Inspection·May 17, 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 and record review, the facility failed to provide appropriate safety measures and adequate supervision to prevent one of two residents (Resident 1) from rolling out of bed and falling on the floor during a bed linen change. The failure to provide sufficient staff or adequate measures to prevent a dependent resident from rolling off the bed during a bed linen change, which resulted in Resident 1 being transported to the emergency department for evaluation after the fall caused a brief loss of consciousness and a headache which lasted over a week. Findings: A review of Resident 1 ' s admission Record, printed 4/10/24, indicated Resident 1 was admitted to the facility in 2017 with diagnoses of multiple sclerosis (MS, a chronic condition that affects the brain and spinal cord) and paraplegia (paralysis of the legs and lower body caused by spinal injury or a disease). A review of Resident 1's Minimum Data Set (MDS, resident assessment tool used to provide care), dated 2/2/24, indicated Resident 1 had clear speech, was able to be understood, and was able to understand others, and had impairment to both sides of the upper and lower extremities. The MDS indicated Resident 1 required substantial/maximal assistance (The helper does more than half the effort of lifting or holding trunk or limbs.) for all activities of daily living (eating, dressing, hygiene, bathing) including transfers between surfaces and moving/changing position in bed. A review of Resident 1's Nursing Progress Notes, dated 2/27/24, at 10:02 p.m., Registered Nurse 1 (RN 1), the progress notes indicated on 2/27/24, at 9:07 p.m., Resident rolled out of bed (between bed and window) during incontinent care. Resident .complained of headache . During a telephone interview on 4/11/24, at 11:36 a.m., with RN 1, RN 1 stated while working in another resident ' s room, Certified Nursing Assistant 1 (CNA 1) called RN 1 to join CNA 1 in Resident 1 ' s room. RN 1 stated upon entering Resident 1 ' s room, RN 1 saw Resident 1 lying on the floor next to the left side of the bed. RN 1 stated CNA 1 said Resident 1 rolled off the bed while CNA 1 was changing the bed linen. During a telephone interview on 4/16/24, at 8:30 a.m., with CNA 1, CNA 1 stated CNA 1 had turned Resident 1 to a left side-lying position on the left side of the bed, with Resident 1 ' s right leg crossed over the left leg while CNA 1 completed a bed linen change. CNA 1 stated Resident 1 rolled off (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 2 Event ID: 555710 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 555710 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tice Valley Post Acute 1975 Tice Valley Blvd. Walnut Creek, CA 94595 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)