Inspection·December 12, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was properly secured during transportation when: Residents Affected - Few 1. Seatbelt was loosely fastened unto Resident 1's wheelchair. 2. Footrest (a removable footplate where the feet are placed to avoid injury and maintain balance) was missing from Resident 1's wheelchair. These failures resulted in Resident 1 falling out of wheelchair, sustaining skin tear to right wrist and abrasion (scrape) to right shin. Findings: 1. During an interview on 11/13/23 at 12:45 p.m. with Licensed Vocational Nurse (LVN), LVN stated Resident 1 was taken to a doctor's appointment on 10/20/23, using the facility van. LVN stated on the way to the appointment, Resident 1's seat belt was placed too loose causing Resident 1 to slid out of the wheelchair and landing on his knees. During a concurrent observation and interview on 11/13/23 at 1:06 p.m. in Resident 1's room, Resident 1 stated during the car ride to the doctor's appointment on 10/20/23, the transport driver had to immediately hit the break on the van to avoid colliding into a car that had gone in-front of them. Resident 1 stated the sudden stop caused him to fall forward in between the front driver and passenger seat, landing on his knees. Resident 1 stated he was not buckled in properly. During a review of Resident 1's Minimum Data Set (MDS - a standardized, comprehensive assessment tool) dated 11/13/23, the MDS indicated, Resident 1 had a BIMS (Brief Interview for Mental Status - which evaluates cognition, the ability to remember and think clearly) score of 14 (score range from 13-15 cognitively intact). During an interview on 11/14/23 at 4:10 p.m. with Activities Assistant (AA), AA stated on 10/20/23, she had transported Resident 1 using the facility van. AA stated another car had gone in-front of the van causing her to make a sudden stop. AA stated the sudden stop caused Resident 1 to slide out of his wheelchair, landing on his knees, with the lap belt ending up on his face. AA stated, the belt was too loose, that's how he fell. During a review of Resident 1's Nurse's Note (NN), dated 10/20/23 at 11:16 a.m. the NN indicated, Resident returned from appointment with skin tear to right lateral wrist and abrasion also noted with (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: 056423 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 056423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gateway Post Acute 661 West Poplar Porterville, CA 93257 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)