Health inspection·June 11, 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. Based on observation, interview, and record review, the facility failed to accurately assess a resident's fall risk status and ensure a care plan was person-centered for one resident (Resident 1) of four sampled residents when Resident 1 was admitted to the facility with a history of falls These failures decreased the facility's ability to supervise and prevent Resident 1's fall on 5/24/25 which resulted in a right nondisplaced (not shifted out of place) distal radius (bone that is near the wrist of your lower arm) fracture (a break) to the right arm, limiting use of her dominant hand. Findings: A review of Resident 1's hospital History and Physical , dated 4/7/25 at 4:30 p.m., indicated Resident 1 fell at home and sustained a right distal femur (thigh bone) fracture. A review of Resident 1's admission record indicated Resident 1 was admitted from a local hospital on 4/14/25 for orthopedic (musculoskeletal) aftercare for a fracture of the right femur and a fracture around an internal prosthetic (artificial) knee joint. A review of Resident 1's Fall Risk Evaluation dated 4/14/25 at 6:06 p.m., indicated, Upon admission .observe the resident status in the 11 clinical condition parameters .by assigning the corresponding score which best describes the resident. If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. Resident 1 was assessed as a moderate risk of falls with a score of 6. A review of Resident 1's Care Plan Report dated 4/15/25 indicated Resident 1 had a goal to be free of falls . The interventions to reach her goal included: Anticipate and meet the resident's needs; ensure call light is in reach and encourage resident to use for assistance; use of bedside Commode (BSC) for facility toileting; educate the resident about safety reminders; ensure the resident is wearing appropriate footwear when mobilizing; follow facility fall protocol; and Physical Therapy (PT) and treat as ordered. A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 4/21/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 7 which indicated moderate cognitive (relating to processes of thinking and reasoning) impairment. Page 1 of 2 055003 055003 06/11/2025 Eureka Rehabilitation & Wellness Center, LP 2353 Twenty Third St Eureka, CA 95501

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 1's Care Plan Report dated 4/25/25 indicated Resident 1 had limited physical mobility due to her femur fracture. Resident 1's goal was to, will remain free from complications related to immobility including .fall related injury. Interventions staff were to implement to help Resident 1 reach her goal was to, .provide .assistance with mobility as needed. A review of Resident 1's Physical Therapy Treatment Encounter Report dated 5/21/25 at 6:49 p.m., indicated Resident 1 required a helper to provide partial/moderate assistance (the helper provides less than half of the effort required to help the resident complete the task) while she completed the activity of transferring from a bed to a chair. A review of Nursing Notes dated 5/24/25, at 1:30 a.m., Licensed Nurse 1 (LN 1) indicated Resident 1 had her call light on while her roommates were calling for help. After entering the room, Resident 1 was noted to be lying on her side and stated, I was pulling my pants up and slid down on my butt and landed on my arm .I think I broke my arm. It hurts so bad. A review of a hospital document titled Radiology Results dated 5/24/25, at 3:52 a.m., an X-ray of Resident 1's hand and forearm indicated a nondisplaced distal radial fracture. During a concurrent observation and interview on 6/11/25, at 2:19 p.m., Resident 1 stated she was getting up from the commode, lost her balance and fell. Resident 1 also stated her right leg was still weak and, gives out on her sometimes. During an interview on 6/11/25 at 2:57 p.m., Physical Therapy Assistant (PTA) stated Resident 1 was forgetful and believed she was too confident in her skills to transfer without assistance. The PTA stated Resident 1 needed moderate assistance while transferring from bed to chair. During an interview on 6/11/25 at 3:17 p.m., LN 1 stated Resident 1 was not a fall risk prior to the fall. LN 1 stated fall risk information was reported during shift change and it could be found in the care plan, and the resident's chart. During an interview and concurrent record review on 6/11/25 at 4:02 p.m., the Regional Quality Management Consultant (RQMC) stated care plan interventions were different for a resident that was a low risk for falls than that of a high risk fall resident, and that it was dependent upon the nursing assessment of the resident. The RMQC stated Resident 1's fall risk evaluation dated 4/14/25 was incorrect because it did not include Resident 1's fall at her home which contributed to her stay at the facility. The RQME confirmed Resident 1 should have been assessed as a high risk for falls upon admisison. The RQMC stated the facility's fall prevention protocol was a document titled Fall Prevention and Management which indicated, Assess the fall risk of each resident, implement measures to prevent a fall, and initiate a care plan that is resident specific. The RMQC confirmed this practice was not followed for Resident 1 upon admission. A review of facility policy titled Fall Management Program dated 3/13/21 indicated As part of the admission Assessment, the licensed nurse will complete a fall risk evaluation. If a fall risk factor is identified, document interventions on Resident's care plan. 055003 Page 2 of 2