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
(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:
555815
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
555815
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Totally Kids Specialty Healthcare - Sun Valley
10716 LA Tuna Canyon Road
Sun Valley, CA 91352
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
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555815
If continuation sheet
Page 2 of 2
