residents Affected - Few Findings: Review of Resident 1's medical record indicated he was admitted on [DATE] and had diagnoses including hemiplegia (one side of the body is paralyzed), disorientation (confusion), and muscle weakness. Review of Resident 1's Morse Fall Scale, dated 4/30/24, indicated Resident 1 was at moderate risk for falling. The instructions printed on the top of the Morse Fall Scale indicated, Complete on admission, quarterly, at change of condition, and after a fall. Review of Resident 1's situation, background, assessment, recommendation (SBAR, a communication tool), dated 5/10/24 and written by licensed nurse A (LN A), indicated Resident 1 was seen scooting out of bed. The SBAR indicated LN A tried to control Resident 1, but he got out in bed in sitting/lying position next to bed. The SBAR further indicated, Let resident lie down on floor safely with pillow on head and LN call for help. During an interview with LN A on 7/8/24, at 3:13 p.m., LN A explained what happened during the incident described in the above SBAR, dated 5/10/24. LN A stated she and another staff member saw Resident 1 sliding off his bed. LN A stated she tried to help Resident 1, but by the time she got to him, he had already slid onto the ground. LN A stated this incident was a witnessed fall. Further review of Resident 1's medical record indicated there was no documentation that the facility completed a Morse Fall Scale after Resident 1's witnessed fall on 5/10/24. During an interview and concurrent record review with LN B on 7/9/24, at 11:26 a.m., LN B confirmed the facility was supposed to complete a Morse Fall Scale after each time a resident fell. LN B reviewed Resident 1's medical record and confirmed there was no documentation that the facility completed a Morse Fall Scale after the resident fell on 5/10/24. The facility's policy titled Fall Risk Assessment, revised 3/2018, indicated the facility will seek to identify risk factors for falls and establish a falls prevention plan based on relevant assessment information. Page 1 of 2 056376 056376 07/09/2024 A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128

F 0684 The facility's undated document titled FALL checklist was reviewed. The document listed the things that should be done if a resident fell. The third item listed on the document was, Morse assessment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056376 Page 2 of 2