Health inspection·July 1, 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 supervision for one of three sampled residents (Resident 1), when Certified Nursing Assistant 1 (CNA 1) transferred Resident 1 with the Sara lift (resident mobility lift), alone. This failure had the potential to negatively impact the resident's safety and increased risk for injury. Findings: A review of Resident 1's clinical record titled, admission Face Sheet (record containing resident personal information), indicated Resident 1 was [AGE] years old. Resident 1 had multiple diagnoses which included Left Hemiplegia (paralysis of left side of the body from a stroke), and contracture of left hand (deformity of hand). During an interview on 6/30/25 at 9:58 a.m., Resident 1 stated, I have to use the Sara lift because my left side hand, leg, and ankle were affected by the stroke. Frequently, just one person gets me on the Sara lift but they are required to have two people. I could hear her [CNA] straining to get me up from the bed and I'm in danger because I can't balance. I don't like her pushing me on it. Resident 1's Minimum Data Set (MDS-a resident assessment tool used to identify resident care needs) dated 5/20/25, contained a brief interview for mental status which identified a score of 15/15, which indicated his cognition was intact. An assessment of functional abilities of upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) identified a score of 1/15, which indicated very little functional ability. During an interview on 6/30/25 at 1:43 p.m., CNA 1 stated she was behind on shower day (6/17/25) and Resident 1 was ready for his shower. She stated she assisted R1 onto the Sara lift by herself. CNA 1 acknowledged she should not have assisted Resident 1 onto the Sara lift by herself. During an interview on 7/1/25 at 1:10 p.m., Physical Therapist (PT) stated each resident was assessed for height, side weakness, cognition, and weight to determine if the Sara lift is a 1- or 2- person assist for use. PT stated the facility should follow common industry practice of a 2-person assist for all mechanical lifts, for the safety of residents. PT stated Resident 1 should have been a 2-person assist for all transfers. During an interview on 7/1/25 at 1:18 p.m., Occupational Therapist (OT) stated Resident 1 was tall, heavy, and he had no functionality on the left side of his body. OT stated Resident 1 required a 2-person assist for all transfers for resident safety. (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 07/01/2025 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)