Health inspection·January 20, 2026

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) bed rails (are adjustable metal or rigid plastic bars that attaches to the bed) are safe, functional and in good working condition in accordance with the facility's policy. This deficient practice has the potential for Resident 1 to be at risk of injury when getting in and out of bed.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included lack of coordination (unsteadiness) and abnormalities of gait and mobility (any noticeable change in a person's walking pattern or ability to move around safely and easily). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 1/9/2026, the MDS indicated Resident 1 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with rolling left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed), sit to lying (the ability to move from sitting on side of bed to lying flat on the bed), lying to sitting on side of bed (the ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support), sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed), chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair or wheelchair). During a review of Resident 1's Physician's order dated 1/15/2026 at 12:19 PM, the physician's order indicated Resident 1 may have 1/3 (quarter or half rails, placed near the head of the bed generally designed to provide stability and support) bilateral bed rails as enabler, to aid in mobility, positioning and transfer. During a concurrent observation and interview on 1/20/2026 at 12:24 PM, Resident 1 was observed lying in bed asleep with both 1/3 bilateral bed rails up and a walker inside the room. Licensed Vocational Nurse 1 (LVN 1) checked both bed rails and found that the bed rails were stuck and could not be lowered. LVN 1 stated the bed rails should not be stuck and should be able to lower easily to allow Resident 1 to get in and out of bed safely. During an observation on 1/20/2026 at 12:30 PM, Maintenance Assistant (MA) checked Resident 1's bilateral bed rails and was unable to lower the bed rails down. MA removed both bed rails from the bed and reinstalled them before rechecking but was unable to successfully lower the left bed rails. During an interview with the MA on 1/20/2026 at 1:30 PM, MA stated he reinstalled the bed rails in the correct holes for Resident 1's but the left bed rail still would not go down. MA also stated the bed rails on this type of bed, which Resident 1 has, are not working properly. During an interview on 1/20/2026 at 2:50 PM, Certified Nursing Assistant 1 (CNA 1) stated the bed rails should be working properly since staff raises and lowers them when changing and positioning residents in the bed. During an interview on 1/20/2026 at 3:51 PM, the Director of Nursing (DON) stated the Page 1 of 2 055376 055376 01/20/2026 Huntington Drive Health and Rehabilitation Center 400 W. Huntinton Dr. Arcadia, CA 91007

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents' bed should be in good working order for the residents' safety and ease of use. During a review of the facility's P&P titled, Maintenance Service, revised December 2009, the P&P indicated maintenance service shall be provided to all areas of the building, grounds, and equipment. The P&P also indicated that the maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. During a review of the facility's Policy and Procedure (P&P) titled, Bed safety and Bed Rails, revised August 2022, the P&P indicated that any worn or malfunctioning bed system components are repaired or replaced using components that meet manufacturer specifications. 055376 Page 2 of 2