Other·January 23, 2018

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 a facility reported incident investigation conducted on 12/18/17 and 1/18/18. For Entity Reported Incident CA00564393 regarding Quality of Care/Treatment and Resident Safety/Falls, a federal deficiency was identified (see F689). The deficiency had a scope and severity of "G". A Class "B" citation was also issued. Inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 38068, Health Facilities Evaluator Nurse.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 02/02/2018 §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. This REQUIREMENT is not met as evidenced by: 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: PMQD11 Facility ID: CA070000780 If continuation sheet 1 of 5 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: _______________ 555538 (X3) DATE SURVEY COMPLETED 01/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EDEN VALLEY CARE CENTER 612 Main St Soledad, CA 93960 (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 Based on interview and record review, the facility failed to ensure the Fall Care Plan was implemented for one of two residents (Resident 1) when staff did not keep the resident within their view after dinner or did not assign available staff until assigned staff was ready to assist the resident back to bed and as a result, the resident fell and sustained a fracture of her left hip. Findings: Resident 1's clinical record was reviewed. Resident 1 was a 101 year-old female, who was admitted to the facility on 3/17/15, with diagnoses including muscle weakness, difficulty in walking, chronic pain, osteoarthritis (chronic inflammation of the joints), cachexia (weakness and wasting of the body due to chronic illness), anemia (deficiency of red blood cells in the body resulting in pallor and weariness), and dementia (loss of mental ability severe enough to interfere with activites of daily living). Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 9/1/16 indicated a Brief Interview for Mental Status (BIMS) score of 6, which means her cognition is severely impaired (a score of 0 to 7 is severe impairment). The MDS' dated 9/1/17 and 12/1/17 indicated she had short and long term memory problems. Resident 1's MDS' dated 9/1/17 and 12/1/17, indicated Resident 1 was not steady, only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around, and moving surface-to-surface transfer. Resident 1 required one-person physical assist in ambulation, and extensive assistance (staff provide weight-bearing support) in transfer. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PMQD11 Facility ID: CA070000780 If continuation sheet 2 of 5 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: _______________ 555538 (X3) DATE SURVEY COMPLETED 01/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EDEN VALLEY CARE CENTER 612 Main St Soledad, CA 93960 (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 1's Fall Risk Assessments dated 10/30/17 indicated a score of 18 and 12/6/17 a score of 20, which means she had a "high risk" fall level. A score of 10 and above is high risk for falls. Review of the physician's order sheet for Resident 1, dated 12/2017 indicated an order of a pressure pad alarm (weight sensitive pad that triggers an alarm sound when a resident is trying to get out of bed or wheelchair) when in bed and wheelchair to alert staff when the resident will attempt to get up unassisted every shift. Review of a nurse's notes for Resident 1's first unwitnessed fall, dated 12/9/17 at 2:43 p.m., indicated the staff and charge nurse responded to pressure pad alarm and upon entering the room noticed Resident 1 on the floor in a sitting position. Upon assessment there was no noted skin injury, no ill effect from the fall and Resident 1's neurological status was normal. Review of another nurse's notes of Resident 1's second unwitnessed fall, dated 12/9/17, indicated on the same day at 6:30 p.m., Resident 1 had a second fall in another resident's room. Resident 1 was found lying down on the floor and leaning on her left side. The notes also indicated while transferring the resident to her room she was guarding her left hip. A bump was found on her left hip. Resident 1's left hip became unsymmetrical to the right hip. Her left hip was swollen and her left lower extremity was shorter than the right lower extremity. An ice bag was placed in the meantime to her left hip's swollen area. Resident 1 was transferred to an acute care hospital. Resident 1's two falls occurred within less than 4 hours and both were unwitnessed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PMQD11 Facility ID: CA070000780 If continuation sheet 3 of 5 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: _______________ 555538 (X3) DATE SURVEY COMPLETED 01/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EDEN VALLEY CARE CENTER 612 Main St Soledad, CA 93960 (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 During a telephone interview with the licensed vocational nurse C (LVN C) on 12/18/17 at 1:43 p.m., she stated she was on break when the second unwitnessed fall incident happened. LVN C further stated both certified nursing assistants (CNAs) should have kept an eye on Resident 1 because Resident 1 already fell earlier and they do not want another fall. During a telephone interview on 12/18/17 at 1:55 p.m. with CNA A regarding Resident 1's second unwitnessed fall episode, she stated she and CNA B were watching Resident 1 who was in her wheelchair in front of the nurses station. She saw another resident (Resident 2) across the nurses station inside his room sliding off his wheelchair. Both CNAs ran to help Resident 2. While assisting Resident 2, CNA A stated no staff observed Resident 1 at that time in front of the nurses station. While they were assisting Resident 2 to put him in bed, she heard the pressure pad alarm, and immediately ran and found Resident 1 on the floor in another resident's room. During an interview with CNA B on 12/18/17 at 2:58 p.m. regarding Resident 1's second unwitnessed fall episode, she stated she was watching Resident 1 in front of the nurses station. She saw Resident 2 across the nurses station sliding off his wheelchair. She and CNA A ran to prevent the resident from sliding off from his wheelchair. CNA B did not call other staff to watch Resident 1. No staff watched Resident 1 while they were assisting to put Resident 2 in his bed, then she heard the pressure pad alarm and CNA A ran to where the alarm was heard and found Resident 1 in another resident's room lying down on the floor. Review of the Fall Care Plan (interventions or tasks to prevent fall) dated 12/6/17, indicated staff to keep Resident 1 within view, after FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PMQD11 Facility ID: CA070000780 If continuation sheet 4 of 5 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: _______________ 555538 (X3) DATE SURVEY COMPLETED 01/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EDEN VALLEY CARE CENTER 612 Main St Soledad, CA 93960 (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 dinner or will assign available staff until an assigned CNA is ready to assist Resident 1 back to bed. During an interview with the director of staff development (DSD) on 12/18/17 at 3:20 p.m., stated all CNAs were given in-service training in nursing interventions to prevent falls for Resident 1. Review of Resident 1's acute hospital radiology report dated 12/9/17, revealed a fracture of the left hip. Further review of Resident 1's acute hospital discharge summary dated 12/12/17, indicated she was admitted on 12/10/17 with a left hip fracture. She was evaluated by an Orthopedic doctor who decided that comfort care required surgical repair. Her left hip fracture was repaired by open reduction and internal fixation (ORIF, a surgical procedure to fix and align the fractured bone) surgery. Review of the facility's undated Fall Management Policy, indicated "Residents will be assessed for fall risk and intervention will be implemented to reduce the risk of falls". It further indicated that "new or existing residents scoring as high risk will have interventions implemented to reduce the potential for falls outlined in their plan of care". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PMQD11 Facility ID: CA070000780 If continuation sheet 5 of 5