Health inspection·March 26, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (R3) when the interdisciplinary team (IDT) did not develop a new intervention after R3 fell on 3/14/25. This failure has the potential risk for R3 to sustain another fall and possible injuries. Findings: An unannounced visit was made on 3/26/25 to investigate a facility report of a fall R1 had on 3/14/25. Three residents were selected who had an actual fall within 30 days. R3 was sampled for the investigation. During a review of R3 facesheet (demographics) indicated R3 was admitted on [DATE] with diagnoses including heart failure, hypertension, peripheral vascular disease. R3 Minimum Data Set (MDS) dated [DATE] indicated R3 was severely cognitively impaired and had a history of two falls with injuries. During a concurrent observation and interview on 3/26/25 at 1:30 pm with R3 in R3's room, R3 was sitting in a recliner. There was a sign posted in the room indicating Call Don't Fall. R3 stated he did not recall falling in his room. During a concurrent interview with Licensed Vocational Nurse (LVN) and record review of R3 chart on 3/26/25 at 1:40 pm, LVN reviewed the fall risk assessment and stated the last assessment date was 3/14/25. LVN stated R3 scored 21 which indicated a high risk for falls. During a concurrent interview with Quality Assurance Nurse (QAN) and record review of R3 chart on 3/26/25 at 1:54 pm., QAN reviewed the IDT note for the fall on 3/14/25 and care plan for falls and stated IDT recommended to continue the plan of care for R3. QAN stated IDT did not need to develop new interventions every time a fall happens if the current interventions were already in place. QAN reviewed the interventions that were in documented in the current care plan for at risk for falls and stated there were no new interventions developed after the fall on 3/14/25. During a review of R3 post-fall nursing note dated 3/14/25, indicated R3 was found on the floor in his room. Under care plan revision/updates section indicated to continue with the current plan of care. During a review of R3 IDT note dated 3/14/25, indicated under new or revised interventions, the (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 03/26/2025 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)