Health inspection·March 24, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to accurately document a Fall Risk Assessment for one of three sampled residents (Resident 1) after Resident 1 had a fall. Residents Affected - Few This deficient practice had the potential for Resident 1 to have inaccurate assessment of the fall that can affect provision of nursing care. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/15/2024 with diagnoses that included muscle weakness (generalized), difficulty in walking, and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/23/2024 indicated Resident 1 had the ability to understand and be understood. The MDS indicated Resident 1 required supervision (helper provides verbal cues and touching) with showering and set up (helper set ups or cleans up) with toileting and was independent (Resident completes the activity by themselves with no assistance from a helper) with eating, oral hygiene, upper body and lower body dressing, putting on and taking off footwear and personal hygiene. During a review of Resident 1's Care Plan, created on7/16/2024, the Care Plan indicated the resident was at risk for falls related to gait and balance problems, muscle weakness, paraplegia, left knee joint disorders. The Care Plan indicated interventions that included meeting resident's needs, call light within reach, and encourage the resident to use it (call light) for assistance as needed. During a review of Resident 1's Fall Risk Evaluation, dated 1/13/2025, the Fall Risk Evaluation indicated a fall risk score of 10 (a total score of 10 or greater is considered as high risk for potential falls). During a review of Resident 1's Situational Background Assessment and Request (SBAR- a structured way to share information between people, especially in healthcare setting) Change of Condition (COC), dated 3/13/2025 at 12:55 p.m., the SBAR indicated Resident 1 had an unwitnessed fall. The SBAR indicated Resident 1 was found lying on the floor in his right side. The SBAR indicated Resident 1 stated he was trying to reach out for his cord charger that was under his bed, and as he reached for the cord he fell off his bed landing on the floor on his left hip. The SBAR indicated Resident 1 was unable to move or turn to left side due to pain. The SBAR indicated the facility called immediately called 911 (the number to call for emergency services) at 1 p.m. and at 1:07 p.m. the paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting Page 1 of 2 055307 055307 03/24/2025 Desert Canyon Post Acute, LLC 1642 West Avenue J Lancaster, CA 93534

F 0689 outside of a hospital) arrived. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1's Fall Risk Evaluation, dated 3/13/2025, the Fall Risk Evaluation indicated a fall risk score of 6. Residents Affected - Few During a concurrent interview and record review on 3/24/2025 at 3 p.m., Resident 1's Fall Risk Evaluation was reviewed with the Director of Nursing (DON). The DON stated Resident 1 had previous falls. The DON stated Resident 1's Fall Risk Evaluation, dated 1/13/2025, indicated Resident 1's fall risk score was 10, a high risk for a fall, then on 3/13/2025 after Resident 1's fall we would expect Resident 1's score to have gone up. The DON stated the Fall Risk Evaluation, dated 3/13/2025, indicated the score was marked lower because the nurse did not mark that Resident 1 had the fall, did not add that Resident 1 required assistive devices, and indicated that Resident 1 had not had a fall in the last three months, but the fall on 3/13/2025 counts as a fall. The DON stated the Fall Risk Evaluation dated 3/13/2025 was inaccurately documented. The DON stated the potential for inaccurate assessment for a fall is that it will affect the nursing interventions. During a review of the facility's policy and procedures (P&P) titled, Documentation policy, last reviewed procedure for Resident Assessment Instrument (RAI), assessment for bowel and bladder, falls, chemical restraints, pressure sore risks and fall risk shall be completed using Care Area Assessments (CAAs). These assessments are validated and reliable in accordance with RAI standards as set forth by CMS. 1. Fall risk assessment is determined by incorporating information from the MDS and/or CAAs and information provided in weekly summaries and or Medicare charting and/or CBE Variance Charting, physician progress notes, history and physical, discharge notes, and or physical orders. During a review of the facility's P&P titled, Fall Management Program, last reviewed 10/30/202, the P&P indicated, the facility strives to provide each resident with adequate supervision and assistance devices to minimize the risk associated with falls. 055307 Page 2 of 2