Other·April 13, 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 an abbreviated survey for the investigation of two entity reported incidents (ERIs). ERI number: CA00506003 Category: Quality of Care/Treatment Sub-category: Resident Safety/Falls One deficiency was written as a result of ERI number CA00506003. ERI number: CA00506843 Category: Quality of Care/Treatment Sub-category: Resident Safety/Falls One deficiency was written as a result of ERI number CA00506843. Representing the California Department of Public Health: 36094, Health Facilities Evaluator Nurse The inspection was limited to the specific ERIs investigated and does not represent a full inspection of the facility.

F309 SS=D PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.25

F309 03/10/2017 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 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: FLSB11 Facility ID: CA080000061 If continuation sheet 1 of 14 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: _______________ 056182 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HILL POST ACUTE 1201 34th St San Diego, CA 92102 (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 This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that nonlicensed staff reported a resident fall to the licensed nurse (LN) promptly for one of three sampled residents (Resident 3). A certified nurse assistant (CNA), dietary aide (DA), and maintenance staff (MS), failed to report a fall of Resident 3 to a LN/management promptly. The facility was not aware Resident 3 had a fall until 10/12/16, five to seven days after the incident occurred when Resident 3 made the report. As a result, Resident 3 was not assessed promptly by a licensed nurse after he had a fall and a physician was not notified of the incident when it occurred. In addition, the facility failed to implement the facility's policy and procedure for Fall Management to ensure that Resident 3 received quality of care after his fall. This failure led to the miscommunication of the care needs of Resident 3 after a fall, in which he had increased swelling and pain of his right wrist. Findings: On 10/13/16 at 12:27 P.M., an entity reported incident was investigated regarding Resident 3 who reported to staff he had a fall. Resident 3 was admitted to the facility on 9/2/16 with diagnoses which included fracture (broken) of fifth lumbar vertebra (lower back) and absence of leg below the knee per the facility's Admission Record. The minimum data set assessment (MDS), Section C, Cognitive Patterns, dated 9/30/16, was reviewed on 12/8/16. It indicated Resident 3 had a BIMS (Brief Interview for Mental Status) coded FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLSB11 Facility ID: CA080000061 If continuation sheet 2 of 14 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: _______________ 056182 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HILL POST ACUTE 1201 34th St San Diego, CA 92102 (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 (score) 14 (according the Resident Assessment Instrument (RAI) 3.0 manual for MDS, a score 13-15 was cognitively intact). The fall risk assessment for Resident 3, dated 9/2/16 indicated, Resident 3 was "Moderate Risk" for falls. An interview with the director of nursing (DON) on 10/13/16 at 12:27 P.M. was conducted. The DON stated Resident 3 reported yesterday (10/12/16) to one of the nurses, "pain on his right wrist". The DON further stated Resident 3 had increased pain on 10/10/16 and on 10/11/16 an x-ray showed Resident 3 had a fracture. The DON stated she spoke to Resident 3 who told her, "He (Resident 3) can't remember the date (of fall incident). He said it was two days after (Resident 2's name) fell. Then said the day after. He said two staff helped him, one from the kitchen (DA 1) and maintenance (MS 1). I met with (maintenance staff's name) and he said he helped position him (Resident 3), but he (Resident 3) was already in the wheelchair...We don't know if the staff reported it." An interview with MS 1 on 10/13/16 at 1:20 P.M. was conducted. MS 1 stated he was informed by another resident that Resident 3 fell. MS 1 further stated he saw Resident 3 sitting down, using the wall to stand up. MS 1 stated it was in the hallway, downstairs near the conference room. MS 1 further stated he held the wheelchair while another staff helped Resident 3 to the wheelchair. MS 1 stated DA 1 helped hold the wheelchair. MS 1 did not state that he reported the incident to the LN or management. A review of MS's statement dated 10/14/16 was conducted. This document indicated, "I not (don't) remember the day. I was at the office and (another resident's name) ask me for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLSB11 Facility ID: CA080000061 If continuation sheet 3 of 14 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: _______________ 056182 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HILL POST ACUTE 1201 34th St San Diego, CA 92102 (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 help. I get out the office and I saw (Resident 3's name) and one of the CNAs (CNA 1) came and