Health inspection·January 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide safety measures and supervision by not assisting, and/or monitoring to prevent falls and injury for one (1) of two (2) sampled residents (Resident 1) when Resident 1 was assessed to be at high risk for falls and fell on [DATE], hitting his head on the floor.This deficient practice has the potential to cause injury and/ or future falls to Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] including but not limited to diagnoses of cataract (a medical condition in which the lens of the eye becomes progressively opaque, resulting in blurred vision), muscle weakness and pain in the right arm.During a review of Resident 1's Care Plan with focus risk for falls, revised 10/30/2025, the Care Plan indicated the following but not limited to:To provide assistance with transferring and locomotion as needed.Educate/ remind resident to request assistance prior to transfer/ambulation.During a review of Resident 1's Care Plan with focus elopement (a patient, resident, or child leaves a care facility or designated safe area without permission) risk, revised 10/30/2025, indicated the following but not limited to:Address wandering behavior by walking with the residentEvaluate need for additional supervision.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/24/2025, the MDS indicated the resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 1 required supervision/ touching assistance (helper provides verbal cues and/or touching/steadying and/ or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.) with walk 10 feet (once standing, the ability to walk at lead 10 feet in the room, corridor, or similar space), walk 50 feet with two turns (once standing, the ability to walk at least 50 feet and make two turns), walk 150 feet (once standing, the ability to walk at least 150 feet in the corridor or similar space) and shower/bath self but required set up/clean up assistance (helper sets up or cleans up; residents completes activity. Helper assists only prior to or following the activity) with toileting hygiene, lower body dressing, putting on/taking off footwear, and personal hygiene.During a review of Resident 1's Fall Risk Assessment, dated 12/3/2025, the assessment indicated Resident 1 is at high risk for falls.During a review of Resident 1's Change of Condition (COC - a significant shift in a person's physical, mental, or functional state) evaluation, dated 12/16/2025, the COC indicated Resident 1 had a witnessed fall and hit his head on the floor.During a review of Resident 1's Progress Notes dated 12/16/2025 at 9AM, the Progress Notes indicated the resident fell outside the patio area while entering another unit. The Progress Notes also indicated the resident fell backwards while trying to grab his wheelchair.During an interview on 1/5/2025 at 10AM, Resident 1 stated he was walking by himself while pushing the wheelchair when he fell outside the unit.During an interview on 1/5/2025 at 12:30PM, Respiratory Therapist (RT) stated she observed Resident 1 Page 1 of 2 055293 055293 01/05/2026 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 using his wheelchair like a walker when Resident 1 fell. RT also stated Resident 1 lost his balance and was trying to hold on to wheelchair when he fell backwards. RT stated she was not there to supervise the resident and was just there to open the door. RT stated Resident 1 was by himself at the time of the fall.During an interview on 1/5/2025 at 12:49PM, Resident 1's MDS, dated [DATE], was reviewed. Registered Nurse (RN) Supervisor stated Resident 1 MDS indicated the resident should have supervision/touching assistance when walking. RN Supervisor also stated it means a person should always be with the resident while providing supervision and assistance as needed. RN Supervisor stated no one was with the resident at the time the resident was ambulating on 12/16/2025.During the same interview on 1/5/2025 at 12:49PM with RN supervisor. Resident 1's Care Plan with focus at risk for falls, dated 10/30/2025, was reviewed. RN supervisor stated the facility should be assisting Resident 1 with transferring and/or locomotion and to remind the resident to ask for assistance when ambulating. RN supervisor stated on 12/26/2025, Resident 1 did not but should have assistance when walking.During an interview on 1/5/2025 at 12:57PM, Quality Assurance (QA) Nurse stated supervising/touching assistance means the person needs to be with the resident while guiding and helping the resident as needed. QA Nurse also stated Resident 1 did require assistance on 12/16/2025 but did not have the assistance.During a review of the facility's Policy and Procedure (P&P) titled Fall Management Program, revised 6/1/2017, the P&P indicated based on information gathered from the history and assessment of the resident, the nursing staff and Interdisciplinary Team (IDT - collaborative group of professionals from different specialties), with input from the attending physician, will identify and nursing staff will develop a plan of care specific to the resident's needs with interventions to reduce the risk of falls. During a review of the facility's P&P titled Care Planning, revised 10/24/2022, the P&P indicated each resident's care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.During a review of the facility's P&P titled Safety of Residents, revised 5/1/2023, the P&P indicated to provide a safe environment for the residents. 055293 Page 2 of 2