Inspection·August 28, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Fall Screen, dated 7/31/2025 was reviewed. The Therapy Post Fall Screen indicated therapy recommendations to include a tab alarm (bed alarm). The Occupational Therapist stated a tab alarm is a device for Resident 1's bed and/or wheelchair that will alarm if she tries to get up or out. During a review of Resident 1's Change of Condition (COC-a significant alteration in a resident's physical, mental, or emotional status that requires attention and intervention from healthcare professionals) Evaluation, dated 8/12/2025, the COC Evaluation indicated Resident 3 had a fall and was found hanging from the bed from side rails (metal or plastic bars that attach to the sides of a bed to provide support for moving, prevent falls from bed, or prevent residents from getting out of bed and wandering). The COC indicated Resident 1 sustained a left elbow skin tear (traumatic wounds caused by friction when the upper layer of the skin becomes torn from the underlying layers), right lower leg skin tear, and left knee contusion (a bruise). During a review of Resident 1's Resident Had an Actual Unwitnessed Fall on 8/12/2025 care plan, initiated 8/12/2025, the care plan indicated staff interventions included were to educate resident on risk for fall and to offer bed alarm. During a review of Resident 1's IDT Post Event Review, dated 8/14/2025, the IDT Post Event Review indicated under Interventions done/IDT recommendations, was the use of a bed alarm for Resident 1. During a concurrent observation and interview on 8/27/2025 at 11:24 AM with Resident 1, at Resident 1's bedside, Resident 1 was observed lying in bed without a bed alarm. Resident 1 stated the staff did not speak with her regarding the use of a bed alarm and has never had one on her bed. Resident 1 also stated she was not cleared to use a wheelchair for her appointment on 7/16/2025 and was told to go via gurney but wanted a wheelchair because she felt it was safer for her than a gurney. During a concurrent observation and interview on 8/27/2025 at 11:36 AM with Licensed Vocational Nurse 1 (LVN 1), at Resident 1's bedside, Resident 1 was observed lying in bed. LVN 1 stated Resident 1 did not have a bed alarm. LVN 1 stated Resident 1's fall interventions included the use of floor mats (a cushioned floor mat placed beside a bed, chair, or other high-risk area to reduce the impact of a fall and minimize the risk of serious injury), to keep the bed in the lowest position, and hourly staff rounding During an interview on 8/27/2025 at 2:10 PM with the Director of Rehabilitation (rehab-therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being), the DOR stated the IDT recommended the use of bed alarm during Resident 1's post fall IDT meeting on 8/14/2025. The DOR stated the use of bed alarm will alert staff when Resident 1 is getting out of bed, which will allow staff to respond promptly to Resident 1's needs to help prevent falls. During a concurrent interview and record review on 8/27/2025 at 3:12 PM with the ADON, Resident 1's electronic medical chart was reviewed. The ADON stated Resident 1's medical chart did not indicate an order for a bed alarm. The ADON stated Resident 1 should have a bed alarm in place to prevent falls or should have been offered a bed alarm because it was recommended by IDT. The ADON stated Resident 1's progress note did not indicate if a bed alarm was offered to Resident 1 or a care plan indicating bed alarm refusal. During a concurrent interview and record review on 8/27/2025 at 5:00 PM with the Director of Nursing (DON), Resident 1's electronic medical chart was reviewed. The DON stated Resident 1's electronic medical record did not indicate that the resident refused a bed alarm. The DON stated there would be an updated IDT meeting and care plan if Resident 1 refused the use of bed alarm. During a review of the facility's Policy & Procedure titled, Fall Management Program, revised 6/1/2027, the P&P indicated the policy had a purpose to prevent resident falls and minimize complications associated with falls, the Nursing staff and IDT, with input from the Attending Physician will identify and implement interventions to reduce the risk of falls and the IDT will routinely review the plan of care at a minimum of quarterly, with a significant change in condition and post fall and interventions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055293 If continuation sheet Page 2 of 3 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 055293 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780 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 0689 will be implemented based on the resident's condition. The P&P also indicated the IDT Committee will meet within 72 hours of a fall and will review and document the interventions to prevent future falls. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055293 If continuation sheet Page 3 of 3