Health inspection·June 20, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 complete post fall assessments and resident centered fall preventive measures for four of four residents reviewed for complete resident records. (Residents 1, 2, 3 and 4) This failure had the potential for residents to have repeated fall incidents. Findings: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses including unspecified abnormalities of gait and mobility according to the facility's Face Sheet. During an observation and interview on 6/13/24, at 9:01 A.M. with Resident 1, Resident 1 stated she returned to the facility from the hospital because she fell. Resident 1 stated she did not remember how and where she fell but stated she broke her hip and was pointing on the left hip. A review of Resident 1's Clinical Notes Report, dated 6/7/24 at 7:23 A.M. a Licensed Nurse documented, .resident was found on the floor of the entryway to her room . An interview with Certified Nurse Assistant (CNA) 1 was conducted on 6/13/24, at 9:11 A.M. CNA 1 stated Resident 1 had a green sticker next to Resident 1's name on the doorway because of a recent fall incident. CNA 1 further stated that Resident 1 was a fall risk because Resident 1 forgot to call for assistance and needed supervision with transfers. An interview and joint record review was conducted on 6/13/24, at 9:42 A.M. with the MDS nurse (MDSN- a nurse who assessed and evaluated the quality of care being given to residents). The MDSN reviewed Resident 1's clinical notes and confirmed Resident 1had a fall incident on 6/7/24. The MDSN reviewed Resident 1's Fall Risk Assessment, dated 3/25/24 and stated Resident 1 scored an 11 which indicated high fall risk. The MDSN stated a score greater than 10 was considered high risk for falls. The MDSN further reviewed Resident 1's records and stated there was no post fall assessment completed after Resident 1's fall on 6/7/24. The MDSN stated fall assessments should be completed upon a resident's admission, quarterly and after each fall incident. Resident 1's risk for fall care plan and IDT (Interdisciplinary Team- team members with various areas of expertise who work together toward the goals of their residents) notes were reviewed by the MDSN. The MDSN stated the care plan, and the IDT notes did not indicate new interventions to prevent further falls. (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 3 Event ID: 555144 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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)