Health inspection·November 6, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that one of three sampled residents, (Resident 1) received treatment and care in accordance with professional standards of practice, when Resident 1 fell off the bed unto the floor during care by a Certified Nursing Assistant (CNA 2). Residents Affected - Few This failure resulted in Resident 1 sustaining a laceration on her right eyebrow. Findings: During a review of Resident 1 ' admission Record (general demographics) the document indicated Resident 1 was originally admitted to the facility on [DATE], with diagnoses that included age-related cataract (a condition of blindness), quadriplegia (a condition of loss of movement and feelings in both arms and legs, cerebral palsy (a condition that affects the movements and coordination) and history of falling (July 9, 2023). During an interview on October 22, 2024, at 12:15 PM, with the Certified Nursing Assistant (CNA 1), the CNA 1 stated, I usually call another CNA to help me change and turn her because she is not able to turn herself. During a concurrent interview and record review on October 22, 2024, at 12:25 PM, Resident 1 ' s clinical report, titled SBAR (Situation Background Assessment Recommendation) a communication tool, dated October 6, 2024, with the Director of Nursing (DON), the document indicated, Fell from bed during patient care. Laceration 3 cm [(Centimeters) units of measurement] noted above right eye. The DON stated, The resident slipped onto the floor when a staff (CNA 2) was providing care to the resident. The DON further stated, The resident requires one to two persons assistance and so the staff (CNA 2) should have called for assistance with providing care to the resident. During an interview on October 22, 2024, at 12:20 PM, with Licensed Vocational Nurse (LVN), the stated, Usually, it requires two persons in turning, changing and transferring her (Resident 1) during care. A review of Resident 1 ' s care plan dated, July 10, 2023, was reviewed. The care plan indicated, Focus: ADL (Activities of daily living) Self Care Performance Deficit r/t(related to) severe cognitive/physical . Goal: ADL needs will be met with total care as required . Interventions: . May provide 1-2 person assist during ADL care . During a review of the facility ' s undated Policy and Procedure (P&P), titled, Quality of Care Falls and Fall Risk, Managing, the P&P indicated, .Based on previous evaluations and current data, the Page 1 of 2 055708 055708 11/06/2024 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

F 0684 staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055708 Page 2 of 2