Health inspection·June 5, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent avoidable accidents when one of seven residents (Resident 1) noted to have swelling of the left thigh and knee. This failure contributed to Resident 1 sustaining an acute distal femur shaft fracture (sudden break in the long part of the thigh bone). Findings: During an observation on May 20, 2024, at 4:15 PM, Resident 1 was lying in bed awake and did not respond verbally. During a review of Resident 4 ' admission Record (general demographics) on May 20, 2024, the document indicated Resident 1 was originally admitted to the facility on [DATE], with diagnoses that include traumatic hemorrhage of cerebrum (a condition brain injury), respiratory failure (a condition that makes it difficult to breathe on your own, asthma, seizures (a condition that causes sudden shaking or stiffness), hypertensive (a condition of high blood pressure, and gastrostomy status (a tube inserted through the wall of the abdomen directly into the stomach). A review of Resident 1 ' s care plan dated September 9, 2023, indicated, . has an alteration in musculoskeletal status r/t (related to): bilateral knee contracture. Goal: The resident will remain free of injuries or complications related to contractures . A review of Progress Notes dated, May 15, 2024, at 05:25, indicated, .Outcomes of Physical Assessment . During positioning this morning CN (Charge Nurse) and CNA (Certified Nursing Assistant) noted left thigh/knee appeared to move abnormal and felt odd around kneecap/joint with popping felt. Possible slight swelling to thigh area, hard to determine as resident is contracted at knees to BLE (bilateral lower extremities) . A review of Resident 1 ' s Radiology Result Report, dated May 20, 2024, indicated, . Knee 1 or 2 Views Interpretation: Reason for Study: .Localized swelling, mass and lump, left lower limb . Findings: No comparison study is available. Acute distal femur shaft fracture with displacement seen . Conclusion: Acute distal femur shaft fracture . During an interview on June 5, 2024, at 2:10 PM, with the Registered Nurse Supervisor (RNS), the RNS stated, Staff are expected to check on residents to provide assistance and supervision every two Page 1 of 2 555350 555350 06/05/2024 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0689 hours and as needed. Level of Harm - Minimal harm or potential for actual harm During an interview on June 5, 2024, at 4:00 PM, with the Administrator, the Administrator indicated staff was not sure of what happened to the Resident 1. He stated, There is no incidents or accidents reported by staff. Residents Affected - Few During a review of the facility ' s P&P, titled, Safety and Supervision of Residents, dated, July 20, 2017, the P&P indicated, Policy Statement Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . 555350 Page 2 of 2