Health inspection·February 23, 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 observation, interview, and record review, the facility failed to follow their policy and procedures for Fall Risk Assessment for one of three sampled residents (Resident 1) when Resident 1 was not accurately assessed for fall risk. Residents Affected - Few This failure resulted in Resident 1 to experience a fall. Findings: An unannounced visit was made to the facility on November 30, 2023, at 5:30 PM, to investigate a Facility Reported Incident (FRI) regarding quality of care/treatment. During an observation on November 30, 2023, at 5:35 PM, in Resident 1's room, Resident 1 was lying down on her bed on her back, with head of the bed elevated. Resident 1 had a bandage wrapped around her leg and heel protector on feet. During an interview on November 30, 2023, at 5:45 PM, in Resident 1's room, Resident 1 stated she did not remember when she had a fall. During a review of Resident 1's face sheet (a document which contain basic information about the resident) indicated Resident 1 was admitted to the facility on [DATE], with diagnosis which include cerebral infarction (stroke), Glaucoma (a disease of the eyes which causes blindness) and osteoporosis (a bone disease which causes brittle bones). During a review of Resident 1's History and physical (H&P) dated June 16, 2023, indicated Resident 1 has a history of falls, and history of compression fracture vertebra (a broken bone that cause the back to collapse, making them shorter). Further Review of Resident 1's H&P dated June 16, 2023, indictated Resident 1 can make decisions. During a review of Resident 1's Fall Risk Assessment dated October 18, 2023, indicated, Score 9, category: Low Risk . Further review of the Resident 1's Fall Risk Assessment dated October 18, 2023, indicated under section, 4. Vision, Resident 1's vision was adequate. Further review of the Resident 1's Fall Risk Assessment dated October 18, 2023, indicate under section, 7. Medications indicated Resident 1 was taking 1- 2 of these medications currently and /or within last 7 days. Page 1 of 2 056365 056365 02/23/2024 Yucaipa Hills Post Acute 13542 2nd St. Yucaipa, CA 92399

F 0684 Level of Harm - Minimal harm or potential for actual harm Further review of the Resident 1's Fall Risk Assessment dated October 18, 2023, indicated under section 9 predisposing diseases indicated Resident 1 had 1 to 2 present. During a telephone interview with Director of Staff Development 2 (DSD 2) on December 13, 2023, at 2:30 PM, DSD 2 stated, the Fall Risk Assessment dated October 18, 2023, was inaccurate. Residents Affected - Few DSD 2 further stated there was a discrepancy on sections 4. VISION STATUS. DSD 2 stated Resident 1 had a diagnose of Glaucoma and it should have been noted. DSD further stated there was a discrepancy on Section 7 MEDICATIONS. DSD 2 stated Resident 1 was taking two blood pressure medications and one nacrotic and it should have been noted. DSD 2 stated there was a discrepancy on Section 9. PRESDISPOSING DISEASE. DSD 2 stated Resident 1 had diagnosis of CVA, Osteoporosis and History of compression fracture and should have been noted. The DSD 2 stated Resident 1's Fall Risk Assessment the score should had been higher than 9, which would have indicated Resident 1 was a high risk for falls. During an interview with DSD 2 conducted via phone on December 14, 2023, at 2:32, DSD stated, that Resident 1, should had been place on a fall prevention program prior the fall but that Resident 1's was not place in the fall prevention program until after the fall. During a review of the policy and procedure titled, Fall Risk Assessment, undated, indicated, The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Further review of the policy and Procedure indicated, 1.Upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. 2.The nursing staff will ask the resident and/or his/her family about any history of the resident falling. 3.The nursing staff, attending physician, and consultant pharmacist will review for medications or medication combinations that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia, or hypotension. 4.The staff will look for evidence of a possible link between the onset of falling (or an increase in falling episodes) and recent changes in the current medication regimen. 5.The attending physician and nursing staff will evaluate the resident's vital signs, assess the resident for medical conditions (such as those that cause dizziness or vertigo) or sensory impairments (such as de-creased vision and peripheral neuropathy) that may predispose to falls. 6.Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis). 056365 Page 2 of 2