Health inspection·February 5, 2026

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 observations, interviews and reviews, the facility failed to ensure monitoring and supervision was provided to one of three sampled residents (Resident 1), who was assessed as a high-fall-risk resident, by failing to: Develop and implement individualized care plan interventions to minimize the occurrence of falls in accordance with the Policy and Procedure (P&P) titled Falling Star Program. Identify specific monitoring required while Resident 1 was on the Falling Star Program. Conduct resident observations in accordance with the P&P for the Falling Star Program.Perform and document scheduled safety round as indicated by the P&P for the Falling Star Program. Determine and identify the type and frequency of supervision required in accordance with the facility's P&P for Safety and Supervision. Ensure interventions were implemented and documented in accordance with the facility's P&P for Safety and Supervision. These deficient practices resulted in Resident 1 sustaining two unwitnessed falls at the facility on 12/15/2025 and 1/25/2026, with the second fall requiring transfer to the General Acute Care Hospital (GACH) on 1/25/2026 where Resident 1 was diagnosed with a left femur fracture and had to undergo open reduction internal fixation (ORIF - surgery to repair a severely broken bone) surgery on 1/26/2026. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident on 1/27/2025, with diagnoses of unsteadiness on feet (poor balance), a history of falling and osteoarthritis (bones breaks over time from lack of cushion). During a review of Resident 1's History and Physical (H&P) dated 8/28/2025, the H&P indicated Resident 1 had a fluctuating capacity to understand and make decisions but was in cognitive decline (problems with a person's ability to think, learn, remember, use judgement, and make decisions). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 10/31/2025, the MDS indicated the resident had moderately impaired cognition. MDS indicated that Resident 1 was partial/moderate assistance for activities of daily living (basic self-care tasks). During a review of Resident 1's Fall Risk Collection record dated 12/15/2025, the Record indicated that Resident 1 was at a high risk for falls with a score of 14 (Score of 14 or above represents a higher risk of falling exist and resident requires increased supervision. During a review of Resident 1's Care Plan for Self transfer without using call light, dated 6/30/2025, the Care Plan indicated to continue use of pad alarm (a pressure-sensitive, wearable, or moisture-detecting device used to alert caregivers when a person leaves a bed/chair) while in the wheelchair and bed. During a review of Resident 1's Care Plan for non -compliant, Resident turns off pad alarm, dated 7/8/2025, the Care Plan indicated to educate resident not to turn off pad alarm. There were no newly updated interventions on the care plan. During a review of Resident 1's Care Plan for Actual Fall, dated 8/23/2025, the Care Plan indicated interventions that Resident 1 would continue the use of pad alarm in bed. During a review of Resident 1's Care Plan titled Falls, dated 8/27/2025, and revied 1/27/2025, the Care Plan interventions indicated that Resident 1 was on the falling star program, had a self release soft belt (a patient safety device designed to prevent falls and unassisted exits from beds or Page 1 of 4 055288 055288 02/05/2026 Autumn Hills Health Care Center 430 N.Glendale Ave Glendale, CA 91206

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wheelchairs while allowing for limited, independent movement), and a pad alarm. During a review of Resident 1's Care Plan titled Falls dated 12/15/2025, the Care Plan interventions indicated that Resident 1 had an actual fall in her room on 12/15/25. The care plan indicated that Resident 1's goal was to minimize repeat fall as much as possible. The care plan indicated interventions to continue use of pad alarm. There was not indication of any additional monitoring on the care plan. During a review of Resident 1's Situation Background Assessment Recommendations (SBAR - a tool used to relay critical healthcare information) dated 12/15/2025 at 1 PM, the SBAR indicated that Resident 1's bed pad alarm was sounding and Registered Nurse (RN 1) found Resident 1 on the floor lying on her left side next to her bed with no apparent injury. During a review of Resident 1's Risk Meeting Notes Weekly dated 12/20/2025, the Notes indicated that Resident 1 will have no further falls, will have self-release soft belt to wheelchair to prevent falling, and pad alarm on bed. During a review of Resident 1's SBAR dated 1/25/2026 at 1 PM, the SBAR indicated that Certified Nursing Assistant (CNA) 1 heard Resident 1's bed pad alarm sounding and when CNA 1 entered Resident 1's room, CNA 1 found Resident 1 lying on the floor, flat on her back. CNA 1 reported to Licensed