Other·November 5, 2019

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 standard survey. Facility Reported Incident (FRI) Number: CA 652451. Category: Quality of Care/Treatment The investigation was limited to the specific FRI and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Health Facilities Evaluator Nurse 36471. A deficiency was identified under the Code of Federal regulations.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §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: Based on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) 1 implemented interventions to prevent falls and injury for one of one sampled 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: OPGD11 Facility ID: CA080000092 If continuation sheet 1 of 7 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: _______________ 555158 (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL CENTRO POST-ACUTE CARE 1700 S Imperial Ave El Centro, CA 92243 (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 (Resident 1). CNA 1 did not place a fall mat (high-impact foam mat beside the bed to help prevent injury from potential falls) on both sides of Resident 1's bed, nor activate a bed sensor alarm (a device that makes a loud sound when a resident moves to alert staff), in accordance with Resident 1's plan of care for falls, when the CNA assisted Resident 1 to bed for a nap after lunch. As a result, Resident 1 had an unwitnessed fall from her bed, and sustained fractures of her tibia and fibula (broken bones in the lower leg), resulting in amputation (removal of the body part) of the resident's left leg below the knee. Findings: Resident 1, a 96-year-old, female was admitted to the facility on 6/21/18, with diagnoses which included osteoarthritis (bone pain) and dementia (impaired memory), per the facility's Record of Admission. A review of Resident 1's clinical record was conducted on 9/18/19. According to a review of the document titled, Fall Risk Assessment, dated 6/21/18, Resident 1 had a total score of 14. A total score of 10 or above represented high risk for sustaining a fall. According to a review of the document titled Resident Care Plan, dated 6/26/18, Resident 1 had a potential for falls or to have injury due to dementia, osteoarthritis, and poor safety awareness. The goal of the care plan was for Resident 1 to have "no falls or injury ..." The approaches and plan to achieve the goal included, the call light and personal belongings were to be within easy reach, reorient to new surroundings, and out of bed as tolerated if FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OPGD11 Facility ID: CA080000092 If continuation sheet 2 of 7 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: _______________ 555158 (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL CENTRO POST-ACUTE CARE 1700 S Imperial Ave El Centro, CA 92243 (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 appropriate. According to a review of the document titled, Episodic Care Plan: Post (First) Fall, dated 8/30/18, Resident 1 had a fall from her wheelchair to the floor. The care plan was updated and interventions put into place were: Resident 1 was to have a tab alarm (device that clipped to resident's clothing, that made a loud sound if resident attempted to stand up from the wheelchair or get out of bed), low bed and a fall mat. According to a review of the document titled, Episodic Care Plan: Post (Second) Fall, dated 8/13/19, Resident 1 was found lying on her left side, on the fall mat, beside her bed. There was no apparent injury noted for this fall. The added interventions were: Resident 1 was to have a sensor (bed) alarm, fall mats on both sides of the bed, and Resident 1 was transferred from Room 5 to Room 10 to be closer to the nursing station for close monitoring. According to a review of the document titled, Licensed Personnel Weekly Progress Notes, dated 8/28/19, Licensed Nurse (LN) 1 documented Resident 1 was found sitting on the floor " ...and noticed blood and exposure of bone to left ankle area ..." LN 1 called the emergency response service (EMS) and Resident 1 was transferred to the hospital. According to a review of the document titled, Episodic Care Plan: Post (third) Fall, dated 8/28/19, under Identified Factors Contributing to this Fall, "alarm was not in place, fall mat not in place ..." According to a review of the General Acute Care Hospital (GACH) 1 Record, dated 8/28/19, Resident 1 had an unwitnessed fall with concern for open leg fracture. Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OPGD11 Facility ID: CA080000092 If continuation sheet 3 of 7 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: _______________ 555158 (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL CENTRO POST-ACUTE CARE 1700 S Imperial Ave El Centro, CA 92243 (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 transferred to GACH 2 for a higher level of care. According to a review of the GACH 2's Operative Note, dated 8/29/19, prior to Resident 1's surgery, the surgeon explained to the family member the risks and benefits of saving Resident 1's leg versus amputation. For saving Resident 1's leg " ...would have required prolonged no weight bearing (amount of weight a resident can put on an injured body part) which the patient (Resident 1) may not have been able to comply with and any accidental weight bearing would have placed the implants (an artificial object inserted in a resident's body during a surgery) at risk of failure ..." The family member expressed understanding of the treatment options and Resident 1 had an extensive surgery of left below the knee amputation. CNA 1 who no longer worked at this facility was unavailable for interview. The facility provided CNA 1's written statement. According to CNA 1's written statement, dated 8/29/19, CNA 1 documented she did not realize Resident 1 had an alarm so she did not activate the alarm. On 9/18/19 at 11:33 A.M., an interview was conducted with LN 2. LN 2 stated after Resident 1's fall on 8/13/19, Resident 1 