Health inspection·May 22, 2025

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 ensure one of three residents (Resident 1) had a non-slip mat on her wheelchair as a care plan intervention to reduce the risk of a fall. This failure had the potential for Resident 1 to have an increased risk of falls, potentially leading to injury including bone fracture, pain, and loss of function. Findings: During a review of Resident 1 ' s admission Record (AR), dated 5/23/25, the AR indicated she was a [AGE] year-old female with diagnoses that included dementia (a progressive disease of the brain that affects memory, judgment, and mood), psychosis (a person ' s thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not), and osteoporosis (a condition where the bones become thin and weak, and more likely to break). During a review of Resident 1 ' s Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool), dated 3/14/25, the MDS indicated at Question GG0170, E, a score of 2, which indicated Resident 1 required substantial/maximal assistance – Helper does MORE THAN HALF the effort for The ability to transfer to and from a bed to a chair (or wheelchair). During a review of Resident 1 ' s Fall Risk Evaluation (FRE), dated 3/14/25, the FRE indicated Resident 1 was a Risk for Falls. During a review of Resident 1 ' s Care Plan (CP) dated 4/5/23, the CP indicated Resident 1 was at risk for injuries related to falls secondary to impaired mobility requiring assistance with ADLs [Activities of Daily Living, such as transfers from bed to chair or wheelchair and/or back again]. One of the Interventions/Tasks listed on the CP was to provide Resident 1 with a Non skid mat provided for w/c [wheelchair] seat. This intervention was dated 4/3/25. During a concurrent record review and interview on 5/22/25, at 1:05 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s CP was reviewed. LVN 1 stated Resident 1 ' s CP indicated she was to have a non-skid mat placed on her wheelchair. During a concurrent observation and interview on 5/22/25, at 1:09 p.m., with LVN 1, LVN 1 produced an example of a non-skid mat from near the nursing station. The non-skid mat was a thin, green, textured mat. LVN 1 stated a mat such as this was to be placed under Resident 1 ' s wheelchair seat cushion to prevent slipping. An observation of Resident 1 ' s wheelchair, with LVN 1, indicated no (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555513 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)