Health inspection·May 9, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm did not hit her head. Patient was wearing non skid socks. Bed was low position. No injury noted .Assisted patient back to bed . A review of Resident 1's Post Fall Assessment, dated 4/30/25 indicated .Fall Summary .Intercepted fall (resident eased to the floor) . Residents Affected - Few A review of Resident 1's IDT Clinical Review, dated 5/1/25, indicated .Witnessed fall .Did any injury (minor or major occur due to incident .? .no .around 16:00 [4:00 p.m.] resident stated she has sharp pain on the right hip this writer administered prn [as needed] dilaudid [Hydromorphone HCL-pain medication] around 16:07 [4:07 p.m.] tried to do ROM [range of motion] to LE [lower extremity] but unable to perform ROM due to sharp pain. Around 17:30 [5:30 p.m.] [Family member] came to this writer and stated [Resident 1] is still c/o [complaining of] pain and requested have her send [sic] to hospital for evaluation . A review of Resident 1's History and Physical Note, 5/1/25, from the hospital, indicated .presents with R [right] hip pain .Patient had unwitnessed fall at 1100 [11:00 a.m.] off bed today .R hip pain since .R hip xray: Impression Minimally displaced right intertrochanteric fracture [right hip fracture] .RIGHT FEMUR INTEROCHANTERIC FX [fracture] .sustained after presumed accidental fall from bed, though no witnesses noted . A review of Resident 1's Medication Administration Record (MAR) for 4/1/25 to 4/30/25, indicated Resident 1 was administered: Hydromorphone HCL (Dilaudid-opioid pain medication) 2 mg (milligram) for pain level 6 out of 10 on 4/30/25 at 11:56 a.m., and Hydromorphone HCL 1 mg for pain level of 7 out of 10 on 4/30/25 at 4:07 p.m. A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in October 2021 with multiple diagnoses including diabetes (disorder characterized by difficulty in blood sugar control), cerebral infarction, and chronic obstructive pulmonary disease (chronic lung disease causing difficulty in breathing). A review of Resident 2's MDS, Cognitive Patterns, dated 3/20/25, indicated Resident 2 had Brief Interview for Mental Status (BIMS-tool to assess cognition) score of 15 out of 15 that indicated Resident 2 was cognitively intact. During a telephone interview on 5/7/25 at 5:11 p.m. with Family Member (FM) 1 and a subsequent telephone interview on 5/8/25 at 2:02 p.m. with FM 2, FM 1 stated Resident 1 fell on 4/30/25 at 11:00 a.m. FM 1 stated the family received a voicemail message from the facility at 3:00 p.m. notifying them of the fall but stating there were no injuries. FM 1 stated family saw Resident 1 at 5:30 p.m. and heard her yell out in pain when they tried to sit her up for dinner. FM1 stated facility staff reported Resident 1 was found on the floor but Resident 1's roommate, Resident 2, stated staff was with her when she fell. FM 2 stated nurse administered pain medication at 11:30 a.m. and at 4:00 p.m. FM 2 stated nurse told her first dose at 11:30 a.m. was given just in case she had pain from the fall. FM 2 stated she wanted Resident 1 sent to the emergency room due to the pain. FM 2 stated Resident 1 had a right hip fracture, surgery was not done and was placed on hospice care. FM 2 stated Resident 1's dementia (a condition characterized by memory loss and impaired judgement) had worsened since the fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555153 If continuation sheet Page 2 of 4 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 555153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Oaks Healthcare Center 11300 Fair Oaks Blvd. Fair Oaks, CA 95628 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/9/25 at 9:39 a.m. with the Administrator (ADM), the ADM stated Resident 1 slid out of bed while a CNA was in room assisting another resident at approximately 10:30 a.m. or 11:00 a.m. on 4/30/25. The ADM stated Resident 1 did not have pain initially but had pain later and sustained a hip fracture. During a joint interview on 5/9/25 at 9:57 a.m. with Assistant Director of Nursing (ADON) 1 and ADON 2, ADON 1 stated Resident 1 had a witnessed fall while CNA was in the room with another resident. ADON 1 stated the CNA saw that Resident 1 had slid to the floor and was in a sitting position and then notified the charge nurse. ADON 1 stated Resident 1 did not complain of pain initially but began to complain of pain at approximately 3:30 p.m. or 4:00 p.m. ADON 1 stated the physician was notified and Resident 1 was sent to the emergency department. During a concurrent observation and interview on 5/9/25 at 11:48 a.m. with Resident 1, Resident 1 was in a low bed, head of bed raised thirty degrees, call light in reach. When asked if Resident 1 remembered recent fall, Resident 1 replied yes. Resident 1 stated she did not remember how it happened but did remember being assisted by a CNA. During an interview on 5/9/25 at 11:54 a.m. with CNA 1, CNA 1 stated she was Resident 1's CNA the day of the fall. CNA 1 stated she was getting Resident 1 dressed and had put her pants on while Resident 1 was lying in bed. CNA 1 stated she then sat Resident 1 at the edge of bed with a Chux (incontinence pad with waterproof plastic on one side and absorbent material on the other) underneath her to put on Resident 1's top. CNA 1 stated Resident 1's bed was in a low position, and she was squatting at the bedside. CNA 1 stated Resident 1 began to slide out of bed with the Chux underneath her. CNA 1 stated she was not