was moved to Room 10, to be closer to the nursing station. LN 2 stated to prevent Resident 1 from a fall or injury, the staff were to ensure the fall mats were placed on both side of the bed. LN 2 further stated Resident 1 was to have a tab alarm when in a wheelchair and a sensor alarm when in bed. LN 2 stated Resident 1 needed to be in the wheelchair for close monitoring when the resident was awake, because Resident 1 moved a lot when awake in bed, and was a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OPGD11 Facility ID: CA080000092 If continuation sheet 4 of 7 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: _______________ 555158 (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL CENTRO POST-ACUTE CARE 1700 S Imperial Ave El Centro, CA 92243 (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 high risk for falls. LN 2 stated CNAs assisted Resident 1 back to bed after lunch, the staff would change her, if Resident 1 was sleepy the staff would leave her on the bed with all the fall interventions in place, and when she woke up she would try to get out of bed. LN 2 stated when Resident 1 was awake, the staff would put her in the wheelchair. LN 2 stated on 8/28/19 around 3:45 P.M., Resident 1 had a third fall. LN 2 stated she, along with LN 1, responded when CNA 4 yelled for assistance. LN 2 stated when she entered the room she did not hear the alarm sound. LN 2 stated she saw Resident 1 sitting on the floor without a fall mat and the alarm was not activated. LN 2 further stated the box alarm was hanging on the wheelchair, by the window, away from Resident 1. On 9/18/19 at 1:24 P.M., an interview was conducted with CNA 3. CNA 3 stated prior to the last fall, Resident 1 was able to stand and turn with two persons for transfer. CNA 3 further stated after the surgery Resident 1 could no longer stand and the staff used a hoyer lift (a mechanical device used for transferring) to transfer Resident 1. CNA 3 stated prior to the last fall, when Resident 1 was awake and on the bed, the staff would get her up to the wheelchair because Resident 1 did not like staying in bed. On 9/24/19 at 11:18 A.M., an interview was conducted with CNA 4. CNA 4 stated she was the lead CNA on 8/28/19. CNA 4 stated she assisted CNA 1 to transfer Resident 1 from wheelchair to bed around 1:30 P.M. CNA 4 stated she reminded CNA 1 to make sure the alarm and fall mats were in place. CNA 4 stated she did not see Resident 1 again until around 3:45 P.M. CNA 4 stated CNA 2 was the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OPGD11 Facility ID: CA080000092 If continuation sheet 5 of 7 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: _______________ 555158 (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL CENTRO POST-ACUTE CARE 1700 S Imperial Ave El Centro, CA 92243 (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 assigned afternoon CNA and CNA 2 was giving a shower to another resident. CNA 4 stated when a resident was at risk for fall and awake in bed, the staff should have all the fall precautions in place or get the resident up in wheelchair and put him/her by the nursing station. CNA 4 stated the LNs and CNA's at the end of their shift provides information about the resident and there were written instructions posted on the bathroom door for every resident on how to care for the resident. On 9/25/19 at 8:30 A.M., an interview was conducted with LN 3. LN 3 stated there were nights when Resident 1's sensor pad would alarm when Resident 1 was trying to get out of bed unassisted. LN 3 stated when Resident 1 awoke, the staff would stay with the resident or the staff would get Resident 1 up to the wheelchair for close monitoring to prevent her from falls. CNA 2 was no longer working at this facility but was available for telephone interview. On 9/25/19 at 11:30 A.M., a joint interview and record review of CNA 2's written statement was conducted with CNA 2. CNA 2 documented, on 8/28/19, "I didn't notice she (Resident 1) wasn't wearing her tab alarm or the sensor alarm ...and mattress on her right side wasn't (placed)." CNA 2 stated after CNA 1 left the unit, she saw Resident 1 in bed, awake but calm. CNA 2 further stated she did not inspect or ensure the alarm was functioning, or if both fall mats were present. CNA 2 stated she proceeded to assist another resident. CNA 2 stated Resident 1 moved a lot when awake in bed and was at risk for falls. CNA 2 also stated Resident 1 should have been up in the wheelchair when she was awake. CNA 2 stated she did not realize FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OPGD11 Facility ID: CA080000092 If continuation sheet 6 of 7 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: _______________ 555158 (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EL CENTRO POST-ACUTE CARE 1700 S Imperial Ave El Centro, CA 92243 (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 would try to get up because Resident 1 looked calm. CNA 2 stated she should have checked all the fall precautions before leaving Resident 1. On 9/26/19 at 11 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the interventions to prevent Resident 1 from falling should have been followed. The DON stated the sensor alarm should have been applied, so when it sounded, the staff would have heard and attended to Resident 1 right away. The DON stated on 8/28/19, CNA 1 did not apply the fall precautions before leaving Resident 1 and CNA 2 did not ensure the fall precautions were in place at the beginning of her shift. The DON further stated the fall care plan interventions were not followed and it was not acceptable. The DON stated Resident 1 sustained a fracture because of the fall and it could have been prevented or at least minimized the injury. Per the undated facility's policy and procedure, titled Fall Management, " ...Residents will be assessed for fall risk and interventions will be implemented to reduce the risk of falls ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OPGD11 Facility ID: CA080000092 If continuation sheet 7 of 7