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 Page 1 of 2 555513 555513 05/22/2025 Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few non-skid mat present. LVN 1 stated Resident 1 was to have a non-skid mat located under the seat cushion of her wheelchair, and none was found. During a review of the facility ' s Policy and Procedure (P&P) titled, Fall Precautions Policy, undated, the P&P indicated, It is the policy of this facility to maximize resident safety through the use of fall prevention procedures. Evaluate for possible therapeutic interventions. Ensure assistive devices and/or equipment is used appropriately. 555513 Page 2 of 2