Health inspection·May 22, 2025

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. Based on interview and record review, the facility failed to ensure the Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) Falls Committee met to review and document findings and interventions addressing the resident's falls on 4/19 and 4/22/2025 for one of two sampled residents (Resident 2) These failures had the potential to result in Resident 2 sustaining injury and/or harm due to falling while in the care of the facility. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 3/27/2025 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), muscle weakness, and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 3/31/2025, the MDS indicated Resident 1 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) from staff for bathing, lower body dressing, and toileting hygiene. During a review of the facility's (Facility) Falling Star (FL, Falls List), updated 5/16/2025, the FL indicated Resident 2 fell while in the care of the facility on 4/19/2025 and 4/22/2025. During an interview on 5/22/2025 at 10:42 a.m. with Resident 2, Resident 2 stated Resident 2 fell twice while residing at the facility. Resident 2 stated both falls happened when Resident 2 fell asleep in the wheelchair. During a concurrent interview and record review on 5/22/2025 at 2:10 p.m. with the Director of Nursing (DON), Resident 2's Change in Condition Evaluation (COC) dated 4/19 and 4/22/2025 and Resident 2's Progress Notes (PN), dated 5/22/2025 were reviewed. The COCs indicated Resident 2 fell on 4/19/2025 and 4/22/2025. The DON stated whenever a resident (in general) experienced a fall, part of the facility's fall management program included that the IDT meet after the fall to evaluate what interventions needed to be implemented to prevent further falls from occurring. The DON stated the IDT meeting would be documented in the residents (in general) Progress Notes or an IDT Assessment Form. The DON confirmed Resident 2's progress notes (PN) did not indicate the IDT met to address Resident 2's falls on 4/19/2025 and 4/22/2025. The DON stated the IDT did not meet following Resident 2's falls since the IDT meeting was not documented in Resident 2's medical record. Page 1 of 4 055202 055202 05/22/2025 Rosemead Healthcare Center 4096 Easy Street El Monte, CA 91731

F 0689 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Fall Management Program, dated 10/1/2023, the P&P indicated, The IDT-Falls Committee will meet within 72 hours of a fall. The IDT-Falls Committee will review and document: i. Summary of event following a fall. Residents Affected - Few ii. Root cause analysis. iii. Referrals, as necessary. iv. Interventions to prevent future falls. 055202 Page 2 of 4 055202 05/22/2025 Rosemead Healthcare Center 4096 Easy Street El Monte, CA 91731

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to maintain a complete and accurate medical record for one of two sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1 failed to document details of Resident 1's fall at the facility on 5/8/2025. This failure resulted in Resident 1's medical record containing incomplete information. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/14/2021 and readmitted Resident 1 on 2/24/2025 with diagnoses including hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebrovascular disease (a range of conditions that affect the blood vessels and blood flow in the brain), dementia (a group of thinking and social symptoms that interferes with daily functioning), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 3/3/2025, the MDS indicated Resident 1 was severely impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for bathing and toileting hygiene. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) from staff for dressing and oral and personal hygiene. During a review of the facility's (Facility) Falling Star (FL, Falls List), updated 5/16/2025, the FL indicated Resident 1 fell while in the care of the facility on 3/20, 4/9, 5/7, and 5/8/2025. During an interview on 5/22/2025 at 10 a.m. with the Director of Nursing (DON), the DON stated Resident 1 had fallen multiple times while residing at the facility. The DON stated Resident 1's latest falls happened on 5/7/2025 and 5/8/2025. During a concurrent interview and record review on 5/22/2025 at 3:02 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Change in Condition Evaluation (COC), dated 5/8/2025 was reviewed. The COC indicated Resident 1 had a fall on 5/8/2025. The COC failed to describe the events surrounding Resident 1's fall. LVN 1 stated a Certified Nursing Assistant (CNA) informed LVN 1 that Resident 1 had fallen. LVN 1 stated LVN 1 went to Resident 1 and found Resident 1 lying on the floor on the right side of Resident 1's bed. LVN 1 stated LVN 1 was a new staff person and that Registered Nurse (RN) 1 showed LVN how to document Resident 1's fall on 5/8/2025. During an interview on 5/22/2025 at 3:13 p.m. with RN 1, RN 1 stated RN1 was the supervisor on 5/8/2025 when Resident 1 fell. RN 1 stated Resident 1's fall was documented in the facility's risk management but not in Resident 1's medical record. RN 1 stated Resident 1's fall should be documented in Resident 1's progress notes to ensure Resident 1's healthcare team knew the health status of Resident 1. During a review of the facility's Policy and Procedure (P&P) titled, Change of Condition Notification, dated 10/1/2023, the P&P indicated, A Licensed Nurse will document .date, time, and pertinent 055202 Page 3 of 4 055202 05/22/2025 Rosemead Healthcare Center 4096 Easy Street El Monte, CA 91731

F 0842 details of the incident and the subsequent assessment in the Nursing Notes . the incident and brief details . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055202 Page 4 of 4