Health inspection·November 13, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for one of three sampled residents (Resident 1). This deficient practice had the potential to result in a delay of care and services and possible injury to Resident 1 when unable to call for assistance.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 10/30/2025, with diagnoses including sepsis (a life-threatening blood infection), schizoaffective disorder bipolar type (a mental illness that can affect thoughts, mood, and behavior characterized by mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (a progressive state of decline in mental abilities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 2's History and Physical (H&P) dated 11/2/2025, the H&P indicated Resident 2 was represented and unable to make decision. During a review of Resident 2's Minimum Data Set, dated [DATE], the MDS indicated Resident 2 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was unable to understand others and make his needs known. The MDS further indicated Resident 2 required partial/moderate assistance with eating; total assistance from staff with toileting and bathing; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 2's fall risk assessment dated [DATE], the fall risk assessment indicated Resident 2 was at a high risk for falls. During a review of Resident 2's care plan (CP) on risk for falls or injury initiated on 11/6/2025, the CP indicated to keep call light within easy reach and encourage resident to use it for assistance as one of the interventions to minimize the risk from falls.During a concurrent observation and interview on 11/13/2025 at 9:07 a.m., inside Resident 2's room with Certified Nursing Assistant (CNA) 1, observed Resident 2 lying in bed asleep. CNA 1 stated Resident 2's call light was on the floor at the foot part of the bed and not within the resident's reach as Resident 2's head of bed was positioned by the window. CNA 1 stated she just finished providing ADL care to Resident 2. CNA 1 stated after providing care to the residents, the staff have to ensure the residents' call light, and all frequently used items are within the residents' reach at all times prior to leaving the room regardless of their cognitive status. CNA 1 stated she should have placed Resident 2's call light within reach so Resident 2 can call for assistance when needed as it placed Resident 2 at risk for his needs not being attended to and met timely and the resident can fall and get injured. During an interview on 11/13/2025 at 12:30 p.m. with the Assistant Director of Nursing (ADON), the ADON stated staff are supposed to ensure that the call lights are placed within the residents' reach after providing care and prior to leaving the room. The ADON stated Resident 2's call light should have been placed within reach and not left Residents Affected - Few Page 1 of 5 055307 055307 11/13/2025 Desert Canyon Post Acute, LLC 1642 West Avenue J Lancaster, CA 93534

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on the floor, especially after providing ADL care as Resident 2 was at a high risk for falls. The ADON stated if the call light was not within Resident 2s reach, the resident would not be able to call for assistance when needed and there could be a delay in providing assistance and meeting Resident 2's needs and lead to falls and/or injury.During an interview with the Director of Nursing (DON) on 11/13/2025 at 4:03 p.m., the DON stated all call lights should be within the resident's reach. The DON stated the CNAs are supposed to ensure the call light and frequently used items are within the resident's reach prior to leaving the room after providing care. The DON stated CNA 1 should have ensured that Resident 2's call light was clipped to the fitted sheet and within reach so Resident 2 can call for assistance when needed which could lead to a delay in the care the resident needs and if the call light was not answered timely, Resident 2 may try to get up unassisted and fall. During a review of the facility's policy and procedure (P&P) titled, Resident Call System, last reviewed on 10/21/2025, the P&P indicated a purpose to provide staff with a method to respond to the resident's requests and needs. The P&P further indicated that the resident call system shall be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 055307 Page 2 of 5 055307 11/13/2025 Desert Canyon Post Acute, LLC 1642 West Avenue J Lancaster, CA 93534

