Other·February 8, 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. Complaint Number: 612222 and 612358 Facility Reported Incident: 612202 Representing the Department: 39763, HFEN The inspection was limited to the specific complaints and entity reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was was written as a result of complaint 612222 and 612358, and facility reported incident 612202.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 01/16/2019 §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 observation, interview, and record review, the facility failed to provide supervision for one of three sampled residents (Resident 1) 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: IT1C11 Facility ID: CA040000020 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: _______________ 055916 (X3) DATE SURVEY COMPLETED 01/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SEQUOIA VISTA 3710 W Tulare Ave Visalia, CA 93277 (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 when the resident was left unattended in the bathroom. This failure resulted in Resident 1 falling and sustaining a dens fracture (a break in the second bone of the spine), bilateral nasal bone fracture (a break on both sides of the nasal bone), and fractures involving the lateral wall of the right orbit (cavity which contains the right eye) and right maxillary sinus (nasal bone area). Findings: During an observation and interview with Resident 1 and Family Member 1 (FM 1), on 11/16/18, at 12:55 PM, in Resident 1's hospital room, Resident 1 was observed to have purple discoloration over her chin, nose, and under both eyes. Resident 1 was wearing a cervical collar (a device used to keep the neck from moving) restricting the movement of Resident 1's neck and head. Resident 1 stated she did not want to talk. FM 1 was at the bedside and stated she believes her mother was in pain and that was the reason Resident 1 did not want to talk. During a review of the clinical record for Resident 1, the Admissions Record dated 9/13/17, indicated Resident 1 was admitted to the facility with diagnoses including: right femur fracture (break in the thigh bone) healing, osteoarthritis (inflammation [redness or swelling] or loss of cartilage [padding which protects the ends of the long bones at the end of the joints] in the joints due to wear and tear), high blood pressure, type 2 diabetes (high blood sugar), anemia (low red blood cell count), intervertebral (in between each) disc degeneration (wear of the discs between each vertebrae) of the lower spine, and a history of falling. Resident 1's MDS (Minimum Data Setan assessment tool), dated 9/22/18, indicated Resident 1 required extensive assistance from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IT1C11 Facility ID: CA040000020 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: _______________ 055916 (X3) DATE SURVEY COMPLETED 01/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SEQUOIA VISTA 3710 W Tulare Ave Visalia, CA 93277 (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 facility staff to transfer, dress, use the toilet, and perform personal hygiene tasks. The MDS assessment indicated Resident 1 has had two or more falls since her admission to the facility on 9/13/17. Resident 1's care plan titled, "At risk for falls related to: impaired balance, use of medications, history of femur fracture, . . . and poor safety awareness" initiated on 9/9/18 and revised on 10/15/18, indicated "Do not leave unattended in bathroom." During an interview with Licensed Vocational Nurse 1 (LVN 1), on 11/16/18, at 3:35 PM, LVN 1 described Resident 1 as Spanish speaking only. LVN 1 stated Resident 1 required assistance from one staff to assist the resident with transferring. She stated the resident was alert, oriented, and impulsive. LVN 1 stated at approximately 2 PM on 11/14/18, Resident 1 was sitting at the nurse's station. LVN 1 stated Resident 1 requested assistance to use the restroom. LVN 1 stated Resident 1's assigned Certified Nursing Assistant 1 (CNA 1) was busy showering another resident, so CNA 2 was asked to assist Resident 1 to the restroom. CNA 2 assisted Resident 1 to the restroom and stepped out. LVN 1 stated about 10 to 15 minutes later, CNA 1 and CNA 2 were walking down the hall when CNA 1 stated Resident 1 was observed on the bathroom floor. LVN 1 stated Resident 1 was found on the bathroom floor and complained of pain to her nose and eyes. She stated Resident 1 had blood coming from her nose. During an interview with CNA 2 and review of the clinical record for Resident 1, on 11/30/18, at 12:05 PM, CNA 2 stated he was not assigned to Resident 1 on the day of the occurrence but worked with her often. He stated Resident 1 had hip problems, she could kind of stand and he believes she has a history of falls. CNA 2 confirmed he assisted Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IT1C11 Facility ID: CA040000020 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: _______________ 055916 (X3) DATE SURVEY COMPLETED 01/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SEQUOIA VISTA 3710 W Tulare Ave Visalia, CA 93277 (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 to the restroom. CNA 2 stated, "We (CNAs) stand right outside the door normally, . . . but I was the only CNA on the floor and call lights were going off. I did not think it would be an issue and she [Resident 1] was taking quite a long time." CNA 2 stated he got tired of waiting and answered some call lights. When he returned back he stated he saw Resident 1 on the floor in the bathroom with a pool of blood around her. CNA 2 stated he learns about residents by working with the residents. Resident 1's care plan titled, "At risk for falls . . ." revised on 10/15/18, indicated under interventions "Do not leave unattended in bathroom", was reviewed with CNA 2, he stated he was never told about that intervention. During an interview with CNA 1 and review of the clinical record for Resident 1, on 11/30/18, at 12:21 PM, CNA 1 confirmed she was assigned to Resident 1 but was giving another resident a shower at the time of the fall. CNA 1 stated, "I never left her [Resident 1] alone in the bathroom by herself, she will try to stand up. I always get a second CNA. I know from previous experience with her she is impatient." CNA 1 stated she learns about the residents needs from a binder at the nurses' station or she will ask the nurse. She stated she was not sure if Resident 1 had fallen in the past. Resident 1's care plan titled, "At risk for falls . . ." revised on 10/15/18, indicated under interventions "Do not leave unattended in bathroom", was reviewed with CNA 1. CNA 1 stated she was not aware of that intervention. During an interview with the Director of Staff Development (DSD) and review of the clinical record for Resident 1, on 11/30/18, at 2:55 PM, the DSD confirmed the Resident Profile (a document used by the facility staff which indicates the type of care/precautions each FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IT1C11 Facility ID: CA040000020 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: _______________ 055916 (X3) DATE SURVEY COMPLETED 01/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SEQUOIA VISTA 3710 W Tulare Ave Visalia, CA 93277 (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 requires) for Resident 1 undated, did not contain documentation related to a history of falls or an intervention which indicated Resident 1 should not be left unattended in the bathroom. During an interview on 12/11/18, at 4:27 PM, with Housekeeper 2 (HK 2), HK 2 stated on 11/14/18 she was cleaning a room two doors down from Resident 1's room. She stated Resident 1 was taken to the bathroom by CNA 2 and ten minutes later the call light came on for Resident 1's room. HK 2 stated the call light was on for about 20 minutes before they found Resident 1 on the floor in the bathroom. The facility policy and procedure titled "Care Planning Process" dated 12/11/17, indicated "3. The comprehensive care plan will be developed by the interdisciplinary team that includes the attending physician, a member of the nutritional services, an RN and a CNA with the responsibility for the patient/resident." The facility policy and procedure titled "Fall Prevention and Fall Related Injury Management" dated 4/11/17, indicated "2. The licensed nurse and/or Interdisciplinary Team (IDT) will develop an initial fall/injury prevention care plan based on the patient/resident specific risk factors that will be communicated to the staff." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IT1C11 Facility ID: CA040000020 If continuation sheet 5 of 5