Health inspection·November 27, 2023

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 interview, observation and record review, the facility failed to remove a building hazard, a threshold (a strip of wood, metal, or stone forming the bottom of a doorway and crossed in entering a house or room) that leads to the patio and is used by residents and families creating a hazard which poses a risk for falls. This failure placed two out of three residents (Resident's 1 and 2) at risk for severe injuries due to falls. Findings: An unannounced visit was made to the facility on November 27, 2023, at 1:19 PM, to investigate a complaint regarding quality of care and Accidents. During review of resident 1's admission Record (general demographics), the document indicated resident 1 was admitted to the facility August 1, 2023, with diagnosis to include Muscle weakness, Hemiplegia(paralysis on one part of the body) and Hemiparesis (weakness or the inability to move on one side of the body) affecting right dominant side following Cerebral Infarction(a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off). During a review of resident 1's progress note, (An ongoing record of a patient's illness and treatment) dated November 19, 2023, at 7:05 AM, the document by Licensed Vocational nurse (LVN 1), it indicated, Another resident was yelling for help. I went to the patio resident was lying on her right side, her right leg was wrapped around the wheelchair that was behind her, she was fully clothed. This happened in the patio entrance into the facility. Resident stated she was trying to get back into the facility and when she reached the doorknob she fell out of her chair, she has a hematoma (a localized swelling that is filled with blood caused by a break in the wall of a blood vessel(a network of tubes through which blood is pumped around the body) on her right forehead with 8/10 pain, res on observation could move all extremities, had PERLA (an acronym for pupils are equal, round and reactive to light and accommodation. Healthcare providers use the PERRLA eye test to check if your pupils look and function as they should), hand grasps bilat weak. She was lifted off floor via 2 persons assist and placed back into her wheelchair. Doctor was notified and res was sent to the ER (emergency room) for further eval. BP (blood pressure, the pressure of blood pushing against the walls of your arteries) 183/78, r (respiratory)85, O2 Sat (measures the percentage of oxyhemoglobin (oxygen-bound hemoglobin) in the blood) 96, temp (temperature) 97.5. Page 1 of 2 555773 555773 11/27/2023 Indian Canyon Post Acute 57333 Joshua LN Yucca Valley, CA 92284

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with resident 1, she stated I fell trying to go to the patio, that thing on the floor to the patio is hard to get over it . She sated she hit her face and her leg has bruises (skin discoloration from damaged, leaking blood vessels underneath your skin). During review of resident 2's admission Record, the document indicated resident 2 was admitted to the facility March 5, 2019, with a diagnosis to include acquired absence of right leg below knee, Hemiplegia and Hemiparesis affecting right dominant side. During a review of resident 2's progress note dated November 26, 2023, at 9:27 PM, the document by LVN 2, it indicated, resident had unwitnessed fall at 2020 hours. It appears that resident was attempting to come back in the facility from smoking and his w/c (wheelchair) tipped backward. Resident hit the back of his head on the concrete. Sent resident to ER. Resident had 2 seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), while awaiting paramedics. First seizure lasted 20 seconds. Second seizure lasted 40 seconds. Paramedics arrived and transported resident to hospital at 2100 . During an interview with resident 2, he stated he is fine and has no issues. States he does not have issues with his wheelchair. States yeah I fell but does not remember when or how. We were by the door, and he wheeled himself through the door without difficulty. During an interview with RN 1 (registered nurse) on November 27, 2023, at 1:40 PM, she stated she is aware of the door threshold by the patio. States she has told maintenance to take care of it but they haven't sates overall everything in the facility is good . During an interview with [NAME] AD (administrator) on November 27, 2023, he stated He stated the threshold was installed a couple of months ago. He stated that they had an IDT (interdisciplinary team) meeting today regarding the threshold on the patio door. It was decided that it will be taken out . On the same day [NAME] notified me at 2:20 PM the threshold to the patio has been taken out . Visually verified. During record review on November 27, 2023, at 2:50, review of Policy and Procedures Titled Falls and Fall Risk, Managing dated March 2018, the document indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . It also indicates , 1. Environmental factors that contribute to the risk of falls includes: d) obstacles in the footpath. 555773 Page 2 of 2