Health inspection·January 8, 2026

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement an appropriate care plan and admission orders to ensure safety interventions were in place, including maintaining non-weightbearing (NWB) status and keeping the immobilizer/splint on at all times, for one of three sampled residents (Resident 1).This deficient practiced placed Resident 1 at risk for worsening of the right lower extremity (RLE) fracture, delayed healing, increased pain, falls and additional injury due to not having proper instructions and interventions in place. Cross Reference F684Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Periprosthetic Fracture around Internal Prosthetic Right Knee Joint (a break in the bone surrounding the replaced joint).A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 12/19/25 indicated, a Brief Interview for Mental Status (BIMSdeveloped by reviewing the resident's status during the prior seven-day period) score of 12 points out of 15 possible points which indicated Resident 1 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. A record review of Resident 1's Discharge Hospital Summary dated 12/10/25 indicated:- .nonweight bearing on the right lower extremity. He will use the immobilization on his knee full-time [on at all times] with a setting locked in extension [leg in a straight position].A record review of Resident 1's Discharge Hospital Summary dated 12/11/25 indicated:- .Once this immobilizer has been applied the patient's transfer to a skilled nursing facility can be pursued. He should remain with his right lower extremity [right leg] in extension [not to be removed]. Physical therapy can work on bed tot chair transfers non-weightbearing on the right lower extremity.On 1/8/26 at 1:55 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she only knew of one resident on the first floor that wore a splint/immobilizer (a medical device that stabilizes a part of your body and holds it in place). CNA 1 stated she was not sure if Resident 1 wore an immobilizer and stated she was unaware of his weight bearing status.On 1/8/26 at 1:57 P.M., an interview was conducted with CNA 2. CNA 2 stated Restorative Nurse Assistants (RNA) or therapy staff were responsible for splint/immobilizer care for residents. CNA 2 stated only one resident wore one that she was aware of and unsure if Resident 1 required a splint/immobilizer and not aware of Resident 1's weight bearing status.On 1/8/26 at 2 P.M., an observation and interview was conducted with Resident 1, in Resident 1's room. Resident 1 had a sign posted on the wall by the head of the bed that indicated Right Knee Immobilizer on at ALL times. Resident 1 had a right knee immobilizer on and stated his immobilizer needed to be on at all times. Resident 1 stated he participated with therapy exercises.On 1/8/26 at 2:10 P.M., an observation and interview was conducted with RNA 1, in Resident 1's room. RNA 1 stated Resident 1 was not on his splint/immobilizer list and was unsure if Resident 1 used a splint/immobilizer. RNA 1 stated she was unaware of Resident 1's weight bearing status.On 1/8/26 at 2:45 P.M., an interview and Page 1 of 4 056388 056388 01/08/2026 Paradise Valley Health Care 2575 E. Eighth St. National City, CA 91950

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few record review was conducted with Licensed Nurse (LN) 1, at the first-floor nursing station. LN 1 stated Resident 1 did not have care plans (a detailed, patient-centered roadmap guiding a nurse's care by outlining a patient's health status, needs, goals and planned interventions, forming the core of the nursing process (Assessment, Diagnosis, Planning/Outcomes, Implementation, Evaluation to ensure consistent, effective and documented care. It's a dynamic tool that improves communication among staff, promotes patient safety, and helps healthcare teams achieve positive health outcomes). The care plan was not initiated or revised for NWB orders. LN 1 stated immobilizer/splint use on admission [DATE]) was also not in place during Resident 1's admission to the facility. LN 1 stated Resident 1's NWB orders and immobilizer/splint was started after admission that indicated:Orders: .Leg brace ON AT ALL TIMES ordered 12/26/25.Orders: .continue with right lower extremity [RLE]at all times. Remain NWB on RLE. PT [Physical Therapy] bed to chair transfer ordered 12/31/25.LN 1 continued to state, NWB and immobilizer use [leg brace] should be carried out on the POS [Physician's Order Sheet] during admission. LN 1 stated it was important that Resident 1's NWB (non-weightbearing) status and immobilizer orders be carried out on admission [DATE]) in order for staff to provide safety and care when providing care for Resident 1 to prevent worsening of Resident 1's fracture and avoid accidents (falls).On 1/12/25 at 10:44 A.M., the Director of Nursing (DON) was interviewed. The DON stated it was important that Resident 1's immobilizer and plan of care should include Resident 1's weight bearing status for the RLE, and immobilizer use should have been communicated to all staff regarding Resident 1's needs to provide safe care. The DON stated it was his expectations for the LN's to follow up and continue weight bearing and immobilizer use for orthopedic (ortho- treatment of bones, joints, and muscles) treatment and for continuity of care to provide safe precautions that are necessary to prevent worsening of fractures and prevent accidents such as fallsThe facility was unable to provide a policy and procedure for comprehensive care plans. 056388 Page 2 of 4 056388 01/08/2026 Paradise Valley Health Care 2575 E. Eighth St. National City, CA 91950