able to push Resident 1 back on the bed because she was off balance while squatting next to the low bed and Resident 1 slid to the floor. CNA 1 stated, It was my mistake to sit her [Resident 1] at the side of the bed .It was my mistake to have Chux pad underneath her. It didn't work out well this time. It caused her to slide out of bed. During an interview on 5/9/25 at 12:14 p.m. with Resident 2, Resident 2 stated she was Resident 1's roommate at the time of the fall. Resident 2 stated Resident 1 was in a very low bed and saw CNA 1 with her. Resident 1 was sitting at the edge of the bed and went down to the floor. Resident 2 stated Resident 1 yelled out My hips hurt. Resident 2 stated Resident 1 was also calling out later that day that her hip hurt. During a telephone interview on 5/9/25 at 1:24 p.m. with the Director of Nursing (DON), the DON stated Resident 1 had an assisted fall when CNA 1 was providing care. The DON stated Resident 1 was slowly lowered to floor because CNA 1 could not support her. The DON stated Resident 1 began complaining of pain several hours later. When asked why pain medication was given at 11:56 a.m. if Resident 1 did not complain of pain, the DON stated pain medication was given in case Resident 1 had pain from fall. The DON stated it was a problem with documentation and is trying to get nurses to document better. The DON stated Resident 1 was on a low bed and the Chux on the bed makes it slippery. The DON stated CNA 1 may not have used good judgement as she was a new CNA and will be retrained. During a telephone interview on 5/9/25 at 1:47 p.m. with Licensed Nurse (LN) 3, LN 3 stated she assessed Resident 1 after the fall before moving her back to bed. LN 3 stated she did not observe any injuries and Resident 1 did not complain of pain at that time. LN 3 stated she gave Resident 1 pain medication, Dilaudid, in case she had pain. Reviewed with LN 3 Resident 1's MAR for 4/30/25 at 11:56 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555153 If continuation sheet Page 3 of 4 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 555153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Oaks Healthcare Center 11300 Fair Oaks Blvd. Fair Oaks, CA 95628 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a.m. and that pain was documented at level 6 out of 10. LN 3 stated that Resident 1 did not necessarily have pain level of 6 but had an ongoing order for pain medication so she gave it. During an interview on 5/9/25 at 2:14 p.m. with LN 4, LN 4 stated she was notified of Resident 1's fall when she started her shift at 2:30 p.m. LN 4 stated she began her rounds at 3 p.m. and Resident 1 was not having any acute pain. LN 4 stated Resident 1's roommate, Resident 2, informed her later that Resident 1 was having pain. LN 4 stated she gave a dose of pain medication, Dilaudid, at 4 p.m. and tried to reposition Resident 1 but was unable due to pain. LN 4 stated at dinner time family was present and could not raise the head of the bed due to pain. LN 4 stated she contacted the physician and sent Resident 1 to the emergency department. During an interview on 5/9/25 at 2:28 p.m. with CNA 2, CNA 2 stated she was notified, when she started her shift at 2:30 p.m., of Resident 1's fall while being assisted with dressing by CNA 1. CNA 2 stated Resident 1 was always in a low bed and was on the edge of the bed when she slid to the floor. CNA 2 stated the staff should not have bed in low position when performing patient care. CNA 2 stated staff should raise bed up to approximately hip height to have better balance and positioning to control resident's movements. A review of the facility's P&P titled Falls and Fall Risk, Managing, revised 3/18, indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try and to minimize complications from falling .Fall Risk Factors .incorrect bed height or width .Resident conditions that may contribute to the risk of falls include: .cognitive impairment .functional impairments . A review of the facility's P&P titled Fall Risk Assessment, revised 3/18, indicated The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information .Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis) .The staff .will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance .activities of daily living (ADL) capabilities .and cognition . A review of the facility's Policy and Procedure (P&P) titled Falls - Clinical Protocol, revised 3/18, Indicated .The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc .Falls should be categorized as: .Other circumstances such as sliding out of a chair or rolling from a low bed to the floor .Falls should also be identified as witnessed or unwitnessed events .For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall .Often multiple factors contribute to a falling problem . A review of the facility's P&P titled Assessing Falls and Their Causes, revised 3/18, indicated .Falls are a leading cause of morbidity and mortality among the elderly in nursing homes .After an observed or probable fall, clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred .distinguish falls in the following categories: .Rolling, sliding, or dropping from an object (e.g., from bed or chair to floor .Evaluate chains of events or circumstances preceding a recent fall, including: .Whether the resident was among other persons or alone .Whether any environmental risk factors were involved FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555153 If continuation sheet Page 4 of 4