Health inspection·May 2, 2024

F 0689 help and tries to get out of bed and wheelchair on his own. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1 ' s IDT Post Fall Review (IDT-team composed of staff from various disciplines) dated March 28, 2024, at 7:19 AM, in indicated . Per LVN (License Vocational Nurse) report, resident was found on the floor by nursing staff in common area (outside of room [ROOM NUMBER]), left side lying in front of wheelchair with both wheelchair locks in the unlocked position. Resident was observed with eyes open and full movement of upper extremities attempting to get themselves up from off the floor .Interventions: resident was sent to ER (emergency room) for further evaluation . Residents Affected - Few During a review of Resident 1 ' s undated care plan for falls (an individualize plan of care) indicated, resident is capable of unlocking w/c (wheelchair) and propels self through hallway. Goal, resident will remain free from falls r/t (related to) independently propelling self through facility, interventions .maintain visual checks for resident safety . During a review of Resident 1 ' s care Plan for falls (an individualize plan of care) undated, indicated Resident 1 is at risk for falls/injury related to: difficulty walking, gen (general) weakness, history of falls, impaired cognition, poor balance, poor safety awareness .interventions visibly observe resident frequently . During a review of Resident 1 ' s care plan for high risk for falls r/t (related to) confusion dated March 12, 2024, indicated Unaware of safety needs .Goal, Resident 1 will be free for falls .Interventions .follow facility fall protocol, [NAME] and [NAME] for Fall Prevention . During a review of Resident 1 ' s admission H & P EMR (admission history and physical of emergency medical record) dated March 27, 2024, at 9:58 PM, it indicated, M (male) BIBA ([NAME] by ambulance) as transfer from (acute hospital name) for ground level fall .Workup at outside of facility subdural hematoma with midline shift (a condition where blood accumulate and put pressure on the brain) . During a review of Resident 1 ' s Nursing Note dated March 30, 2024, at 2:01 PM, it indicated Resident [Resident 1] is admitted to ICU (intensive care unit) trauma. Resident is s/p (status post) neurosurgery / craniotomy (surgery in the skull) for removal of subdural hematoma after recent fall . During a telephone interview on April 3, 2024, at 4:15 PM with the Administrator (Admin), the Admin stated leaving Resident 1, who has cognitive impairment and high risk for falls, without supervision was not a safe practice. During a telephone interview on April 3, 2024, at 6:41 PM with Certified Nurse Assistant, (CNA 1), CNA 1 stated that prior to the start of the shift on the day of Resident 1 ' s fall incident, they did not have a huddle. CNA 1 further stated there was a lack of communication between license nurses and CNA ' s. During an interview on April 8, 2024, at 10:06 AM, with CNA 2, CNA2, indicated that no huddle had occurred on that day or on any other day. CNA 2 expressed concerns regarding lack of communication between licensed nurses and CNAs regarding resident care. During an interview on April 8, 2024, at 11:05 AM with CNA 3, CNA 3, stated on March 27, 2024, they did not have a huddle the day when Resident 1 fell. During a review of the facility ' s policy and procedure titled Jack and [NAME] – Fall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555772 If continuation sheet Page 2 of 3 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 555772 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joshua Tree Post Acute 8515 Cholla Ave Yucca Valley, CA 92284 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevention Program dated 2015, indicated, 2. Any resident who fell withing the 3-month period would be given yellow bands until they graduate off the [NAME] and [NAME] Program. 5. Management will identify a [NAME] and [NAME] Champion per shift for continuous re-education to staff on the floor. High fall risk residents should be mentioned every huddle for reinforcement . During a review of the facility ' s policy and procedure (P&P) titled Safety and Supervision of Residents undated, indicated Facility – Oriented Approach to Safety 1. Our resident-oriented approach to safety address risk identified based on assessments .Individualized, Resident -Centered Approach to Safety .10. Implementing interventions to reduce accidents risk and hazards shall include the following: a. Communication specific interventions to all relevant staff .c. Ensuring that interventions are implemented; and d. Documenting interventions . During a review of the facility ' s policy and procedure (P&P) titled Falls – Clinical Protocol undated 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 risk of clinically significant consequences of falling .2. If the underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessments of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) .Monitor and Follow -Up .2. The staff and physician will monitor and document the individual ' s response to interventions intended to reduce falling or the consequences of falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555772 If continuation sheet Page 3 of 3