Health inspection·May 14, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, the facility failed to ensure adequate supervision and assistance was provided for one of three sampled residents (Resident 1) to prevent avoidable accident and injury. This failure resulted in, Resident 1 fell on the floor and sustained a right distal (further from the trunk of the body) femur (thighbone) fracture (partial or complete break in the bone). Findings: During a concurrent observation and interview, on 4/4/2024 at 9:45 a.m., in Resident 1's room, Resident 1 was observed on a bed wearing a soft helmet (head protection) with blankets up to her chest. No bed tab alarm was observed. Resident 1 was awake and asked about her recent fall stated, My knee hurts, right side .I don't remember. I think I was going to get up or something, but I don't know. Certified Nursing Assistant (CNA 1) entered Resident 1's room and verbalized, Resident 1 didn't have a bed alarm. During an interview on 4/4/2024 at 9:53 a.m., in Resident 1's room with a Licensed Nurse (LN 2), when asked if Resident 1 had a bed tab alarm LN 2 stated, Not that I can currently see. Resident 1 assessed by the facility as, history of falling, unspecified dementia (loss of brain function), hemiplegia (loss of ability to move one side of the body) and hemiparesis (weakness or inability to move one side of the body) following cerebral infarction (stroke, damage to tissues in brain) affecting right dominant side, muscle weakness, and epilepsy (uncontrollable body movements), was to have a tab alarm (alerts staff that resident is on the move) while on her bed. While in her room, Resident 1 fell to the ground and was found near her bed by a Certified Nursing Assistant (CNA) during the CNA's rounds. During an interview on 4/4/2024 at with the Administrator (Admin), the Admin was asked if a bed alarm was in use when Resident 1 fell. The Admin verbalized no and further stated, It was an unwitnessed fall. (CNA 2) found the resident. She was on her way to change (Resident 1) and found her on the floor. During a concurrent interview and record review on 4/4/2024 at 10:53 a.m., with Admin, the facility's policy and procedure (P&P) titled Accident/Fall Risk/Injury Assessment and Prevention, dated 2/2012 was reviewed. The P&P indicated, Strategies for reducing fall risk .Environmental .bed alarm for moderate and high-risk residents. The Admin stated, The bed alarm wasn't on. This section definitely wasn't followed. (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555066 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555066 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenfield Care Center of Fillmore, LLC 118 B Street Fillmore, CA 93015 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)