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 (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: 055293 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 01/05/2026 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)