Health inspection·August 13, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement its policy and procedure to conduct a post-fall evaluation and prevention meeting within 72 hours of two unwitnessed falls for a resident who was rated at moderate risk for falls for one of four sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for future additional falls and injury. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included polyneuropathy (multiple peripheral nerves become damaged and include problems with sensation, coordination, or other body functions), paraplegia (loss of movement and/or sensation, to some degree, of the legs), muscle weakness (loss of muscle strength), schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety disorder (excessive, persistent worry or fear), bipolar disorder, (mood swings that range from the lows of depression to elevated periods of emotional highs), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 2's History and Physical (H&P), dated 3/27/25, the H&P indicated, Resident 2 had the capacity to understand and make medical decisions. The H&P also indicated, Based on the clinical picture, diagnoses, and comorbidities Resident 2 is at risk for malnutrition, weight loss, pressure ulcers, dehydration, falls.During a review of Resident 2's Nursing admission Assessment (NAA), dated 3/27/25, the NAA indicated Resident 2's Morse Fall Risk Score was 40 - Moderate Risk (Scoring: High Risk: 45 and higher; Moderate Risk: 25-44; and Low Risk: 0-24).During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 3/31/25, the MDS indicated Resident 2 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 2 required substantial/maximal assistance with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear.During a review of Resident 2's Care Plan, At Risk for Fall related to Diagnosis and History: Paraplegia and Multiple Medical Comorbidities, the care plan indicated the date initiated was 3/31/25 with a goal target date of 9/29/25. The care plan further indicated it was revised on 7/30/25. Resident 2 was discharged home from the facility on 7/5/25.During a review of Resident 2's Physician Orders (POs) active as of 4/1/25, the POs indicated the following orders:1. Anti-anxiety: Monitor side effects such as sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, skin rash for the use of Alprazolam.2. Anti-coagulant: Monitor for signs and symptoms of bleeding such as but not limited to discolored urine, black tarry stool, sudden severe headache, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status, confusion, shortness of breath, nose bleeding, dizziness, ecchymoses, and bleeding gums every shift for use of Eliquis.3. Anti-depressant: Monitor side effects such as sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055202 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 055202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosemead Healthcare Center 4096 Easy Street El Monte, CA 91731 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)