help him and (name) from kitchen and me help him to go back to the chair." An interview with DA 1 on 10/13/16 at 3:50 P.M. was conducted. DA 1 stated she believed Resident 3 fell on 10/7/16. DA 1 further stated she saw Resident 3 on the floor and went over. DA 1 stated Resident 3 told her he slipped off of his cushion. DA 1 further stated she held the wheelchair while CNA 1 and the MS 1 helped Resident 3 into the wheelchair. DA 1 did not state that she reported the incident to the LN or management. A review of the DA 1's statement dated 10/13/16 was conducted. This document indicated, "Came through the door by the kitchen and (MS 1's name) ask me to come over to help. I saw 1 resident (Resident 3) on the floor and a CNA (CNA 1) and (MS 1's name) wants me to hold the wheelchair while the resident was being pick up off the floor claiming he slipped off the cushion. So I went over held the wheelchair. After that I went back to the kitchen. The CNA (CNA 1) took him outside to smoke." This statement confirmed that Resident 3 was picked up and escorted to the smoking area without a LN's assessment. A review of Resident 3's clinical record was conducted on 10/13/16. There was no documentation related to Resident 3's fall incident found on 10/5-10/11/16 in the clinical record. The care plan for Resident 3, dated 9/16/16, indicated, "The resident is (High) risk for falls and injury... Interventions Follow facility fall protocol... Pt (patient) evaluate and treat as ordered or PRN (as needed)..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLSB11 Facility ID: CA080000061 If continuation sheet 4 of 14 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: _______________ 056182 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HILL POST ACUTE 1201 34th St San Diego, CA 92102 (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 A review of resident 3's progress notes, dated 10/5/16 at 8:13 A.M., was conducted. This document indicated, "...Morphine Sulfate (pain medication) Tablet 15 mg (milligram) Give 3 tablet by mouth every 12 hours routine pain management... Resident c/o (complain of) pain, pain level is 7 out of 10. Only given 2 tabs (tablets) of Morphine Sulfate 15 mg. Other extra 15 mg of Morphine was not available. Called pharmacy and asked if I can pull one 15 mg Morphine from E-kit but pharmacy said there's none in the E-kit..." Resident 3's progress notes, dated 10/5/16 at 8:05 P.M., indicated "Resident with hx (history of) arthritis to bilateral wrists. Resident requesting ace wrap bandage to wrists as needed to immobilize r/t (related to) pain..." A review of Resident 3's physician order, dated 10/10/16 at 7:26 A.M., was conducted. This document indicated, "...right wrist x-ray due to increase swelling..." A review of Resident 3's x-ray report of right wrist, dated 10/10/16, was conducted. This document indicated, "...the base of the ulnar styloid process (wrist bone) suggests a nondisplaced fracture (break). Moderate soft tissue swelling adjacent to the ulnar styloid process." The progress notes for Resident 3, dated 10/10/16 at 5:27 P.M., indicated "...Right wrist x-ray results faxed to Dr. (doctor)... Ortho (bone doctor) consult ASAP (as soon as possible) for fracture... Resident stated, so that's why I've been having pain." There was no further documentation on 10/10/16 of a nurse assessment regarding Resident 3's swelling of his right wrist. The progress notes for Resident 3, dated 10/12/16 at 5:28 P.M. indicated, "Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLSB11 Facility ID: CA080000061 If continuation sheet 5 of 14 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: _______________ 056182 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HILL POST ACUTE 1201 34th St San Diego, CA 92102 (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 stating I had fall few days ago but I don't remember when or who helped me... no falls have been reported in the last week for resident... Resident with c/o (complaint of) increased pain and swelling to right wrist..." The progress notes for Resident 3, dated 10/13/16 at 10:26 A.M. indicated, "...per resident he fell from his wheel chair in the hallway going to smoking down stairs per (resident I fell from my wheel chair forward trying to support my weight on my right hand, it is natural to do that) resident unable to remember exact date..." Resident 3's ortho consultation report, dated 10/13/16, indicated "...Right wrist pain... old ulnar styloid nonunion. No acute injuries are identified..." An interview was conducted with the DON on 10/13/16 at 3:55 P.M. The DON stated she was getting conflicting statements of who the CNA was when Resident 3 fell, but that CNA 1 was not in the facility. The DON further stated if the staff witness or suspect a fall, they have to report it to the charge nurse and her right away. The DON acknowledged that the facility failed to implement the facility's policy and procedure for Fall Management; as a result Resident 3 was not evaluated by a LN immediately at the location of the fall without moving the resident until safe to do so. An observation and interview