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for two (2) of three (3) sampled residents (Residents 1 and 2) reviewed for physical restraints during a random observation by:1. Failing to complete a restraint assessment quarterly for the continued use of the restraint bed against the wall according to the facility policy and procedure for Resident 1.2. Failing to ensure Resident 2 did not have pillows tucked under the fitted sheet on the right side of the bed.These deficient practices had the potential to result in the restriction of Resident 1 and Resident 2's freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment, and death of residents.Findings:a. During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 12/7/2020 and readmitted in the facility on 5/18/2020, with diagnoses including schizoaffective disorder bipolar type (a mental illness that can affect thoughts, mood, and behavior characterized by mood swings that range from the lows of depression to elevated periods of emotional highs), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 1's History and Physical (H&P) dated 6/24/2025, the H&P indicated Resident 1 was alert and verbally responsive and did not indicate the resident's capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 9/12/2025, the MDS indicated Resident 1 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and was able to understand others and make her needs known and Resident 1 required set up or clean up assistance with eating and substantial or maximal to total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated that Resident 1 had impairment on the upper extremity.During a review of Resident 1's Order Summary Report dated 11/13/2025, the Order Summary Report indicated a physician's order dated 7/18/2025 for a high/low bed against the wall to prevent potential injury when Resident 1 rolls out of bed.During a review of Resident 1's fall risk assessments dated 3/26/2025, 5/19/2025, 6/23/2025, and 9/12/2025, the fall risk assessments indicated Resident 2 was at a high risk for falls. During a review of Resident 2's care plan (CP) titled, Use of device/s: Bed against the wall for safety., initiated on 6/14/2024 and last revised on 11/4/2025, the CP indicated interventions that included the following:- Discuss and record with the resident/family/caregivers the risks and benefits of the device.- Evaluate and record continuing risks and benefits of device, alternatives to device, need for ongoing use, and reason for device use.- Discussion by the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients) on the risks, benefits, and effect of device with resident or resident representative at a minimum if quarterly or as resident's condition necessitates and IDT review of possible device discontinuation of use as appropriate.During a concurrent observation and interview on 11/13/2025 at 8:39 a.m., inside Resident 1's room with Certified Nursing Assistant (CNA) 2, observed Resident 1 lying in bed with the head of bed in upright position and the bed placed against the wall on the left side. CNA 2 stated Resident 1's bed was placed against the wall to prevent Residents Affected - Few 055307 Page 3 of 5 055307 11/13/2025 Desert Canyon Post Acute, LLC 1642 West Avenue J Lancaster, CA 93534

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident falls.During a concurrent observation and interview on 11/13/2025 at 8:42 a.m. inside Resident 1's room with Registered Nurse (RN) 1, RN 1 stated that Resident 1's bed was placed against the wall on the left side to prevent falls as the resident was at a high risk for falls and had the tendency to roll out of bed.During a concurrent interview and record review on 11/13/2025 at 12:33 p.m., reviewed Resident 1's Order Summary Report, CP on use of bed against the wall, fall risk assessments, and Device/Physical Restraint Reassessment/Reevaluation dated 3/10/2024, 4/24/2024, 7/24/2025, 10/20/2024, 11/25/2025, 5/19/2025, 6/23/2025, and 9/12/2025 with the Assistant Director of Nursing (ADON). The Device/Physical Restraint Reassessment/Reevaluation form did not indicate the use of bed against the wall. The ADON stated the audit trail for the physician's order for bed against the wall did not indicate the original order date. The ADON stated the only restraint assessment for the use of bed against the wall was on 2/22/2024. The ADON stated restraint assessments are supposed to be done quarterly and as needed whenever there is a change in the resident's condition. The ADON stated Resident 1's restraint assessment should have been completed at least quarterly per facility policy and according to the CP to ensure that the use of bed against the wall for Resident 1 remained appropriate as it placed Resident 1 at risk for being restrained inappropriately and not honoring Resident 1's right to be restraint-free.During an interview on 11/13/2025 at 4:03 p.m. with the Director of Nursing (DON), the DON stated she was made aware that Resident 1 did not have a quarterly assessment for the continued use of bed against the wall. The DON stated quarterly assessments are completed together with the MDS assessment and discussed in the IDT meeting. The DON stated Resident 1's restraint assessment for the continued use of bed against the wall should have been completed quarterly per facility policy and as indicated in the CP to ensure appropriateness on the use of restraint bed against the wall for Resident 1 and honoring her right to be free from restraints and move freely which can lead to a decline in physical functioning.During a review of the facility's policy and procedure (P&P) titled, Respect and Dignity - Physical Restraints, last reviewed on 10//21/2025, the P&P indicated:- Physical restraints: any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.- Removes easily: the manual method, device, material, or equipment can be removed intentionally by the resident in the same manner as it was applied by staff considering the resident's physical condition and ability to accomplish objective.