Health inspection·July 31, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure interventions for fall prevention were implemented for two of seven residents, (Resident 1 and Resident 7).This failure had the potential for Resident 1 and Resident 7 to fall and sustain serious injuries. Findings:On July 30, 2025, at 11:07 a.m., an unannounced visit to the facility on a complaint investigation was initiated.1.A review of Resident 1's medical records indicated that resident was admitted on [DATE], with diagnoses of systemic lupus erythematosus, (SLE - a chronic autoimmune disease where the body's immune system mistakenly attacks its own healthy tissues and organs), chronic obstructive pulmonary disease, (COPD - a chronic inflammatory disease that causes obstructed airflow from the lungs), type 2 diabetes mellitus, (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), dementia, (a chronic or persistent disorder of mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), muscle wasting and atrophy, (the loss of muscle mass and strength), and adult failure to thrive, (AFTT - a syndrome in older adults characterized by weight loss, decreased appetite, poor nutrition, and inactivity indicating a decline in physical and psychological health).A review of Resident 1's History and Physical dated July 17, 2025, indicated resident had intermittent capacity to make decisions.On July 30, 2025, at 12:20 p.m., an interview was conducted with Resident 1. Resident 1 stated she had been at the facility for a month. Resident 1 stated she recalled falling after tripping over her shoes. Resident 1 was unable to account for the date, or time of the incident. Resident 1 stated she did not have any injuries from the fall. Resident 1 stated she gets physical therapy every day and that she had been instructed to use the call light and call for assistance before getting out of bed. On July 30, 2025, at 3:10 p.m., an interview was conducted with Resident 1's Responsible Party, (RP). The RP stated that Resident 1 had been in the facility since March 2025 and had approximately four falls. The RP stated upon admission, he informed them that she was a fall risk. The RP stated in July 2025, Resident 1 slipped out of bed while reaching for her belongings placed on a wheeled table.On July 31, 2025, at 3:31 a.m., an interview was conducted with the Licensed Vocational Nurse, (LVN 1). LVN 1 stated, for all residents who are at high risk for fall, or who have had more than one fall, the interventions should include: bed in low position, call light within reach, all frequently used personal items should be within reach. On July 31, 2025, at 8:20 a.m., an interview was conducted with the Physical Therapist, (PT). The PT stated, on July 24, 2025, Resident 1 slipped out of bed while reaching for the over-bed table. The PT stated, personal items should have been kept within reach to prevent over-reaching and falling out of bed. A review of Resident 1's Care Plan initiated May 7, 2025, indicated Focus. Resident is at risk for falls with or without injury related to altered balance while standing and/or walking, altered mental Page 1 of 2 555297 555297 07/31/2025 Hemet Hills Post Acute 1717 West Stetson Avenue Hemet, CA 92545

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few status, antipsychotic medication, cardiovascular disease, diuretic medication, unsteady gait.Interventions. Keep personal items frequently used within reach.A review of Resident 1's Progress Notes dated July 24, 2025, at 07:25 a.m., indicated Resident was found on the floor on fall mat next to her bed by CNA. Resident was lying on her back on the fall mat. Resident denies hitting her head and denies any pain related to the fall. CNA immediately notified Nurse. RN and Nurse preformed a full body assessment, head-to-toe was completed. No skin tears, bruising or visible injuries were noted. Resident was able to move b/l [bilateral] upper extremities without difficulty. Resident reported that she was reaching for her bedside table when she accidentally slipped out of bed. Resident is A/Ox3 [alert and oriented to person, place, and time] cooperative, and denies any pain at this time.2. A review of Resident 7's medical records indicated Resident 7 was admitted to the facility on [DATE], with diagnoses of encounter for surgical aftercare following surgery on the digestive system, malignant neoplasm of colon, (a cancerous tumor that develops in the colon, which is part of the large intestine), secondary malignant neoplasm of liver and intrahepatic bile duct, (cancer that has spread to the liver and bile ducts from a primary cancer site elsewhere in the body), secondary malignant neoplasm of lung, (a cancerous tumor that has spread to the lung from a primary tumor located elsewhere in the body), metabolic encephalopathy, (a problem in the brain caused by a chemical imbalance in the blood), and muscle wasting and atrophy,A review of Resident 7's History and Physical dated June 17, 2025, indicated Resident 7 had the capacity to make decisions.On July 30, 2025, at 12:42 p.m., the Certified Nursing Assistant, (CNA 1) was interviewed. CNA 1 stated that fall-risk residents should always have the call light within reach. On July 31, 2025, at 3:31 a.m., an interview was conducted with the Licensed Vocational Nurse (LVN 1). LVN 1 stated, for all residents who are at high risk for falls, or who have had more than one fall, the interventions should include: bed in low position, call light within reach and all frequently used personal items should be within reach. On July 31, 2025, at 8:53 a.m., observed Resident 7 lying in bed, on her right side, with eyes closed, respirations even and unlabored. Resident 7's call light was observed on the right side of the bed on the floor. On July 31, 2025, at 8:58 a.m., a concurrent observation of Resident 7's call light on the right side of the bed on the floor and an interview was conducted with LVN 2. LVN 2 stated, Resident 7's call light was not within the residents' reach and it should be within reach at all times. A review of Resident 7's NURSING - FALL RISK OBSERVATION/ASSESSMENT dated June 19, 2025, at 8:30 a.m., indicated .Score of 14.Scoring: B. MODERATE RISK 9-15.A review of Resident 7's Care Plan initiated July 9, 2025, indicated Focus: Resident is at risk for falls with or without injury related to altered balance while standing and/or walking. disease, unsteady gait.Interventions. Keep call light within reach.A review of the facility's policy and procedure titled Falls - Clinical Protocol revised March 2018, indicated .Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.A review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered revised March 2022, indicated .9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 555297 Page 2 of 2