Other·November 17, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the State of California Department of Public Health during an abbreviated standard survey for the investigation of one Entity Reported Incident. Entity Reported Incident number: CA00506968. Representing the California Department of Public Health: HFEN; 2699/32871. The inspection was limited to the specific Entity Reported Incident and does not reflect the findings of a full inspection of the facility. A deficiency was issued for Entity Reported Incident number CA00506968.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 10/25/2016 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LOW511 Facility ID: 630014894 If continuation sheet 1 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555900 (X3) DATE SURVEY COMPLETED 10/19/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on staff interview and clinical record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one sampled resident (Resident 1), when Resident 1 was not adequately supervised during his personal care. This failure resulted in Resident 1 falling from bed causing Resident 1 to sustain a Left Femur (hip) Fracture. This failure resulted in the injury of Resident 1 and the potential for further health complications and possible death. Findings: On 10/27/16 at 3:15 p.m., during an interview, Certified Nurse Assistant (CNA) 1 stated on 10/11/16 at approximately 10:30 p.m. Resident 1 needed to have personal care provided. CNA 1 stated Resident 1 requires assistance from two CNAs to perform this task as Resident 1 has a history of aggressive behavior toward staff while they are performing care. CNA 1 stated, "Usually we have two people [to assist with personal care] but at that time he [Resident 1] was being pleasant and there wasn't anybody around to help, they were all busy," was the reason why she decided to perform the personal care without the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LOW511 Facility ID: 630014894 If continuation sheet 2 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555900 (X3) DATE SURVEY COMPLETED 10/19/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assistance of a second CNA. CNA 1 stated she raised Resident 1's bed into high position, lowered the bed rails and asked Resident 1 to turn on his right side so she could perform personal care. CNA 1 stated Resident 1's back was toward her and his left arm was on top. CNA 1 stated as she was performing the personal care Resident 1 aggressively swung his left arm back over his body toward her and when she stepped back to dodge the blow, Resident 1 rolled out of bed and landed on the floor with his weight on his left knee. Review of Resident 1's clinical record indicated Resident 1 was transferred to the emergency department where he was diagnosed with an acute left femur fracture. Review of Resident 1's "Minimum Data Set" (MDS- assessment tool used to indicate what type of care a resident requires), dated 8/3/16, indicated Resident 1 required a two person physical assist for bed mobility. Review of Resident 1's Activity of Daily Living (ADL) care plan dated 8/16/16 had no documented evidence with the number of staff needed for assistance with bed mobility. On 4/19/17 at 2:40 p.m., during an interview, CNA 2 stated it would not be safe to attempt providing a one person physical assist for personal care on a resident who was supposed to have a two person assist especially if they had a history of aggressive behavior. CNA 2 stated, "Don't risk it." On 4/19/17 at 2:45 p.m., during an interview, CNA 3 stated it would place the resident at risk of falling if a one person assist is used when the resident needs a two person physical assist. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LOW511 Facility ID: 630014894 If continuation sheet 3 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555900 (X3) DATE SURVEY COMPLETED 10/19/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - FRESNO 2811 W Cesar Chavez Blvd Fresno, CA 93706 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 4/19/17 at 2:50 p.m., during an interview, CNA 4 stated if an aggressive resident requires a two person physical assist you would not want to do it on your own. CNA 4 stated two people should be used for safety so the patient does not fall. Review of Resident 1's clinical record indicated, "Death Notification Form "dated 10/20/16 at 9:55 a.m. indicated, "Death caused by...Respiratory Failure... Due to, or as a consequence of, Probable Pulmonary Embolism... Due to, or as consequence of Left Femoral Fracture..." The facility was not able to provide a policy procedure for Accident/Hazard or Care Planning as requested by the end of the investigation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LOW511 Facility ID: 630014894 If continuation sheet 4 of 4