Vocation Nurse (LVN) 1. The SBAR indicated that Resident 1 was assessed, and no injuries were observed. The SBAR indicated that Resident 1 was assessed for pain and reported a level 3 out of 10 pain on a pain scale (a subjective tool, most commonly a 0-10 numeric rating system, used by clinicians to measure pain intensity and guide treatment). Resident 1 was administered pain medication. During a review of Residents 1's Care Plan titled Falls dated 1/25/2026, the Care Plan indicated that Resident 1 had an actual fall and was found on the floor lying on her back. The care plan indicated interventions to continue pad alarm in bed and soft belt in the wheelchair. There was not additional interventions to indicate monitoring. During a review of Resident 1's Nursing Progress Notes dated 1/25/2026 at 5 AM, the Note indicated that Resident 1 bed pad alarm sounded, and when CNA 1 entered Resident 1's room, Resident 1 was on the floor lying on her back. The Note indicated that LVN 1 had assessed Resident 1 and no bodily injuries were observed, however Resident 1 complained of left leg pain and was medicated for pain. During a review of Resident 1's Medication Administration Record for 1/1/26 to 1/31/26, the Record indicated that Resident 1 was medicated with Tylenol (pain medication) 500 milligrams (mg - unit of measurement) for pain on 1/25/2026 at 4:54 AM. During a review of Resident 1's Medication Administration Records for 1/1/26 to 1/31/26, the record indicated that Resident 1 was medicated with Tylenol (pain medication) 500 milligrams (mg - unit of measurement) for pain on 1/25/2026 at 12:03 PM for complaints of left leg pain 8/10. During a review of Resident 1's Nursing Progress Notes dated 1/25/2026 at 12:10 PM, the Notes indicated that Resident 1's left leg was observed slightly externally rotated and RN supervisor was notified. The Note indicated at 12:20 PM the Nurse Practitioner (NP) was notified with orders to transfer Resident 1 to the General Acute Care Hospital (GACH) 1 for further evaluation. The Note indicated at 1:05 PM Emergency Medical Technician (EMT) arrived and transported Resident 1 to GACH 1. During a review of Resident 1's General Acute Care Hospital (GACH 1) records dated 1/25/2026, the records indicated that Resident 1 was brought to the emergency room because Resident 1 had a fall with leg pain. The GACH indicated that an x-ray of Resident 1's left hip with 2 to 3 views resulted in left femur (largest bone in the body) fracture and Resident 1 had to undergo ORIF surgery on 1/26/2026. During a review of Resident 1's Risk Meeting Notes Weekly dated 1/25/2026, the Notes indicated that Resident 1's fall incident was an isolated incident, unavoidable and Resident 1's plan of care included the bed pad alarm, bed in low position and falling star program for closer monitoring. During a review of Resident 1's Observation Detail List Report for Interdisciplinary Team (IDT) risk meeting notes initial week one status post fall, dated 1/26/26 at 10 AM, the report 055288 Page 2 of 4 055288 02/05/2026 Autumn Hills Health Care Center 430 N.Glendale Ave Glendale, CA 91206

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated the plan of care included bed alarm, and falling star program for closer monitoring. The Report indicated IDT would recommend impact pad when Resident [1] is in bed to reduce risk of injury from fall, upon return from the hospital. During a review of Resident 1's Nursing Progress Notes dated 2/3/2026 at 2 PM, the Note indicated Resident 1 was readmitted back to the facility with a diagnosis of left femur fracture and ORIF of the left femur. During an observation of Resident 1 room on 2/4/2026 at 1:25 PM, Resident 1 room did not have a fall mat at the side of her bed. During an interview on 2/4/2026 at 1:50 PM with CNA 2, CNA 2 stated that Resident 1 was a high fall risk and was on the falling stars program (Identifies residents at high risk for falls/injuries and visually monitors them) because she had more than 1 fall while in the facility. CNA 2 stated that Resident 1 was alert to self and required frequent reminders to use the call light for assistance. CNA 2 stated that Resident 1 did not have a fall mat. During an interview on 2/4/2026 at 2:45 PM with RN 1, RN 1 stated that Resident 1 was assessed as a high risk for falls resident and was on the falling stars program after Resident 1 sustained a second fall on 1/25/2026. RN 1 stated that residents on the falling stars program were all residents who were assessed as a high fall risk, and that a designated staff from the activities department and one CNA monitored these residents in the morning at 8 AM to 4 PM and afternoon starting at 4 PM to 11 PM. There was no monitoring conducted from 11 PM to 7 AM. RN 1 stated that Resident 1 had a fall on 12/15/2025 at around 1 PM without any injuries and a second fall, which was unwitnessed on 1/25/2026 at around 5 AM. RN 1 stated that CNA 1 heard Resident 1's bed pad alarm