Health inspection·November 9, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents remained free of accident hazards for one of three sampled residents (Resident 1), when one Certified Nursing Assistant (CNA) assisted during briefs (adult diaper) change alone, not using two - person assist (two staff members to one resident) as required. This failure resulted in Resident 1 falling out of bed during briefs change and sustained a sprained (soft tissue injury) right ankle. Findings: During a concurrent observation and interview on 3/15/23 at 10:19 a.m. with Resident 1, in Resident 1 ' s room, Resident 1 was in bed with a bruised (skin discoloration) right ankle. Resident 1 stated, she fell off the bed on 2/26/23 during briefs change and injured her right ankle. Resident 1 stated, Certified Nursing Assistant (CNA) 2 was changing her brief and rolled her too far off the bed. Resident 1 stated, she fell off the bed and landed on both knees on the floor. Resident 1 stated, she was supposed to have two CNAs assist during briefs change. Resident 1 stated, her ankle pain was 9/10 (pain scale used to measure the level of pain - 0 indicating no pain, 10 indicating worse pain imaginable). During an interview on 3/15/23 at 10:57 a.m. with CNA 1, CNA 1 stated, Resident 1 was continent (able to control) of bowel (digestive system) and bladder (urinary system). CNA 1 stated, Resident 1 called staff when she needed her brief changed. CNA 1 stated, two staff members were required to assist Resident 1 with turning from side to side while in bed and with transfers (movement from one area to another). During an interview on 3/15/23 at 11:18 a.m. with CNA 2, CNA 2 stated, on 2/26/23, Resident 1 needed her brief changed. CNA 1 stated, CNA 1 told Resident 1 that two assistants were required to change Resident 1 but Resident 1 refused to wait so CNA 1 proceeded to clean Resident 1 by herself. CNA 1 stated, when Resident 1 was instructed to roll over to her right side, Resident 1 slipped off the bed onto the floor. CNA 1 stated, the fall could have been prevented (avoided) if two persons had assisted as required. During an interview on 3/15/23 at 11:50 a.m. with Licensed Vocational Nurse (LVN), LVN stated, she was informed on 2/27/23 that Resident 1 had a fall on 2/26/23 during brief change. LVN stated, Resident 1 required two persons assist during briefs change. Page 1 of 2 555118 555118 11/09/2023 Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1 ' s Minimum Data Set (MDS) assessment (an evaluation of a resident's cognitive and functional status), dated 2/15/23, the MDS indicated, Section G Functional Status . A. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture . Support Coding 3: Two + persons physical assist . During a review of Resident 1 ' s Care Plan (CP) dated 5/9/22, the CP indicated, [name of Resident 1] is at high risk for falls and injuries due to the following risk factors: decline in functional status, Hx (history) of falls, use of antidepressant drugs . Interventions . [name of Resident 1] requires 2 person assist and mechanical lift for transfers. During a review of Resident 1 ' s CP dated 2/27/23, the CP indicated, The resident (Resident 1) has had an actual witnessed fall on 2/26 . Interventions . 2 CNAs to assist during care. During a review of Resident 1 ' s [name] Mobile X-Ray (a photographic or digital image of the internal structure using electronic wave of high energy and very short wavelength) Corporation (X-Ray report) dated 2/26/23, the X-ray report indicated, Right Ankle X-Ray Complete 3 view: Impression: Findings concerning for a nondisplaced (broken or cracked bone but retains its proper alignment) talar dome (top of the ankle bone) fracture. Consider CT (computed tomography - an X-ray procedure producing a series of detailed pictures of the areas inside the body) to evaluate for other occult (hidden) osseous lesions (bone abnormality). During a review of Resident 1 ' s Patient Portal - Patient Viewable Radiology (PVR), dated 3/15/23, the PVR indicated, Procedure: XR (X-ray) Ankle Complete Right. FINDINGS: The examination somewhat limited due to difficulty positioning. There is no evidence of any acute fracture or dislocation. Soft tissue edema is present around the ankle. During a concurrent interview and record review on 5/12/23 at 2:15 p.m., with the Director of Nursing (DON), Resident 1 ' s MDS dated [DATE], CP dated 5/9/22, and X-ray report dated 3/15/23 were reviewed. DON stated a CT scan of Resident 1 ' s right ankle was unobtainable (not able to obtain) due to Resident 1 ' s weight of 403 pounds. DON stated, the facility transferred Resident 1 to the acute care hospital for further evaluation of Resident 1 ' s right ankle on 3/15/23. DON stated, the acute care hospitals X-ray of Resident 1 right ankle on 3/15/23 indicated Resident 1 sustained a sprained right ankle. DON stated, two CNAs should have assisted Resident 1 during briefs change on 2/26/23 as required to avoid the fall resulting in an injury to Resident 1 ' s right ankle. During a review of the facility ' s policy and procedure (P&P) titled, Falls - Clinical Protocol, dated 2001, the P&P indicated, Treatment/Management . 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling . According to the interviews and records review, the facility is in compliance with the deficient practice and do not need to submit a plan of correction for this 2567. The facility self reported a fall on 2/28/23 which was assigned on 3/1/23 and investigated onsite on 3/15/23. The facility made corrections on 2/27/23 and completed them by 2/29/23. The POC reflected 2/29/23 as the date back into compliance. The POC approved on 1/5/24 was not required. The intake was exited on 11/9/23. 555118 Page 2 of 2