Health inspection·August 28, 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 the use of a bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) for one (1) of four (4) sampled residents (Resident 1) as indicated on the care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) and facility fall policy.This failure had the potential for Resident 1 to have repeated falls which could cause injury and harm to the resident. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness, lack of coordination, and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/8/2025, the MDS indicated Resident 1 with moderately impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues, touching/steadying and/or contact guard assistance during activity) with eating, oral and personal hygiene and substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with toileting, bathing and lower body dressing. The MDS also indicated Resident 1 was dependent (helper does all effort needed to complete activity) with rolling left and right, bed to chair transfers, toilet transfers and the ability to move from lying to sitting on the side of the bed. During a review of Resident 1's Physical Therapy (PT- a therapy that focuses on restoring, maintaining, and improving physical function and movement) Therapy Progress Report, dated 7/15/2025, the PT Therapy Progress Report indicated Resident 1 with the following functional deficits: decreased sitting balance, decreased standing balance, decreased endurance and poor postural control during sitting and standing. During a review of Resident 1's Occupational Therapy (OT- a therapy that aims to improve individuals' ability to engage in meaningful activities of daily living) Therapy Progress Report, dated 7/15/2025, the OT Progress Report indicated Resident 1 had decreased safety awareness and decreased overall strength. During a review of the Resident 3's Actual Witnessed Fall Care Plan revised 7/16/2025, the Care Plan indicated Resident 1 had a witnessed fall with minor injury to the left hand after sliding off wheelchair while in transportation van after going to an appointment. The care plan indicated Resident 1 with a history of weakness, lack of coordination, dementia (a progressive state of decline in mental abilities) with forgetfulness and poor posture. The care plan indicated staff interventions included PT and OT evaluation, use of tilt in wheelchair (wheelchair allows the user's entire seat and back to tilt as a single unit) while going to appointments, and a post fall rehabilitation screen for possible skilled interventions.During a concurrent interview and record review on 8/27/2025 at 1:17 PM with the Occupational Therapist, Resident 1's Therapy Post Page 1 of 3 055293 055293 08/28/2025 Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 055293 Page 2 of 3 055293 08/28/2025 Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

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 055293 Page 3 of 3