Other·April 26, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding investigation of a complaint conducted on 3/23/17, 3/27/17, 3/29/17, 4/13/17, and 4/20/17. For Complaint CA00527047 regarding Accidents, federal deficiencies were identified (see F281 and F323). A Class "B" Citation was also issued under F323. Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 10918, Health Facilities Evaluator Nurse.

F281 SS=D SERVICES PROVIDED MEET PROFESSIONAL STANDARDS CFR(s): 483.21(b)(3)(i)

F281 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to meet professional standards of practice for one of three sampled residents (1) when: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SCVX11 Facility ID: CA070000089 If continuation sheet 1 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055318 (X3) DATE SURVEY COMPLETED 04/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. A licensed vocational nurse, (LVN) C, did not timely identify and act on an abnormal neurological check (known as neuro check, a quick tool to evaluate neurological functions and level of consciousness to determine whether an individual was functioning properly after an injury or surgery) finding for Resident 1, 2. The Interdisciplinary Team (IDT, team members from different departments involved in a resident's care) determined Resident 1, with poor decision making skills, as a safe smoker, and 3. Licensed nurses failed to document every shift for 72 hours indicating the status of Resident 1 after he fell. These failures had the potential of delaying and recognizing a change in the resident's condition, and in causing health complications. Findings: 1. Review of Resident 1's clinical record indicated he had diagnoses including dementia (loss of mental ability severe enough to interfere with normal activities of daily living) with behavioral disturbance. His Minimum Data Set (MDS, an assessment tool) dated 2/9/17, indicated he had short and long term memory problems, made poor decisions, required cues (prompting) and supervision for activities of daily living (ADL). Review of Resident 1's clinical record indicated he fell on 1/9/17. The Neurological Record, dated from 1/9/17 to 1/12/17, indicated his motor responses (voluntary movement in response to stimulation) were coded 6, indicating his left and right legs had no deficits (normal result). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SCVX11 Facility ID: CA070000089 If continuation sheet 2 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055318 (X3) DATE SURVEY COMPLETED 04/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 1's clinical record also indicted he fell on 2/24/17 at 7 a.m. The Neurological Record, dated on 2/24/17 from 7 a.m. to 11 a.m., indicated his right leg motor responses were normal (coded 6) and his left leg was coded 5, indicating "localized signs of weakness i.e. drifting of extremity." Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, an assessment tool used to facilitate prompt and appropriate communication of a problem) form, dated 2/24/27 beginning at 7 a.m., indicated that at 9:05 a.m., Resident 1 was complaining of pain on his left hip, and the medical director was informed. There was no documentation indicating Resident 1's leg was immobilized. During an interview on 3/27/17 at 11:15 a.m., the nursing supervisor (NS) who reviewed the record stated if a resident had an abnormal motor neuro check it could be a fracture or a bone problem. The NS stated nurses were to immobilize the extremity and call the doctor. The NS stated she thought it was late to call the doctor for Resident 1. During a follow-up interview on 3/29/17 at 8 a.m., licensed vocational nurse (LVN) A stated she coded 5 for Resident 1's left leg motor response in the 2/24/17 Neurological Record because he had an existing weakened condition. LVN A, who reviewed Resident 1's prior Neurological Records, did not see an abnormal result for his left leg. The "Neurological Assessment" policy, dated 03/2000, indicated dangerous trends that needed to be reported to the physician included any sensory or motor loss or decline. 2. Review of Resident 1's Safe Smoking FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SCVX11 Facility ID: CA070000089 If continuation sheet 3 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055318 (X3) DATE SURVEY COMPLETED 04/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Assessment form, dated by different IDT members from 5/5/16 to 11/10/16, indicated checkmarks that the resident had the ability to understand the dangers of smoking. The form also indicated the IDT determined Resident 1 was a safe and independent smoker. During an interview on 3/27/17 at 11:15 a.m., the NS stated Resident 1 would often get physically combative when staff tried to redirect him, and certified nursing assistants were to provide visual checks on Resident 1, especially when he smoked. During an interview on 3/29/17 at 8:50 a.m., LVN E stated Resident 1 smoked on the patio, that Resident 1 was not safe to smoke alone, he had a history of falls, was confused and could injure himself or others. 