Health inspection·January 24, 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 interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) remained free from the accident hazards. * CNA 1 had provided ADL care to Resident 1 in bed by herself instead of two or more persons to assist as per the resident's MDS and plan of care. When CNA 1 turned the resident to the right side, the resident rolled and fell off the bed to the floor sustaining multiple bruises and a skin tear to the right cheek. This failure had the potential for Resident 1 to sustain serious injury. Findings: Review of the facility's P&P titled Fall Risk/Prevention revised 7/2018 showed the policy of the facility is to identify the residents that are at risk for falls and to implement a plan of care in an attempt to prevent falls. Upon admission, a Fall Risk Assessment will be completed for all residents. If the Fall Risk Assessment score is 10 or above, the resident is at risk for falls and a plan of care will be developed with approaches in an attempt to prevent falls. Review of the facility's P&P titled Safety and Supervision of Residents revised 2/2019 showed the policy of the facility is to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The resident-oriented approach to safety addresses safety and accident hazards for individual residents. The IDT shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for each resident. The care team shall target interventions to reduce the potential for accidents. Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as necessary, ensuring that interventions are implemented, and documenting interventions. Closed medical record review for Resident 1 was initiated on 1/23/24. Resident 1 was admitted to the facility on [DATE], and discharged on 1/16/24, to the acute care hospital. Review of Resident 1's H&P examination dated 7/10/23, showed Resident 1 could make needs known but could not make medical decisions. Resident 1's MDS, Section G Functional Status dated 8/15/23, showed Resident 1 required two or more persons for physical assistance for bed mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed) and transfers (how resident moves between Page 1 of 3 555520 555520 01/24/2024 Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

F 0689 surfaces including to and from: bed, chair, wheelchair). Level of Harm - Minimal harm or potential for actual harm Resident 1's MDS, Section C, dated 11/14/23, showed Resident 1 had severely impaired cognition. Resident 1's Fall Risk assessment dated [DATE], showed Resident 1 was a high risk for falls. Residents Affected - Few Review of Resident 1's care plan titled Need Assistance with ADL care updated 11/16/23, showed Resident 1 needed two to three staff to assist with toileting hygiene, toilet transfers, and chair/bed transfers. Review of Resident 1's Weekly Summary dated 1/12/24, showed the resident needed two or more persons' assistance for ADL support for bed mobility and transfers. Review of Resident 1's Nurses Progress Notes dated 1/16/24 at 1110 hours, showed Resident 1 sustained a fall while receiving ADL care from CNA 1. Resident 1 was placed on her right side while being cleaned in bed and Resident 1 fell onto the floor before CNA 1 was able to catch her. Resident 1 was observed to have the following wounds: - right check ecchymosis (bruising) with skin tear - right below the ear scratch - right elbow ecchymosis - right upper arm bluish-purplish skin discoloration - right forearm ecchymosis - right 3rdtoe purplish discoloration - right 4thtoe purplish discoloration - left lateral knee bluish discoloration Review of Resident 1's Body/Skin Check form dated 1/16/24, showed Resident 1 had the above wounds. Review of Resident 1's care plan titled Status Post Fall dated 1/16/24, showed an intervention for the resident to always need two-person assist during care. On 1/18/24 at 1500 hours, an interview was conducted with Resident 1's DPOA for healthcare (Family Member 1). Family Member 1 stated she was not contacted regarding Resident 1 sustaining a fall while in the facility. On 1/23/24 at 0900 hours, an interview was conducted with CNA 1. CNA 1 stated she was assigned to care for Resident 1 at the time of her fall on 1/16/24 at 1110 hours. CNA 1 stated she provided one-person assist during transfers in and out of bed and ADL care for Resident 1. CNA 1 stated she knew Resident 1 was a two-person assistance. CNA 1 stated at the time of Resident 1's fall, she was cleaning the resident after the resident had a bowel movement and had placed Resident 1 on her right side with Resident 1's back toward CNA 1. CNA 1 stated Resident 1 then rolled away from her, off the bed, 555520 Page 2 of 3 555520 01/24/2024 Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

F 0689 and fell onto the floor. CNA 1 stated she left Resident 1's room to call LVN 1 for assistance. Level of Harm - Minimal harm or potential for actual harm On 1/23/24 at 0940 hours, an interview was conducted with LVN 1. LVN 1 stated she was assigned to care for Resident 1 at the time of her fall on 1/16/24 at 1110 hours. LVN 1 stated Resident 1 was a two-person assist with transfers and ADL care. LVN 1 stated after Resident 1 had fallen, he entered Resident 1's room. LVN 1 stated he saw Resident 1 laying on her side on the floor next to her bed. LVN 1 stated Resident 1 had sustained the above wounds. LVN 1 stated Resident 1 should have been provided with two-person assist during the time of Resident 1's fall. LVN 1 stated Resident 1 was then transferred back onto her bed using four staff members with the use of Hoyer lift. Residents Affected - Few On 1/23/24 at 1015 hours, an interview was conducted with RN 1. RN 1 stated she was assigned to care for Resident 1 at the time of her fall on 1/16/24 at 1110 hours. RN 1 stated Resident 1 was a two-person assist with transfers and ADL care. RN 1 stated after Resident 1 had fallen and transferred back onto her bed, she entered Resident 1's room. RN 1 stated LVN 2 was providing wound treatment to the above wounds. On 1/24/24 at 0830 hours, an interview was conducted with CNA 2. CNA 2 stated she had been previously assigned to Resident 1 prior to her sustaining the fall on 1/16/24 at 1110 hours. CNA 2 stated Resident 1 was a two-person assist for transfers and ADL care. On 1/24/24 at 1315 hours, an interview was conducted with LVN 2. LVN 2 stated he provided wound treatment to Resident 1 after her fall on 1/16/24 at 1110 hours. On 1/24/24 at 1530 hours, an interview was conducted with the DON. The DON stated Resident 1 was a two- person assist with transfers and ADL care. The DON stated there was a note in Resident 1's closet stating she was a two-person assist. The DON stated CNA 1 should not have been providing assistance to Resident 1 by herself and there should have been one additional staff member. 555520 Page 3 of 3