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 physician (MD) orders and failed to put safety measures in place to prevent injury, for one of three sampled residents (Resident 1).This deficient practice placed one resident (Resident 1) at risk for worsening of a fracture, unsafe movement of the injured limb, potential accidents (falls)and additional injury due to failure to carry out non-weight bearing (NWB) and continuous immobilizer orders.Cross Reference F656Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Periprosthetic Fracture around Internal Prosthetic Right Knee Joint (a break in the bone surrounding the replaced joint).A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 12/19/25 indicated, a Brief Interview for Mental Status (BIMSdeveloped by reviewing the resident's status during the prior seven-day period) score of 12 points out of 15 possible points which indicated Resident 1 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. A record review of Resident 1's Discharge Hospital Summary dated 12/10/25 indicated:- .nonweight bearing on the right lower extremity [RLE]. He will use the immobilization on his knee full-time [on at all times] with a setting locked in extension [leg in a straight position].A record review of Resident 1's Discharge Hospital Summary dated 12/11/25 indicated:- .Once this immobilizer has been applied the patient's transfer to a skilled nursing facility can be pursued. He should remain with his right lower extremity [right leg] in extension [not to be removed]. Physical therapy can work on bed tot chair transfers non-weightbearing on the right lower extremity.On 1/8/26 at 1:55 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she only knew of one resident on the first floor that wore a splint/immobilizer (a medical device that stabilizes a part of your body and holds it in place). CNA 1 stated she was not sure if Resident 1 wore an immobilizer and stated she was unaware of his weight bearing status.On 1/8/26 at 1:57 P.M., an interview was conducted with CNA 2. CNA 2 stated Restorative Nurse Assistants (RNA's) or therapy staff were responsible for splint/immobilizer care for residents. CNA 2 stated only one resident wore one (splint/immobilizer) that she was aware of and unsure if Resident 1 required a splint/immobilizer and not aware of Resident 1's weight bearing status.On 1/8/26 at 2 P.M., an observation and interview was conducted with Resident 1, in Resident 1's room. Resident 1 had a sign posted on the wall by the head of the bed that indicated Right Knee Immobilizer on at ALL times. Resident 1 had a right knee immobilizer on and stated his immobilizer needed to be on at all times. Resident 1 stated he participated with therapy exercises.On 1/8/26 at 2:10 P.M., an observation and interview was conducted with RNA 1, in Resident 1's room. RNA 1 stated Resident 1 was not listed on his splint/immobilizer list and was unsure if Resident 1 used a splint/immobilizer. RNA 1 stated he was unaware of Resident 1's weight bearing status.On 1/8/26 at 2:45 P.M., an interview and record review was conducted with Licensed Nurse (LN) 1, at the first-floor nursing station. LN 1 stated Resident 1 did not have care plans that was initiated or revised for NWB (non weight bearing) orders since admission [DATE]). LN 1 stated immobilizer/splint use on admission [DATE]) was also not in place during Resident 1's admission to the facility. LN 1 stated Resident 1's NWB orders and immobilizer/splint was started after admission that indicated:Orders: .Leg brace ON AT ALL TIMES ordered 12/26/25.Orders: .continue with right lower extremity [RLE] at all times. Remain NWB on RLE. PT [Physical Therapy] bed to chair transfer ordered 12/31/25.LN 1 stated NWB and immobilizer use [leg brace] should be carried out in the POS [Physician's Order Sheet] during admission. LN 1 stated it was important that Resident 1's NWB status and immobilizer orders be carried out on admission [DATE]) in Residents Affected - Few 056388 Page 3 of 4 056388 01/08/2026 Paradise Valley Health Care 2575 E. Eighth St. National City, CA 91950

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few order for staff to provide safety and care when providing care for Resident 1 to prevent worsening of Resident 1's fracture and avoid accidents (falls).On 1/12/26 at 10:44 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated it was important that Resident 1's immobilizer and plan of care to include Resident 1's weight bearing status for the RLE and immobilizer use was to communicate to all staff regarding Resident 1's needs to provide safe care. The DON stated it was his expectations for the LNs to follow up and continue weight bearing and immobilizer use for orthopedic (ortho- treatment of bones, joints, and muscles) to provide safe precautions that were necessary to prevent worsening of fractures and prevent accidents such as falls.The facility was unable to provide a policy and procedure for Splint/immobilizer use. 056388 Page 4 of 4