Health inspection·February 5, 2025

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 adequate assistance to a resident (Resident 2) who required total dependence with activities of daily living (ADL-bathing or showering, dressing, getting in and out of bed or a chair, walking, toileting and eating) reviewed for accidents. This failure resulted in Resident 2 falling from bed. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia (a condition where the lungs fail to adequately exchange oxygen, leading to low oxygen in the blood) and dependence on ventilator (breathing machine) according to the facility's admission Record. A complaint investigation was conducted on 2/5/25 at the facility. At 8:57 A.M during an interview with Licensed Nurse (LN) 1, LN 1 stated Resident 2 was still at the hospital due to a fall incident. An interview was conducted with Certified Nurse Assistant (CNA) 1 on 2/5/25 at 9:45 A.M. CNA 1 stated she was assigned to the subacute (a place where residents require higher level of care including ventilator [breathing machine] dependent residents) side of the facility. CNA 1 stated she had been assigned to Resident 2. CNA 1 stated Resident 2 had a tracheostomy (an opening on the neck with a tube to help with breathing) connected to a ventilator. CNA 1 stated Resident 2 was dependent on staff for all ADLs. CNA 1 stated Resident 2 required two-person assist with brief change because Resident 2 was heavy, had a tracheostomy and had episodes of being combative. An interview was conducted with CNA 2 on 2/5/25 at 9:55 A.M. CNA 2 stated she had been assigned to Resident 2. CNA 2 stated Resident 2 was dependent with ADLs. CNA 2 stated Resident 2 was, A big guy and moved a lot. CNA 2 stated she had to ask for another staff to assist with changing Resident 2's brief for safety. CNA 2 further stated Resident 2 had episodes of refusing care and had struck out at staff. During an interview on 2/5/25 at 10:15 A.M. with Licensed Nurse (LN) 2, LN 2 stated she was the assigned nurse on the day Resident 2 fell out of bed. LN 2 stated she was at another room when she heard a CNA calling for the Respiratory Therapist (RT). LN 2 stated she followed the RT to Resident 2's room and saw Resident 2 lying on the floor, perpendicular to the bed. LN 2 stated she assessed Resident 2 and found skin tears on the left great toe, a red mark on the left eyebrow and reddened knees. LN 2 stated upon interview of CNA 3, CNA 3 told LN 2 that Resident 2 rolled off the bed during Page 1 of 2 555871 555871 02/05/2025 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0689 brief change. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with CNA 3 on 2/5/25 at 10:27 A.M. CNA 3 stated she was assigned to Resident 2 the day of the fall incident. CNA 3 stated Resident 2 had a bowel movement with smears on Resident 2's face and arms. CNA 3 stated she stood on the left side of Resident 2's bed as she cleaned Resident 2' s face and arm. CNA 3 stated she pulled the flat sheet under Resident 2 towards her then turned Resident 2 to his right side. CNA 3 stated as she cleaned Resident 2's back, Resident 2, Moved his arms, wiggled his body and started rolling off the bed. CNA 3 stated she was not able to stop Resident 2 from rolling off the bed and Resident 2 landed on the floor. CNA 3 stated she usually had a second person to assist with caring for Resident 2, but at that time CNA 3 stated, It was a lapse in my judgment. Residents Affected - Few During a review of Resident 2's weights in the electronic medical record, the weight record indicated Resident 2 weighed 175.1 pounds as of 1/3/25. A review of a fall assessment for Resident 2 dated 12/2/24 indicated a score of 13 . High Risk. A review of Resident 2's care plans were conducted. A care plan for Resident 2 titled, ADL Self Care Performance Deficit r/t Chronic respiratory failure, dated 12/3/24 indicated Resident 2 required total assistance with personal hygiene, toilet use, bathing, dressing. The care plan did not address the number of staff assistance Resident 2 required for ADLs. During a review of Resident 2's fall risk care plan dated 12/3/24, the care plan indicated, At risk for falls r/t: Epilepsy [a brain disorder causing seizures], CVA [Cerebrovascular Accident-stroke] .Goal .Will be free of falls . A review of Resident 2's Minimum Data Set (MDS-a clinical assessment tool), dated 12/6/24 was conducted. The MDS section GG0170A indicated, 01 .Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed . The MDS indicated coding of 01 indicated, Dependent-Helper does ALL of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity . An interview was conducted on 2/14/25 with the Director of Nursing (DON). The DON stated Resident 2's CNA should have called for someone to assist her during resident's care. The DON stated it was best practice to have two people to care for Resident 2 for safety. A review of the facility's undated policy and procedure (P&P) titled, Fall Prevention was conducted. The P&P indicated, .When a resident is admitted to this facility, a Fall assessment will be completed for the resident .A care plan is formulated based on that assessment. If a potential for a fall is triggered, a care plan will be formulated pertaining to fall prevention . The policy did not indicate fall preventive measures. 555871 Page 2 of 2