with Resident 3 on 10/13/16 at 6 P.M. was conducted. Resident 3 was sitting in his wheelchair in his room. Resident 3 stated the fall happened about a week ago when he was moving in his wheelchair. Resident 3 further stated he had an extra cushion in his wheelchair, pulled himself out of the wheelchair with his left foot, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLSB11 Facility ID: CA080000061 If continuation sheet 6 of 14 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: _______________ 056182 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HILL POST ACUTE 1201 34th St San Diego, CA 92102 (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 and fell forward. Resident 3 stated, "The maintenance man (MS 1's name) helped pick me up. I fell on my hand." A review of resident 3's physician order, dated 10/18/16, indicated "Wrist splint to right." A review of the facility's policy and procedure titled Fall Management; dated 7/08 was conducted. This policy indicated, "Policy: ...Residents will be assessed for injuries, nursing or medical interventions will be provided to maintain the well-being of the resident, and required notifications will be made when a fall-related injury occurs... Procedure for responding to a fall: 1. Resident is to be immediately evaluated by a nurse at the location of the fall without moving the resident until safe to do so. Assessment should include, but is not limited to, an evaluation of ABC, signs of bleeding, trauma, an evaluation of pain, and vital signs. Assist resident to a comfortable position as tolerated, paying attention to verbal & (and) non-verbal indicators of pain/discomfort... 3. Physician is to be notified as soon as practicable following the fall. Collaborative effort is needed in the event an injury has occurred or is suspected... 5. Resident is to be assessed by a licensed nurse and the related circumstances and suspected or identified causes will be documented in the nurse's notes. 6. Continued monitoring by a licensed nurse is necessary, as symptoms may present at any time, even days following the actual event. This will include assessing for injury and monitoring of vital signs every shift for a minimum of 72 hours and documented in the nurse's notes. Promptly notify MD about abnormal symptoms..." A telephone interview with the DON and Administrator (Admin) on 3/6/17 at 3:10 P.M., was conducted. The DON acknowledged there FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLSB11 Facility ID: CA080000061 If continuation sheet 7 of 14 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: _______________ 056182 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HILL POST ACUTE 1201 34th St San Diego, CA 92102 (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 was no nursing skin assessment or documentation that she could see in Resident 3's clinical record on 10/10/16, prior to the x-ray order for Resident 3. The DON further stated Resident 3 was having pain. The Admin stated Resident 3 had swelling of the hand. The Admin further stated on 10/12/16 Resident 3 was asked how could this happen and "he told us he fell." This interview confirmed that the facility did not know Resident 3 had a fall until he reported it on 10/12/16. During the same telephone interview, the DON stated the facility identified the CNA involved in the incident was CNA 1. The DON acknowledged non-licensed staff cannot move residents from the area of the fall incident. The Administrator stated, "He (Resident 3) was getting up on his own. The CNA is going to help, they aren't just going to let a resident flounder around." The DON stated CNAs are to report falls right away to management or at least a charge nurse. The DON further stated CNA 1 did not know the patient. The Administrator stated they consistently have inservices about reporting falls. A telephone interview with the director of staff development (DSD) on 3/6/17 at 3:26 P.M., was conducted. The DSD stated training for fall management is done at least annually and in-services as needed. The DSD further stated staff receives the training upon orientation. The DSD stated the staff is trained to get a charge nurse immediately if a resident had a fall. The DSD further stated a CNA can't get a resident up from a fall unless a charge nurse has assessed the resident. The DSD stated CNA 1 is out on leave and is unsure of his return. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLSB11 Facility ID: CA080000061 If continuation sheet 8 of 14 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: _______________ 056182 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HILL POST ACUTE 1201 34th St San Diego, CA 92102 (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 concurrent interview with the Admin and DON, the Admin stated she can't guarantee CNA 1 didn't report the fall. The DON acknowledged CNA 1 did not report a fall to the LN promptly for Resident 3. The DON acknowledged that the facility failed to implement the facility's policy and procedure for Fall Management. A telephone interview with the medical director (MD) on 3/6/17 at 4:58 P.M., was conducted. The MD stated he did a chart review of Resident 3's record. The MD further stated, "The events that led up to this, sometime in the morning when he (Resident 3) had a smoke break on 10/10/16 around 7:00 A.M. He had an episode he was found on the ground..." The MD acknowledged there was no documentation of the fall incident on 10/10/16 but he stated he "assumed" it occurred on that date due to the x-ray being ordered. The MD stated he did not speak to any of the staff who witnessed Resident 3's fall incident and stated, "I didn't really look at the evidence." The MD further stated it's his expectation that staff (CNA, DA, or MS) who witnesses a resident fall, report it right away. The MD stated, "I don't have information to determine. I have to assume it happened on the 10th (10/16/16). I don't have any documentation. The staff should document. I believe they reported it." The medical director did not acknowledge the lack of staff reporting Resident 3's fall to a licensed nurse according to the facility's Fall Management policy delayed the assessment of Resident 3 after he had a fall and the facility's investigation of the incident." A review of CNA 1's job description, dated 8/11, was conducted. This document indicated, "...Reports to: Charge Nurse... Duties and Responsibilities... 5. Complies with all company and departmental policies and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLSB11 Facility ID: CA080000061 If continuation sheet 9 of 14 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: _______________ 056182 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HILL POST ACUTE 1201 34th St San Diego, CA 92102 (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 procedures. 18. Reports the following in accordance with established facility procedures and regulatory standards: accidents and incidents... 22. Takes responsibility for staying updated on new regulations, best practices and internal policies and procedures..." This document was signed and acknowledged by CNA 1 on 6/21/16.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(h)

F323 04/01/2017 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that the facility was free of accident hazards and that a safe environment was provided for one of three sampled residents (Resident 2). An uneven level of two adjoining (touching) surfaces, a concrete pavement and a sand pit, in the patio was a hazard to residents. This failure resulted in Resident 2 sustaining serious injuries to include a fractured femur (thigh bone), a fractured cervical vertebra (neck bone), and a head laceration (deep cut). Findings: On 10/13/16 at 8 A.M., an entity reported incident was investigated regarding Resident 2, who had a fall on 10/4/16. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLSB11 Facility ID: CA080000061 If continuation sheet 10 of 14 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: _______________ 056182 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HILL POST ACUTE 1201 34th St San Diego, CA 92102 (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 2 was readmitted on 10/7/16 with diagnoses which included a history of falling and difficulty in walking, per the facility's Admission Record. The minimum data set assessment (MDS), Section C, Cognitive Patterns, dated 10/14/16, was reviewed. It indicated Resident 2 had a BIMS (Brief Interview for Mental Status) coded (score) of 15. According to the Resident Assessment Instrument (RAI) 3.0 manual for MDS, a score of 13-15 indicated that the resident was cognitively intact. An interview with the director of nursing (DON) was conducted on 10/13/16 at 8:30 A.M. The DON stated Resident 2 fell while smoking on the patio on 10/4/16 at 3:35 P.M. She stated the housekeeper supervisor (HS) witnessed Resident 2 trip, fall forward, and hit her head on the pole. The DON stated Resident 2 was sent out of the facility on 10/4/16 by calling 911. The DON stated Resident 2 returned to the facility on 10/7/16 after she had surgery and now wore a neck collar. The DON further stated, "We put a fence now to prevent the problem." The DON acknowledged that the uneven level of the two adjoining surfaces, a concrete pavement and a sand pit in the patio was an accident hazard. An observation of Resident 2 was conducted on 10/13/16 at 9:10 A.M. Resident 2 sat in a wheelchair and propelled herself out onto the smoking patio. She wore a neck collar. A concurrent interview and observation of the smoking patio was made with the DON on 10/13/16 at 9:12 A.M. The smoking patio had a cement porch, a fence, and just beyond the fence a lower level of sand, not even surface level. The lower level of sand area was accessible, by walking around the fence, which was done with the DON while touring the area. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLSB11 Facility ID: CA080000061 If continuation sheet 11 of 14 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: _______________ 056182 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HILL POST ACUTE 1201 34th St San Diego, CA 92102 (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 The porch also had four poles which supported an awning (covering that provided shade). The DON acknowledged that the facility's environmental hazard of an uneven level of the two adjoining surfaces, a concrete pavement and a sand pit, was not fenced off to prevent an unnecessary/avoidable accident, on 10/4/16. An interview with the HS was conducted on 10/13/16 at 9:20 A.M. The HS stated that on 10/4/16 around 3:20 P.M., Resident 2 asked for another cigarette. She was standing in the sand area trying to step up to the cement porch area, tripped, and fell. The HS stated Resident 2 hit her head on the left front steel pole of the porch awning. The HS stated that Resident 2 complained of hip pain and her head was bleeding. The HS stated two licensed nurses arrived to the patio and tended to Resident 2. An interview with licensed nurse (LN) 1 was conducted on 10/13/16 at 9:40 A.M. LN 1 stated that on 10/4/16, during change of shift report, HS 1 called the nurse's station and said someone fell. LN 1 stated, "I and another nurse, (LN 2's name), went to smoking patio. (Resident 2's name) was on the floor. There's an overhang/pole and she was holding her upper body up using the pole. Her whole body was around the pole. Her lower body was completely on the floor, but upper body up 'cause she was holding on to the pole. There's a dirt pit. She said she was trying to walk around the pole... She said she slipped off of the pavement. She was bleeding on her forehead... She didn't initially complain of pain but started holding her neck. She didn't have facial grimacing. She later complained of hip pain. She was brought to her room. Charge nurse notified and received order from doctor to send her out." An interview with LN 2 was conducted on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLSB11 Facility ID: CA080000061 If continuation sheet 12 of 14 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: _______________ 056182 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HILL POST ACUTE 1201 34th St San Diego, CA 92102 (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 10/13/16 at 10 A.M. LN 2 stated, "It was during change of shift, 3 o'clock or so (on 10/4/16). I was giving a report. Charge nurse let, I believe (LN 1's name) was charge, me know an incident happened downstairs and needed help. (LN 1's name), I, and an oncoming nurse (name), went to smoking patio. I saw (Resident 2's name) sitting to her right side on edge of cement/dirt area. I saw bleeding on forehead" An observation and interview with Resident 2 on 10/13/16 at 12:50 P.M. was conducted. Resident 2 was lying in bed in her room. She was observed with a sutured cut on the top center part of her forehead. Resident 2 stated she was getting a cigarette and stepped off of the (patio) platform into the sand area when she fell. Resident 2 stated when she came back to step on the (patio) platform, she misjudged the depth and fell. Resident 2 stated she broke her neck, femur, and had a head laceration (deep cut) with seven to nine stitches. Resident 2 stated she was sent to the hospital and went to surgery. The clinical record review for Resident 2 was conducted. A care plan for Resident 2, dated 4/25/16, indicated "This resident is (Moderate) risk for falls." Per the care plan a goal for the resident was to "be free of minor injury." The Progress Notes for resident 2, dated 10/4/16 at 3:59 P.M., indicated "Resident stated she fell on pavement/edge next to sand pit located next to smoking area while she was trying to walk around the pole. Resident stated "if that ledge wasn't there, I wouldn't of tripped," Resident expressed frustration on depth of sand pit next to pavement..." The Assessment Summary Notes for Resident 2, dated 10/4/16 at 4:16 P.M., indicated "IDT (interdisciplinary team) Fall Investigation notes ... Resident did not see the step off at the end of concrete sidewalk, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLSB11 Facility ID: CA080000061 If continuation sheet 13 of 14 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: _______________ 056182 (X3) DATE SURVEY COMPLETED 03/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN HILL POST ACUTE 1201 34th St San Diego, CA 92102 (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 leading to sandy patch. Conclusion (Including new interventions) ... Smoking participants will be reminded of smoking break safety and need to stay within smoking area (not beyond awning pole). Sandy patch area next to concrete sidewalk will be filled so that sand is leveled with pavement so that there is no step off ..." The hospital discharge summary for Resident 2, dated 10/7/16, indicated "diagnosis- fall, fracture of femur, and cervical spine fracture... head laceration (deep cut) sutured on 10/4/16." The facility's policy and procedure titled Fall Management, dated 7/08 was conducted. This policy indicated, "Policy: It is the policy of SNF (skilled nursing facility) that our physical environment remains as free of accident hazards as possible." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLSB11 Facility ID: CA080000061 If continuation sheet 14 of 14