Health inspection·March 25, 2024

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 implement a care plan (a document outlining how to best care for a resident and meet their needs) for one of three sampled residents (Resident 3) after Resident 3 suffered a fall with injury. This failure had the potential for Resident 3 to suffer a subsequent fall that could result in another injury or worsening of Resident 3's current injury to his left ribs. Findings: During a review of Resident 3's admission Record (a document with basic client information), the admission Record indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD - a disease of the lungs that causes air-flow blockage and breathing-related problems), Epilepsy (abnormal electrical brain activity, also known as a seizure) and History of Falling (resident has fallen in the past). During an observation on February 8, 2024 at 9:48 AM, in the facilities 400 hallway, Resident's 3 room was located at the end of the 400 hallway and not close to the nurses station. During a concurrent observation and interview on February 8, 2024, at 9:52 AM Resident 3's room with Certified Nursing Assistant (CNA 1) Resident 3's call light (device used to call for help and assistance) was tied to the bed rail and hanging near the floor behind his head and not accessible to Resident 3. CNA 1 stated Resident 3 could not reach the call light and Resident 3 could decide to get up to call for help and fall again. During a concurrent interview and record review on February 8, 2024, at 11:00 AM with Licensed Vocational Nurse (LVN 1), Resident 3's Care Plan dated January 31, 2024 was reviewed. The Care Plan indicated, .Interventions Attach call light to bed within access of resident .Place resident close to nursing station for close observation . LVN 1 stated Resident 3's care plan was not fully implemented . She stated Resident 3's room is not close to the nurse's station and the resident should be able to access his call light from his bed. The LVN 1 further stated, Resident 3 would have difficulty requesting help if he needed it and could try to get up and fall again. During a concurrent interview and record review, on February 8, 2024, at 11:30 AM, with Registered Nurse (RN), the facility policy and procedure (P&P) titled, Care Planning, undated, was reviewed. The P&P indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives to meet the resident's physical, psychosocial and functional needs is developed and Page 1 of 2 555773 555773 03/25/2024 Indian Canyon Post Acute 57333 Joshua LN Yucca Valley, CA 92284

F 0656 Level of Harm - Minimal harm or potential for actual harm implemented for each resident .1. The interdisciplinary Team (IDT) .develops and implements a comprehensive, person center care plan for each resident . RN stated, the purpose of a care plan is to implement interventions to prevent another fall. RN further stated Resident 3 could have fallen again if he was not able to reach the call light and him being far away from the nurses station makes it hard for staff to observe Resident 3 and monitor him for falls. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Falls-Clinical Policy, undated, the P&P indicated, .Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls . 555773 Page 2 of 2