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
observation, interviews, and record review, the facility failed to maintain a safe environment, free from
accidents and hazards, for one of the three sampled residents (Resident 1). Resident 1, who was fully
dependent and required assistance for all Activities of Daily Living (ADLs), sustained an injury while being
repositioned by a Certified Nursing Assistant (CNA).
This failure resulted in Resident 1 sustaining a head injury when his head hit the headboard of the bed,
resulting in an abrasion on the posterior head, accompanied by a bump and bleeding.
Findings:
During a review of Resident 1's admission Face Sheet Record (document containing resident demographic
information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the
facility on [DATE] with diagnoses which included, vascular dementia (a chronic condition that affect
memory, thinking, and behavior), unspecified osteoarthritis (a degenerative joint disease), repeated falls.
During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool used to identify
cognitive [mental processes] and physical functional level) dated 6/7/24, the MDS indicated Resident 1's
Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was
99- the resident was unable to complete the interview . Section GG (Function Status) indicated . A 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
[was] code 01 Dependent, [required] helper does all of the effort. Resident does none of the effort to
complete the activity .
During a review of Resident 1's Nurses Progress Notes (NPN), dated 7/4/24, the NPN indicated, CNA
reported around 0430 [4:30 a.m.] that resident accidently hit his head against the head board of the bed.
Upon assessment, noted 3 x 4 cm abrasion to posterior head with bump and some bleeding .
During an interview on 8/21/24 at 9:58 a.m., with Supervising Registered Nurse 2 (SRN 2), SRN 2
confirmed that on 7/4/24 at around 4:30 a.m., a CNA reported that Resident 1 accidentally hit his head
against the headboard during repositioning. SRN 2 noted that Resident 1 sustained a 3 x 4 cm (unit of
measure) abrasion with a bump and some bleeding. It was also mentioned that the incident could have
been prevented. SRN 2 noted that Resident 1 was non-ambulatory and fully dependent on assistance, as
indicated in the MDS.
During an interview on 8/22/24 at 1:48 p.m., with SRN 1, SRN 1 acknowledged the hospice nurse (a
(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:
555900
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
555900
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - Fresno
2811 W Cesar Chavez Blvd
Fresno, CA 93706
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
nurse who specializes in providing care for the terminally ill patients in the final stages of their life), as part
of a collaborative care approach, informed the RP.
During an interview on 8/23/24 at 6:28 a.m., with CNA 1, CNA 1, who assigned to Resident 1 on 7/4/24,
confirmed that Resident 1 was totally dependent on care. She stated that while repositioning Resident 1,
his head hit the headboard, resulting in a head injury. Upon noticing the injury, CNA 1 immediately sought
assistance from a nurse.
During an interview on 8/23/24 at 10:15 a.m., with MDS Nurse, MDS Nurse confirmed that Resident 1's
quarterly assessment and care screening were completed on 6/7/24. The assessment indicated that
Resident 1 was completely dependent on assistance for repositioning, requiring the support of one or more
helpers. The nurse emphasized that Resident 1 needed assistance for all activities and was not capable of
completing them independently. MDS Nurse stated Resident 1 was not a big person, and he needed 1 staff
assistance for positioning.
During a review of Resident 1's care plan dated 3/30/23, the care plan indicated .decreased functional
mobility .Resident is non-ambulatory .generalized weakness requiring extensive to total assist with ADLs
.Provide extensive to total assistance in all his ADLs while promoting independence if able . Reposition
resident for comfort, avoid shearing .
During a review of the Policy and Procedure (P&P) titled, Accident Prevention, dated 1/22/24, the P&P
indicated, The facility will ensure that the resident environment remains as free of accident hazards as is
possible and each resident receives adequate supervision and assistance devices to prevent accidents. I.
The facility will develop a culture of safety and commitment to implement systems that address resident risk
and environmental hazards to minimize the likelihood of accident .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555900
If continuation sheet
Page 2 of 2