alerting and found Resident 1 on the floor lying on her back. RN 1 stated that Resident 1 was assessed for any displacement and neuro-checks were done. RN 1 stated that Resident 1 was medicated for pain with Tylenol per physician orders. RN 1 stated that Resident 1 had complained of increased pain of 8/10 to the left leg at 12 PM on 1/25/2026 and the NP was notified. The NP had ordered for Resident 1 to be transferred to GACH 1 for a higher level of care. RN 1 stated that Resident 1 was transferred to the GACH at 1:15 PM During an interview on 2/4/2026 at 3:20 PM with CNA 1, CNA 1 stated that on 1/25/2026 at 5 AM, she had started her rounds since she heard Resident 1 pad alarm alerting. CNA 1 stated when she had entered Resident 1's room she observed Resident 1 lying on her back on the floor. CNA 1 stated that she then called for help and LVN 1 came to help. CNA 1 that LVN 1 had assessed Resident 1 for any injuries, then Resident 1 was assisted back in bed. During an interview on 2/4/2026 at 3:45 PM with the Director of Nursing (DON), DON stated that Resident 1 was identified as a high risk for falls since admission to the facility should have been placed on the falling star program to increase monitoring and supervision of Resident 1. The DON stated that the falling star program may have prevented Resident 1 from sustaining a fall, since staff would provide more observations. DON stated that Resident 1 had her first fall without injury on 12/15/2025 at around 1 PM. DON stated that Resident 1 had a second fall with an injury on 1/25/2026 at 5 AM. DON stated that Resident 1 was transported to GACH 1 on 1/25/2026 at around 1 PM. DON stated that when Resident 1 was first assessed at 5 AM, Resident 1 did not present with any injuries and was medicated for pain with Tylenol. DON stated that around 12 PM Resident 1 had increased pain, Resident 1 left leg was assessed and appeared to be slightly externally rotated. DON stated that the NP was notified and ordered for Resident 1 to be transferred to GACH 1 for further evaluation. DON stated that GACH 1 reported that Resident 1 had sustained a left femur fracture. The DON stated Resident 1's care plans interventions were general and not specific to Resident 1 to address the type and frequency of monitoring required for Resident 1. The DON could not state what type of monitoring should be implemented for Resident 1 and that only visual monitoring was conducted, however the monitoring was not documented. The DON stated that when a resident was on a falling star program, it was because the resident was 055288 Page 3 of 4 055288 02/05/2026 Autumn Hills Health Care Center 430 N.Glendale Ave Glendale, CA 91206

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few at high risk for falls and required more supervision. The DON stated when a resident was provided increased monitoring supervision, it may prevent the occurrence of falls. DON stated that Resident 1 did not have a fall mat because the floor mat presented an environmental hazard. DON stated that Resident 1 had an unsteady balance and the spongy surface of the fall mat would cause Resident 1 to lose her balance and fall, therefore use of a floor mat was never done for Resident 1. During a review of the facility P&P titled Safety Supervision of Residents revised on 9/12/2025, the P&P indicated safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes. The P&P indicated resident supervision is a core component of the systems approach to safety and the type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The P&P indicated the type and frequency of resident supervision may vary among residents and over time for the same resident, for example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition. During a review of the facility P&P titled Fall Management undated, 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 reduce the risk of the resident falling and to try to minimize complications from falling. The P&P indicated if falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. The P&P indicated if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. During a review of the facility P&P titled Falling Star Program undated, indicated that The Falling Star Program identifies residents at highest risk for falls and/or injuries. The P&P indicated that the program is designed to monitor these residents and determine the predisposing factors and underlying reasons for the fall incidents, develop and implement a plan of care to minimize the risk of falls and major injuries. The P&P indicated the Admitting Licensed Nurse/Licensed Nurse Designee will complete the Fall Risk Data Collection upon admission, quarterly, after every fall incident, and whenever there is a significant change in resident's status. The P&P indicated that residents with a total score of 14 and above will be initially placed in the Falling Star Program by the Admitting Licensed Nurse/Licensed Nurse Designee. 055288 Page 4 of 4