Desert Canyon Post Acute, Llc

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

on the floor, especially after providing ADL care as Resident 2 was at a high risk for falls. The ADON stated if the call light was not within Resident 2s reach, the resident would not be able to call for assistance when needed and there could be a delay in providing assistance and meeting Resident 2's needs and lead to falls and/or injury.During an interview with the Director of Nursing (DON) on 11/13/2025 at 4:03 p.m., the DON stated all call lights should be within the resident's reach. The DON stated the CNAs are supposed to ensure the call light and frequently used items are within the resident's reach prior to leaving the room after providing care. The DON stated CNA 1 should have ensured that Resident 2's call light was clipped to the fitted sheet and within reach so Resident 2 can call for assistance when needed which could lead to a delay

in the care the resident needs and if the call light was not answered timely, Resident 2 may try to get up unassisted and fall. During a review of the facility's policy and procedure (P&P) titled, Resident Call System, last reviewed on 10/21/2025, the P&P indicated a purpose to provide staff with a method to respond to the resident's requests and needs. The P&P further indicated that the resident call system shall be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Desert Canyon Post Acute, LLC

1642 West Avenue J Lancaster, CA 93534

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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

partial/moderate assistance with eating; total assistance from staff with toileting and bathing; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 2's Order Summary Report dated 11/13/2025, the Order Summary Report did not indicate a physician's order for the use of pillows tucked under the fitted sheet. During a review of Resident 2's fall risk assessment dated [DATE REDACTED], the fall risk assessment indicated Resident 2 was a high risk for falls. During a review of Resident 2's care plan (CP) on risk for falls or injury initiated on 11/6/2025, the CP indicated to keep needed items, water in reach, and promote a safe environment as a few of the interventions to minimize the risk of falls.During a concurrent

observation and interview on 11/13/2025 at 9:07 a.m., inside Resident 2's room with CNA 1, observed Resident 2 lying in bed asleep. CNA 1 stated Resident 2 had pillows tucked under the fitted sheet on the right side of the bed with the bed against the wall on the left side. CNA 1 state they usually put the pillows under the fitted sheet to prevent falls or injury when Resident 2 gets out of bed unassisted. CNA 1 stated

the pillows tucked under the fitted sheet is not a restraint as Resident 2 was still able to climb over the pillows. CNA 1 stated they had in-services regarding restraints but does not remember that the pillows under the fitted sheet cannot be used and is considered a restraint.During a concurrent interview and

record review on 11/13/2025 at 12:33 p.m., reviewed Resident 2's Order Summary Report, care plans, and fall risk assessments with the ADON. The ADON stated that Resident 2 was at a high risk for falls due to his cognition and dementia. The ADON stated Resident 2 did not have a physician's order for the use of pillows tucked under the fitted sheet and it was not in the CP as one of the interventions to minimize risk of falls. The ADON stated the facility does not allow the use of pillows tucked under the fitted sheet as it is considered a restraint. The ADON stated application of the pillows tucked under the fitted sheet for Resident 2 is not honoring the resident's right to be restraint-free. During an interview on 11/13/2025 at 4:15 p.m. with the DON, the DON stated the use pillows tucked under the fitted sheet is not a practice in the facility and should not be used at any time as it is considered a restraint and restricting the resident's freedom of movement. The DON stated CNA 1 should have placed the pillows on top of the fitted sheet but not tucked as it restricts Resident 2's freedom of movement which can lead to a decline in physical functioning and increased dependence to staff. During a review of the facility's policy and procedure (P&P) titled, Respect and Dignity - Physical Restraints, last reviewed on 10/21/2025, the P&P indicated:- Physical restraints: any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.- Removes easily: the manual method, device, material, or equipment can be removed intentionally by the resident in the same manner as it was applied by staff considering the resident's physical condition and ability to accomplish objective.- The following practices shall be considered a physical restraint including but not limited to tucking in a sheet tightly so that the resident cannot get out of bed restricting resident's freedom of movement.- Physical restraint may increase

the risk for a decline in physical functioning including an increased dependence in ADLs, impaired muscle strength and balance, decline in range of motion, and risk for development of contractures; accidents such as falls, strangulation, or entrapment.- Psychosocial impact related to the use of any physical restraint may include feelings of imprisonment or restriction of freedom of movement.

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