Inspection·February 13, 2025

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 ensure the safety measures were provided to prevent accident hazards for three of five residents sampled for accidents (Resident 1, 4, 8) when the wheels attached to the headboard of the bed were not locked. This failure had the potential to negatively affect the residents' well-being and increased the risk of accidents or injuries to the residents. Findings: During a review of U.S. Food & Drug (FDA) document titled, A Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts , revised 4/2010 , indicated that to meet the patients' needs for safety, keep the bed in the lowest positions with wheels locked was one of the recommended practices. During a review of the American Parkinson Disease Association (APDA) website document titled, Impaired Balance and Falls in people with Parkinson's Disease , dated 6/8/21, indicated, One of the most challenging symptoms of Parkinson's disease (PD) that fundamentally affects quality of life is balance impairment that can lead to falls. During a review of Resident 1's clinical record, indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses which included right hip fracture, fall, and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) without dyskinesia (uncontrolled, involuntary muscle movement). Resident 1 was her own healthcare decision maker. During a review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool), dated 12/25/24, the MDS indicated that Resident 1 had a brief interview for mental status (BIMS) score of 15, at section C Cognitive Patterns indicating that her cognition was intact. During a review of Resident 1's MDS, dated [DATE], at the section GG (refers to a section on the MDS assessment form used in nursing homes, which stands for Functional Abilities and Goals; it specifically assesses a patient's ability to perform self-care tasks and mobility activities, including their admission performance, discharge goals, and how much assistance they require for these functions) – Functional Abilities – Admission, Self-Care and Mobility (Assessment period is the first 3 days of the stay), indicated that Resident 1 needed maximal assistance (helper does more than half the effort) for: (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: 555535 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 555535 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Valley Care Center 9000 Larkin Road Live Oak, CA 95953 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)