Health inspection·December 16, 2025

Facility: Santa Cruz Post Acute Event ID:1D5AB9-H1 Incident 2595659 State Citation A was issued. F689 §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 9/4/2025 an unannounced abbreviated survey was conducted at the facility. The facility failed to ensure the safety of one of three sampled residents (Resident 1) during in-bed care (involves a wide range of activities to ensure the health, comfort, and hygiene of someone who is bedridden), when: 1. The facility failed to maintain Resident 1's safety during in-bed care; 2. The facility failed to accurately complete Resident 1's fall risk assessment; and 3. The facility failed to implement Resident 1's ADL (activities of daily living like bed bath, shower, transfer, positioning, etc.) care plan intervention to "Ensure proper position." These failures resulted in Resident 1 sustaining comminuted fractures (broken bone where the bone is shattered into more than two pieces) to the right tibia and fibula (the two bones in the right lower leg), requiring hospital transfer on August 17, 2025. A review of Resident1's face sheet indicated he was admitted to the facility on May 28, 2024, with diagnoses including unspecified dementia (the loss of cognitive functioning that interferes with daily life and activities) and dysphagia following cerebral infarction (difficulty swallowing commonly associated with neurological impairment), Traumatic subdural hemorrhage (a collection of blood that accumulates between the brain and the outermost layer of the brain's protective membranes)with loss of consciousness of unspecified duration, other seizures (abnormal electrical activity in your brain). A review of Resident 1's Minimum Data Set (MDS, an assessment tool), GG section (Functional abilities) indicated Resident 1 was dependent (helper does all of the effort, Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helper is required for the resident to complete the activity) on staff for self-care (the ability to care for oneself including bathing, dressing, using the toilet, or eating ), and mobility (the ability to move or be moved including toilet transfers, sitting to lying, lying to sitting on side of bed, and rolling left and right). A Review of Resident 1's MDS dated 7/18/2025, indicated brief interview for mental status (BIMS, cognition level) score was 00 (severe cognitive impairment, as the 0-7 points range is used for this category). A further Review of Resident 1's MDS, GG section dated 7/18/2025, indicated Resident 1 had impairments on one upper extremity (the shoulder, elbow, wrist, and hand) and both lower extremities (hip, knee, ankle, and foot). 1. A review of Resident 1's Interdisciplinary Team (IDT) Notes dated August 19, 2025, indicated that on August 14, 2025, at approximately 2:20 p.m., Resident 1 fell from bed during routine in-bed care performed by a CNA (certified nursing assistant). A review of Resident1's X-ray result dated August 17, 2025, revealed comminuted distal tibia and fibula fractures with displacement and soft tissue swelling. During an interview with the Director of Nursing (DON) on October 3, 2025, at 1:10 p.m., the DON stated that certified nursing assistant (CNA) B rolled Resident 1 to the side of the bed while providing in-bed care. During this process, Resident 1 fell from the bed onto the floor mat on 8/14/2025. Resident 1's X-ray result dated August 17, 2025, revealed comminuted distal tibia and fibula fractures, and Resident 1 was transferred to the hospital for treatment the same day. The DON further stated that the CNA should have kept Resident 1 safe during care. During a phone interview with the Assistant Director of Nursing (ADON) on October 13, 2025, at 11:50 a.m., the ADON confirmed that the Minimum Data Set (MDS) Section GG, dated July 18, 2025, indicated Resident 1 was dependent and required the helper do all the effort or the assistance of two or more helpers for toilet transfers, sitting to lying, lying to sitting on side of bed, and rolling left and right. The ADON further confirmed that only one CNA was providing care to Resident 1 at the time of the fall incident on 8/14/2025, and that Resident 1 needed two-person assistance when rolling him to his left and right sides during care to prevent accidental falls. During a phone interview with the MDS Coordinator (MDSC) on October 16, 2025, at 3:10 p.m., The MDSC confirmed that Minimum Data Set (MDS) Section GG, dated July 18, 2025, indicated Resident 1 was dependent and she further stated that Resident 1 had impairment on one of his upper extremity and both lower extremities, he need another helper to ensure safety when rolling left and right. A review of the facility's policy and procedure (P&P), Revision Date March 2018, titled "Falls and Fall Risk, Managing" indicated: "...Several possible interventions may be identified considering resident fall risks, and staff may prioritize certain interventions based on the circumstances..." 2. A review of Resident 1's SBAR (an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication) Communication Form and Progress Note dated March 23, 2025, indicated an unwitnessed fall when a nurse was doing rounds and found Resident 1 was sitting on the floor next to his bed. A review of Resident 1's Fall Risk Assessment dated April 21, 2025, indicated a score of 14 (scores of 16-42 indicate high fall risk). The assessment documented "no falls" within the last 90 days; however, the March 23,2025 fall incident occurred within that period of 90 days. During a phone interview with the Assistant Director of Nursing (ADON) on October 13, 2025, at 11:44 a.m., the ADON confirmed the fall risk assessment done on April 21, 2025, was inaccurate because it should have reflected one fall within the last 90 days. A review of the facility's policy and procedure (P&P), revision date March 2018, titled "Fall Risk Assessment " indicated: "...the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. The nursing staff will ask the resident and/or his/her family about any history of the resident falling..." 3. A review of Resident 1's care plan, initiated on November 23, 2023, indicated that the resident was at risk for falls related to confusion, gait and balance problems, incontinence, crawling to the floor, refusal to use the call light, difficulty walking, muscle wasting and atrophy, seizures, and abnormal gait. The care plan interventions included: "Ensure that the resident is properly positioned in bed." During a phone interview with the ADON on October 15, 2025, at a.m., the ADON confirmed that the care plan interventions indicated, "Ensure that the resident is properly positioned on bed". The ADON stated that the staff should have implemented the intervention to ensure that Resident was positioned properly on the bed to prevent fall when turned to her side. A review of the facility's policy and procedure (P&P), revision date March 2022, titled " Care Plans, Comprehensive Person-Centered" indicated: " ... A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident...The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident ..." The facility failed to maintain Resident 1's safety during in-bed care, failed to accurately complete Resident 1's fall risk assessment, and failed to implement Resident 1's activities of daily living (ADL) care plan. The above violations had a direct or immediate relationship to the health, safety, or security of patients.