Health inspection·December 19, 2023

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, interview and record review, the facility failed to complete a post fall assessment for one of one resident (Resident 5), after a fall. This failure had the potential for Resident 5 to have a repeat fall and at risk for further injury. Findings: Resident 5 was admitted to the facility of 10/13/23 with diagnoses including protein-calorie malnutrition (reduced nutrients in the body) and history of falling according to the facility ' s admission Record. During an interview on 12/5/23, at 10:27 A.M. with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 5 was brought near the nurse ' s station because Resident 5 was unsafe. CNA 1 stated Resident 5 had attempted to get up from bed or wheelchair unassisted and has had fall incidents. An interview and joint record review was conducted on 12/5/23, at 10:54 A.M. with the Clinical Support Nurse (CS). The CS stated Resident 5 had a fall incident on 11/22/23 according to the facility ' s change of condition document. The CS reviewed Resident 5 ' s fall assessment dated [DATE] and the score was 10, which indicated a high fall risk. The CS further stated there was no post fall assessment completed for Resident 5 ' s fall incident on 11/22/23. During an interview with Licensed Nurse (LN) 1 on 12/5/23, at 4:24 P.M., LN 1 stated Resident 5 was a fall risk. LN 1 stated a post fall assessment was completed upon admission and after each fall incident. LN 1 further stated a post fall assessment was important to do to assess for other changes. The Director of Nurses (DON) was interviewed on 12/8/23, at 1:14 P.M. The DON stated upon review of Resident 5 ' s fall assessments, there was no record of a post fall assessment on 11/22/23. The DON stated it was the facility ' s policy to update fall assessments. The DON further stated it was important to identify increased risk for falls and determine or guide further interventions to prevent falls. The facility ' s policy and procedure (P&P) titled, Falls Intervention Policy and Procedure, dated 10/4/23 was reviewed. The P&P indicated, .Residents will be evaluated for risk for falling .The evaluation will be completed upon admission, quarterly, annually, and/or if a significant change in condition .Steps following a fall .Review and update causative factors, interventions, care plan and fall assessment will be completed . Page 1 of 3 555928 555928 12/19/2023 Ridgeview Skilled Nursing Facility 9825 Glen Center Drive San Diego, CA 92131

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to complete an accurate documentation after a significant event for one resident (Resident 5) related to: 1. Resident 5 ' s fall incident and, 2. Post fall assessment. Failure to have an accurate documentation after a significant event had the potential for residents to not have proper assessment and interventions related to a fall. Findings: Resident 5 was admitted to the facility of 10/13/23 with the diagnoses including protein-calorie malnutrition (reduced nutrients in the body) and history of falling according to the facility ' s admission Record. 1. An interview and joint record revie was conducted on 12/5/23, at 10:54 A.M. with the Clinical Support Nurse (CS). The CS stated Resident 5 had a fall incident on 11/22/23 according to the change of condition document. The CS reviewed Resident 5 ' s progress notes to verify details of the fall incident. The CS stated there was no documentation in the progress notes about Resident 5 ' s fall incident on 11/22/23. The CS further stated there was no documentation to show what transpired during Resident 5 ' s fall incident. During an interview with Licensed Nurse (LN) 1on 12/5/23m at 4:24 P.M., LN 1 stated Resident 5 did not have any pain post fall incident on 11/22/23. LN 1 stated on 11/24/23 Resident 5 started to have pain and was restless. LN 1 stated an X-ray was completed and showed a right hip fracture. An interview was conducted on 12/8/23, at 1:14 P.M. with the Director of Nursing (DON). The DON stated he was aware Resident 5 fell on [DATE]. The DON stated nursing notes for Resident 5 was reviewed and there was no documentation regarding Resident 5 ' s fall incident on 11/22/23. The DON stated he did not interview staff who were involved for detailed events of the fall. The DON further stated there should have been nursing documentation regarding the fall incident to show how the fall occurred and to determine interventions to prevent falls. The facility ' s policy and procedure (P&P) titled, Falls Intervention Policy and Procedure, dated 10/4/23 was reviewed. The P&P indicated, .Steps following a fall .3. Documentation will include Risk Management Report, the nurse ' s notes, and a fall investigation . The facility ' s P&P titled, Change of Condition Guidelines, dated 10/4/23 was reviewed. The P&P indicated, .An accident or incident involving the resident .6. The Nurse Supervisor/Charge Nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status . 2. During an interview on 12/5/23, at 10:27 A.M. with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 5 was brought near the nurse ' s station because Resident 5 was unsafe. CNA 1 stated 555928 Page 2 of 3 555928 12/19/2023 Ridgeview Skilled Nursing Facility 9825 Glen Center Drive San Diego, CA 92131

F 0842 Resident 5 had attempted to get up from bed or wheelchair unassisted and has had fall incidents. Level of Harm - Minimal harm or potential for actual harm An interview and joint record review was conducted on 12/5/23, at 10:54 A.M. with the Clinical Support Nurse (CS). The CS stated Resident 5 had a fall incident on 11/22/23 according to the facility ' s change of condition document. The CS reviewed Resident 5 ' s post fall assessments: 10/26/23 score was 16, high risk and 11/14/23 score was 10, high risk. The CS further stated there was no post fall assessment completed for Resident 5 ' s fall incident on 11/22/23. Residents Affected - Few During an interview with Licensed Nurse (LN) 1 on 12/5/23, at 4:24 P.M., LN 1 stated Resident 5 was a fall risk. LN 1 stated a post fall assessment was completed upon admission and after each fall incident. LN 1 further stated a post fall assessment was important to do to assess for other changes. The Director of Nurses (DON) was interviewed on 12/8/23, at 1:14 P.M. The DON stated upon review of Resident 5 ' s fall assessments, there was no record of a post fall assessment on 11/22/23. The DON stated it was the facility ' s policy to update fall assessments. The DON further stated it was important to identify increased risk for falls and determine or guide further interventions to prevent falls. The facility ' s policy and procedure (P&P) titled, Falls Intervention Policy and Procedure, dated 10/4/23 was reviewed. The P&P indicated, .Residents will be evaluated for risk for falling .The evaluation will be completed upon admission, quarterly, annually, and/or if a significant change in condition .Steps following a fall .Review and update causative factors, interventions, care plan and fall assessment will be completed . 555928 Page 3 of 3