Health inspection·August 1, 2023

F 0689 6. Systolic blood pressure (pressure in the arteries [blood vessel, transports blood throughout the body] when your heart beats): No drop between lying and standing, score of 0. Level of Harm - Actual harm 7 Predisposing diseases: three or more present, score of 4. Residents Affected - Few 8. Scoring: High risk for potential for falls 10 or greater. A review of the care plan initiated on 11/6/21 addressing Resident 1 risk for Falls and injuries, indicated .related to (r/t) .Cognitive Impairment, weakness, right (R) hemiplegia (weakness of one side of the body), (HX) of cerebrovascular accident (CVA, stroke), indicated .Interventions: Assess toileting needs and address toileting needs. Encourage use of call light. Instruct to avoid sudden position change. Keep call light within reach. Keep environment clutter free. Keep personal belongings within reach. Low bed. Notify medical doctor (MD) and responsible party (RP) for all fall incidents with (w/) or without (w/o) injury, Observe for side effects of medications (meds). Observe for unsteady gait or balance. Orient to new room/environment. Occupational therapy and treatment as indicated. Provide adequate lighting. Provide verbal cues. Provide/reinforce use of assistive devices: wheelchair. Provide reinforce use of nonskid footwear. Physical therapy evaluation and treatment as indicated . A review of the care plan initiated on 11/6/21 addressing Resident 1's Activities of Daily Living (ADL's, indicated, .The resident has an activity of daily living (ADL) self-care performance deficit related to (r/t) right (R) hemiplegia (weakness of one side of the body), history (HX) of cerebrovascular accident (stroke) .Interventions .bed mobility: The resident is totally dependent on one to two (1-2) staff for positioning and turning in bed frequently and as necessary . The care plans were not revised and did not include the MDS assessment dated [DATE] to address that Resident 1 required extensive assistance with two-person physical assistance on bed mobility. During observation and interview on 7/10/23. at 11:46 AM, Resident 1 was sitting up in bed, awake, eyes were not tracking movement, has no verbal response. He has contracture (deformity and stiffness of the joints) to the right elbow and to the right hand. Certified Nurse Assistant (CNA, a caregiver) 1 stated, He [Resident 1] cannot do anything for himself. He is total dependent with care. During an interview on 7/10/23, at 1:26 PM, CNA 2 stated, On February 25 this year (2023), it was around 9:00 PM, I went to the resident to change his diaper. I turned him [Resident 1] to his right side towards me. I was not able to prepare the diaper ready. The diapers were kept at the shelf where the TV was, at the foot of his bed. I am confident that he will not move. So, I left to get the diaper. The resident rolled over and fell off the bed. He [Resident 1] had some bleeding and a bump on the forehead, above the left eyebrow. I ask the CNA who was in the hallway to call for the nurse. The nurse put a band aid on the skin tear. After the fall incident, the Director of Staff Development (DSD, facility educator) gave Inservice that from then there has to be two CNA's present when giving care to the resident (Resident 1). Before he had a fall, I used to care for him (Resident 1) by myself. A review of the facility communication tool (SBAR) and progress noted for change of condition (COC) dated 2/25/23, at 9:15 PM, indicated Resident 1 was assessed and noted, .abrasions (when your skin rubs off) on right (r) knee and bump on the forehead A review of the post fall documentation dated 2/26/23, indicated, . upon arrival on the night (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 2 of 3 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 555813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Devonshire Oaks Nursing Center 3635 Jefferson Avenue Redwood City, CA 94062 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 shift, the CNA noted bleeding on the left side of the residents (Resident 1) forehead .scant bleeding and skin discoloration on the resident ' s forehead and around his left eye . Level of Harm - Actual harm Residents Affected - Few A review of Emergency Department visits notes dated 2/26/23, indicated, .Discharge diagnosis: head contusion (caused by a direct blow), traumatic hematoma (blood that gathers, get thick [makes a clot]) of the forehead . A review of the physician (medical doctor) progress notes dated 2/28/23, indicated, .status post fall (s/p, a fall recently occurred) 2/25/23, rolled out of bed .General appearance: forehead hematoma, bruising of face, extends down neck to clavicle (collarbone, located on the upper chest) area . During an interview on 7/10/23 at 1:05 PM, Licensed Vocational Nurse 1 (LVN 1) stated that some of the interventions for fall were not applicable knowing the conditions of Resident 1 and stated, The resident (Resident 1) does not move, unless you move him. He is unable to talk. He does not understand. He is totally dependent with care. During an interview on 8/1/23, at 11:00 AM, CNA 3 stated, It is safer for the resident laying on his back. The resident was left in right side lying position. He was turned on his weak side when he rolled out of bed and fell. Now, we need two CNAs when giving him (Resident 1) care. During an interview on 8/9/23, at 11:04 AM, the Director of Staff Development (DSD) stated, During the licensed nurses and CNA's Inservice after the fall incident, I addressed that he (Resident 1) was extensive to totally dependent and required two staff present when providing care. I told the (CNA 1 named) to ask for help from now on. The DSD also stated, The nurse communicates with the CNAs and tell them what the resident's needs are. CNAs has no access to the resident's care plan. The MDS Nurse (Assessment Nurse) particularly is responsible for updating resident's care plan after they completed an assessment. A review of the Policy and Procedure titled, Fall and Fall Risk Managing dated 3/2018. indicated, Based on previous evaluations and current data the staff will identify intervention related the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .Residents conditions that may contribute to risk of fall includes: fever, infection, delirium (disturbance in mental abilities) or cognitive impairment (decline in memory or thinking skills) , pain, lower extremity (legs) weakness, poor grip strength, medication side effects, orthostatic hypotension (when the blood pressure drops when you stand up), functional impairments, visual deficits, and incontinence. Medical factors that contribute to the risk of falls include: arthritis (pain and inflammation of the joints), heart failure ( when the heart muscle doesn ' t pump as strong as it should) , anemia (abnormally low red blood cell count), neurological (including the brain) disorders and balance and gait (manner of walking) disorders .Resident-Centered approaches to Managing Falls and fall risk: .staff will implement additional or different intervention, or indicate why the current approach remains relevant .staff will try various interventions, based on assessment of the nature are category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 3 of 3