Health inspection·May 5, 2023

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. Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1), who required assistance from two facility staff during provided incontinent care (any involuntary or accidental leakage of urine or feces) and bed bath, was provided the appropriate number of staff to ensure safety of the resident. This deficient practice resulted in Resident 1 sustaining an assisted fall with a laceration (cut) to the left eyebrows when only one staff provided the resident with incontinent care during a bed bath. Findings: A review of Resident 1`s admission Record indicated the facility admitted the resident on 01/10/2023 with diagnoses that included epilepsy (a brain disorder that causes recurring, unprovoked seizures [involuntary movement]) and dependence on ventilator ( dependent upon mechanical life support because of a resident ' s inability to breathe effectively). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/10/2023, indicated the resident is in a persistent vegetative state (a person in this state is awake but unaware of the world around them and doesn't show any intentional behaviors) and required total assistance from staff with activities of daily living (daily self-care activities including feeding, bathing, grooming, dressing, bowel control, bladder control, toilet use, transfers (bed to chair and back) care 100% of the time. A review of Resident 1`s History and Physical (H&P- a form to indicate the residents previous and current medical related health issues) dated 1/10/2023, indicated a current weight of 41.1 kilogram (kg- unit of measure) or 91 pounds (lbs-unit of measure). A review of the facility`s Incident Report, dated 4/12/2023, indicated that Resident 1 fell on the floor after Certified Nurse Assistant 1 (CNA 1) turned patient towards her resulting in a left eyebrow laceration. On 4/18/2023 at 12:39 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated that on 4/12/2023 at around 7:30 p.m., LVN 1 entered Resident 1`s room and saw CNA 1 giving Resident 1 a bed bath. LVN 1 stated that after noticing CNA 1 was providing the bed bath alone to Resident 1, LVN 1 asked CNA 1 if assistance was needed. LVN 1 stated she asked CNA 1 where her assigned partner was to help, to which CNA 1 responded that her assigned partner was busy in another resident room. LVN 1 stated that approximately five (five) to 10 minutes later, screaming was heard inside Resident 1 ' s Page 1 of 2 555815 555815 05/05/2023 Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few room. LVN 1 stated that upon entering Resident 1 ' s room, she noted Resident 1 on the floor lying on his right side. LVN 1 stated that Resident 1 ' s fall on 4/12/2023 could have been prevented if CNA 1 had waited for her buddy to help in providing bed bath to the resident. On 4/18/23 at 2:00 p.m. m during an interview with Director of Staff Development (DSD), DSD stated that for all residents weighing more than 19 kg, staff is to provide two-person assist with activities of daily living (ADLs- basic self-care tasks like bathing) DSD stated this is part of the facility program known as the Buddy System where in staff are paired to provide help to one another with resident ' s ADLs. On 4/18/2023 at 3:59 p.m., during an interview, Director of Nursing (DON) stated that residents who are totally dependent on staff for ADLs require two staff assistance to complete ADL tasks such as bed bath and incontinence care. DON stated that if CNA 1 had waited for her assigned partner, Resident 1 ' s fall on 4/12/2023 could have been avoided. On 4/21/2023 at 9:00 a.m., during a telephone interview of CNA 1, CNA 1 stated that on 4/12/2023 she noticed Resident 1 with feces in his diaper. CNA 1 stated she decided not to wait for her assigned partner because the assigned partner was busy taking care of another resident, and instead immediately began to clean and bathe Resident 1. CNA 1 stated that while she was cleaning Resident 1, the resident began coughing causing the Resident to slip out of bed. On 5/5/2023 at 8:45 a.m., during an interview, DON stated that for the fall incident of Resident 1 on 4/12/2023 could have been prevented if LVN1 had stopped to help CNA 1 when LVN 1 had noticed CNA 1 alone providing a bed bath. A review of the facility`s policy and procedure dated 12/2/2022, titled Lifting and Transfer, indicated that two-person assistance is required for residents weighing 20 kilograms or more. 555815 Page 2 of 2