3. During an interview on 3/27/17 at 11:15 a.m., the NS stated after a resident fell, nursing staff were to monitor and document every shift (8 hours) for 72 hours if a resident had any ill effects from the fall (alert charting). The NS who reviewed Resident 1's record confirmed the alert charting was missing. Resident 1's clinical record indicated he fell on 9/17/16 at 12:30 a.m. There was no alert charting on 9/20/16 night shift and 9/20/16 day shift. Resident 1's clinical record indicated he also fell on 1/9/17 at 11:28 a.m. There was no alert charting on 1/11/17 evening shift and 1/12/17 night shift. The "Changes in Resident Condition" policy, dated 2/4/08, indicated changes in resident status were documented in the nurses notes when indicated. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SCVX11 Facility ID: CA070000089 If continuation sheet 4 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055318 (X3) DATE SURVEY COMPLETED 04/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F323 FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 SS=G PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received adequate supervision to prevent falls and injury. Resident 1 had a history of falls and problem behaviors, including not being redirectable (capable of changing thoughts and/or behaviors) and physical and verbal aggression to staff. The staff failed to follow their care plan to ensure Resident 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SCVX11 Facility ID: CA070000089 If continuation sheet 5 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055318 (X3) DATE SURVEY COMPLETED 04/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE checked frequently, and to ensure equipment (patio chair) was safe for use. Resident 1 was not supervised when he walked to the dining/patio area and fell, sustained a broken hip, and required surgical repair. This failure caused pain and suffering to the resident. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility on 7/24/15 with diagnoses including dementia (loss of mental ability severe enough to interfere with normal activities of daily living) with behavioral disturbance, difficulty walking, and chorea (rapid, jerky, involuntary movements of the limbs or face). His Minimum Data Set (MDS, an assessment tool) dated 2/9/17, indicated he had short and long term memory problems, made poor decisions, required cues (prompting) and supervision for activities of daily living (ADL). Review of Resident 1's Fall Risk Data Collection form indicated he scored 22 on 9/30/16 and 20 on 2/4/17. The form indicated a total score of 10 or above represented a high falls risk. Review of Resident 1's Non-Compliant care plan, dated 4/12/16, indicated the resident had problem behaviors including refusing care, and was difficult to redirect by nursing staff as he became verbally and physically aggressive. Review of Resident 1's at risk for falls/injury care plan, dated 2/12/16, indicated he had a history of falls, balance problems, involuntary movements, and wandered (moving around or going to different places without having a particular purpose or direction). The interventions (approaches) to prevent falls included to identify type of assistance the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SCVX11 Facility ID: CA070000089 If continuation sheet 6 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055318 (X3) DATE SURVEY COMPLETED 04/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident needed, provide assistance as identified with transfer and mobility, and to provide frequent visual checks. Review of Resident 1's At Risk for Wandering Out of the Facility care plan, dated 2/12/16, indicated he had interventions of having a WanderGuard (device placed on a person's extremity that would alarm when entering a designated area), and to check the resident's whereabouts. Review of Resident 1's clinical record indicated he fell seven times between 9/8/16 and 2/24/17. The 9/8/16, 9/17/16, and 11/6/16 falls occurred in the dining room. The 9/30/16, 1/9/17, and 2/24/17 falls occurred on the patio next to the dining room. Review of the physical therapy progress and discharge notes, with the end of care date of 9/29/16, indicated the physical therapist recommended the resident was "not safe to ambulate (walk) with staff." Review of the facility floor plan indicated there was an elevator in Station 2 and a dining room was next to the elevator. The dining room led to a patio area. During an observation on 3/23/17 at 3:15 p.m., the dining room located near Station 2 led to a patio. The patio had two glass sliding doors, concrete flooring and was not locked. There were residents seated in dining room chairs and no staff in attendance. During an interview at the time of the observation on 3/23/17 at 3:15 p.m., licensed vocational nurse (LVN) A stated she found Resident 1 on the patio floor off the dining room near Station 2 on 2/24/17 before 7 a.m., and the patio door was not kept locked. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SCVX11 Facility ID: CA070000089 If continuation sheet 7 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055318 (X3) DATE SURVEY COMPLETED 04/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, an assessment tool used to facilitate prompt and appropriate communication of a problem) form, dated 9/30/16 at 2:40 p.m., indicated the resident fell on the patio when a leg of the chair "suddenly" broke. Review of the Witnessed Fall care plan, revised on 9/30/16, had preventative measures of visual checks, monitor whereabouts of the resident and have maintenance staff check the patio chair for safety. During an interview with the Maintenance/Housekeeping Supervisor, who reviewed the maintenance log on 3/27/17 at 9:40 a.m., he stated he had no knowledge and no maintenance request of a broken patio chair. During an interview, on 3/27/17 at 9:40 a.m., certified nurse assistant (CNA) B stated Resident 1 smoked on the patio, that his walk was "wobbly," he sometimes lost his balance, and he walked around the facility without supervision. During an interview on 3/27/17 at 11:15 a.m., the nursing supervisor (NS) stated Resident 1 walked around the facility independently without an assistive device (cane or walker) and would often get physically combative when staff tried to redirect him. The NS said that staff were afraid of Resident 1 and did not know where he was going when he walked. The NS stated frequent visual checks indicated to observe a resident every one to two hours. During an interview on 3/29/17 at 7:10 a.m., the charge nurse (CN) C stated that during the night shift there were a maximum of 43 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SCVX11 Facility ID: CA070000089 If continuation sheet 8 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055318 (X3) DATE SURVEY COMPLETED 04/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents on Station 2 with one licensed nurse and two CNAs on duty. CN C stated the two CNAs worked together as a team and had several duties including making rounds, passing water pitchers, and providing incontinence care. The CN said that residents who were awake at night were grouped together in a hallway where one CNA watched them, and Resident 1, when awake at night, walked to the kitchen and elevator and he could not be closely watched. During an interview on 3/29/17 at 7:25 a.m., the CN D stated Resident 1 ambulated around the hall by himself unsupervised and was able to open the patio door. CN D recalled she was passing medications on 2/24/17 at 6:50 a.m. when an alarm sounded at the elevator. CNA D stated CNAs "maybe" checked on Resident 1, who triggered the alarm, and later left him in the dining room. CN D stated she was informed by a CNA at 7 a.m. about Resident 1 having fallen on the patio. The WanderGuard only triggered the alarm when residents passed by the elevator. During an interview on 3/29/17 at 8:50 a.m., LVN E described Resident 1 as physically and verbally aggressive to staff, able to open the patio door, did not want to be redirected and had a history of falls last year. LVN E stated Resident 1 always went to the dining room or patio by himself and he did not like to stay still. LVN E stated that Resident 1 walked, he called for CNAs to assist and watch, and the resident would became angry when he was watched or followed by staff. LVN E stated frequent checks indicated checking on the resident every 30 minutes to one hour. During an interview on 3/29/17 at 11:10 a.m., CNA F described Resident 1 as hard to approach, that he would suddenly become FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SCVX11 Facility ID: CA070000089 If continuation sheet 9 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055318 (X3) DATE SURVEY COMPLETED 04/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE angry and aggressive, and she was afraid to be physically hurt by him. The CNA stated on the morning he fell (2/24/17), Resident 1 slept in late. She said an alarm sounded at 6:50 a.m. when Resident 1 passed by the Station 2 elevator. She said she and another CNA checked on Resident 1 and left him in the dining room. CNA F stated she and another CNA were in a hurry to change Resident 1's bedsheet because CNAs had to sign out by 6:53 a.m. She said when she returned to work that night, she learned Resident 1 had fallen. During an interview on 3/29/17 at 11 a.m., the director of nurses (DON) confirmed there was no specific policy for supervision and presented a form, "EVERY 30 MINUTES SAFETY WATCH," which was to be completed for frequent visual checks. The monitoring forms were requested for Resident 1 on the days of his falls. The DON stated the forms were not part of the medical records and were not provided. Review of the "Fall Prevention" policy, dated 11/17/18, did not address a process in place as to how residents were frequently checked or supervised. Review of the acute care hospital "Inpatient Medicine Discharge Summary," dated 2/28/17, indicated Resident 1 was brought in for an "unwitnessed fall and found to have a left intertrochanteric fx" (hip fracture) and was taken for urgent left hip surgery. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SCVX11 Facility ID: CA070000089 If continuation sheet 10 of 10