- Physical restraint may increase the risk for a decline in physical functioning including an increased dependence in ADLs, impaired muscle strength and balance, decline in range of motion, and risk for development of contractures; accidents such as falls, strangulation, or entrapment.- The IDT will provide an on-going documentation for the use of physical restraint; and use the restraint for the least amount of time possible, with ongoing re-evaluation.b. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 10/30/2025, with diagnoses including sepsis (a life-threatening blood infection), schizoaffective disorder bipolar type (a mental illness that can affect thoughts, mood, and behavior characterized by mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (a progressive state of decline in mental abilities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 2's History and Physical (H&P) dated 11/2/2025, the H&P indicated Resident 2 was represented and unable to make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was unable to understand others and make his needs known. The MDS further indicated Resident 2 required 055307 Page 4 of 5 055307 11/13/2025 Desert Canyon Post Acute, LLC 1642 West Avenue J Lancaster, CA 93534

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few partial/moderate assistance with eating; total assistance from staff with toileting and bathing; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 2's Order Summary Report dated 11/13/2025, the Order Summary Report did not indicate a physician's order for the use of pillows tucked under the fitted sheet. During a review of Resident 2's fall risk assessment dated [DATE], the fall risk assessment indicated Resident 2 was a high risk for falls. During a review of Resident 2's care plan (CP) on risk for falls or injury initiated on 11/6/2025, the CP indicated to keep needed items, water in reach, and promote a safe environment as a few of the interventions to minimize the risk of falls.During a concurrent observation and interview on 11/13/2025 at 9:07 a.m., inside Resident 2's room with CNA 1, observed Resident 2 lying in bed asleep. CNA 1 stated Resident 2 had pillows tucked under the fitted sheet on the right side of the bed with the bed against the wall on the left side. CNA 1 state they usually put the pillows under the fitted sheet to prevent falls or injury when Resident 2 gets out of bed unassisted. CNA 1 stated the pillows tucked under the fitted sheet is not a restraint as Resident 2 was still able to climb over the pillows. CNA 1 stated they had in-services regarding restraints but does not remember that the pillows under the fitted sheet cannot be used and is considered a restraint.During a concurrent interview and record review on 11/13/2025 at 12:33 p.m., reviewed Resident 2's Order Summary Report, care plans, and fall risk assessments with the ADON. The ADON stated that Resident 2 was at a high risk for falls due to his cognition and dementia. The ADON stated Resident 2 did not have a physician's order for the use of pillows tucked under the fitted sheet and it was not in the CP as one of the interventions to minimize risk of falls. The ADON stated the facility does not allow the use of pillows tucked under the fitted sheet as it is considered a restraint. The ADON stated application of the pillows tucked under the fitted sheet for Resident 2 is not honoring the resident's right to be restraint-free. During an interview on 11/13/2025 at 4:15 p.m. with the DON, the DON stated the use pillows tucked under the fitted sheet is not a practice in the facility and should not be used at any time as it is considered a restraint and restricting the resident's freedom of movement. The DON stated CNA 1 should have placed the pillows on top of the fitted sheet but not tucked as it restricts Resident 2's freedom of movement which can lead to a decline in physical functioning and increased dependence to staff. During a review of the facility's policy and procedure (P&P) titled, Respect and Dignity - Physical Restraints, last reviewed on 10/21/2025, the P&P indicated:- Physical restraints: any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.- Removes easily: the manual method, device, material, or equipment can be removed intentionally by the resident in the same manner as it was applied by staff considering the resident's physical condition and ability to accomplish objective.- The following practices shall be considered a physical restraint including but not limited to tucking in a sheet tightly so that the resident cannot get out of bed restricting resident's freedom of movement.- Physical restraint may increase the risk for a decline in physical functioning including an increased dependence in ADLs, impaired muscle strength and balance, decline in range of motion, and risk for development of contractures; accidents such as falls, strangulation, or entrapment.- Psychosocial impact related to the use of any physical restraint may include feelings of imprisonment or restriction of freedom of movement. 055307 Page 5 of 5