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** S483.25(d) Accidents. The facility must ensure that - S483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Based on interview and record review, the facility failed to provide adequate supervision for one of four sampled residents (Resident 1) who was assessed as high risk for falls by failing to develop a comprehensive resident-centered care plan (a care plan developed and implemented to meet his or her preferences and goals, and addressed the resident's medical, physical, mental, and psychosocial needs) after Resident 1's fall on 8/10/2025. This deficient practice resulted in Resident 1's repeated fall on 8/12/2025 at 6:19 PM. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses that included non-traumatic intracerebral hemorrhage (the bleeding into the brain tissue that occurs without a physical injury or trauma), ataxia (a condition characterized by a lack of coordination and balance), and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/6/2025, the MDS indicated Resident 1 was assessed having severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 1 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds the trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. Resident 1 required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs but provides less than half the effort) with sit to lying, sit to stand, chair/bed-to-chair transfer, and walking 10 feet (ft- unit of measurement). During a review of Resident 1's Fall Risk Assessment, dated 8/10/2025, the Fall Risk Assessment indicated a score of 12 (a score of 10 or above represents high risk for falls). During a review of Resident 1's Progress Notes, dated 8/10/2025, timed at 2:30 PM, the Progress Notes indicated Resident was found sitting on the floor mat at the left (L) side of her bed. When asked the resident what happened, resident was not able to describe what happened. During a review of Resident 1's Interdisciplinary Team (IDT- a meeting where healthcare professionals from different disciplines collaborate to develop or review a resident's care plan) Progress Note, dated 8/11/2025, the IDT Progress Note indicated Resident 1 was found sitting on the floor on the left side of her bed. The IDT Recommendation indicated, Resident 1 remains at risk for falls due to impaired safety awareness. Education provided and reinforced regarding use of call light. Plan of care to continue with fall precautions and ongoing monitoring. During a review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR- a document that provides a framework for communication between members of the health care team about a resident's condition), dated 8/12/2025, the SBAR indicated that on 8/12/2025, at 6:19 PM, an unknown resident's Responsible Party 1 (RP 1) saw Resident 1 trying to Page 1 of 3 055480 055480 08/28/2025 The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reposition self from her wheelchair and got up. Licensed Vocational Nurse 1 (LVN 1) stated heard a sound and got up and saw the Resident on the floor before he could catch her. SBAR indicated, per LVN, Resident 1 fell forward on the floor on her left side. Resident 1 was unresponsive to verbal and physical stimuli and loudly snoring as she was asleep. During a review of Resident 1's Progress Notes, dated 8/12/2025, timed at 6:37PM, the Progress notes indicated at 5:45PM, after dinner, Resident 1, while on the wheelchair was placed in front of the nurses' station with other residents. At 6:15PM, Resident 1 was in a wheelchair in front of the nurses' station while LVN (not specified) was passing medications. At 6:19PM, RP 1 saw Resident 1 trying to reposition self from the wheelchair and got up. The LVN (LVN 1) at the nurse's station heard the sound and got up but Resident 1 was already on the floor before LVN 1 could catch her. During an interview, on 8/27/2025, at 1:45 PM, with LVN 1, LVN 1 stated CNA 1 placed Resident 1 in the hallway across from Nurse's Station after dinner. LVN 1 stated Resident 1 was not confused but was not moving around in her wheelchair when CNA 1 left her by the hallway. LVN 1 stated he was not familiar with Resident 1's care but knew that she was in the Falling Star Program (a program that serves as a visual identifier and reminder system for staff to recognize residents who are determined to be at risk for falls). LVN 1 stated he did not know that Resident 1 had a history of falls or what type of supervision Resident 1 needed. LVN 1 stated he was inside the Nurse's Station assisting another family member with lab results when he saw Resident 1 try to get up from her wheelchair. LVN 1 stated he attempted to assist Resident 1 but by the time he got to Resident 1 she already fell on the floor. LVN 1 stated he saw Resident 1 fall face down and was in deep sleep when he got to her in the hallway. During an interview, on 8/27/2025, at 2:51 PM, with LVN 2, LVN 2 stated Resident 1 was found on the floor in her room on 8/10/2025. LVN 2 stated Resident 1 had poor safety awareness and was impulsive with her actions and needed to be supervised to prevent future falls. LVN 2 stated facility staff placed Resident 1 by the Nurse's Station so she can be supervised closely. LVN 2 stated it was important for Resident 1's care plan interventions to be specific and resident-centered and specific to her needs to prevent falls. During a concurrent interview and record review, on 8/27/2025, at 3:31 PM, with the Director of Rehabilitation (DOR), Resident 1's Physical Therapy Evaluation and Plan of Treatment, with the certification period from 8/6/2025 to 9/1/2025 was reviewed. The DOR stated Resident 1 needed moderate assistance with transfer, bed mobility, and walking 10 ft. The DOR stated Resident 1 needed assistance from staff to stand up safely from a wheelchair. The DOR stated Resident 1 required prompts, had impaired safety awareness and had moderately impaired decision making. The DOR stated it would not be safe for Resident 1 to stand up from her wheelchair without assistance. The DOR stated Resident 1 needed supervision when left sitting in her wheelchair. The DOR stated that the facility staff supervising Resident 1 should have Resident 1 within his eye line to ensure she receives assistance when she tries to stand up. During an interview, on 8/28/2025, at 9:51 AM, with CNA 1, CNA 1 stated Resident 1 needed to be supervised because she was at risk for falls and was in the Falling Star Program. CNA 1 stated on 8/12/2025, Resident 1 turned and twisted in her wheelchair from time to time. CNA 1 stated on 8/12/2024, at around 6 PM, she placed Resident 1 in front of the Nurse's Station so Resident 1 can be supervised while CNA 1 assisted another resident in the dining room. CNA 1 stated she informed LVN 1 that Resident 1 was in her wheelchair in front of the Nurse's Station before leaving. CNA 1 stated she heard someone fall in the hallway while helping another Resident and ran to the nurse's station to check on Resident 1. CNA 1 stated she saw Resident 1 in front of the Nurse's Station snoring and face down on the floor. During a concurrent interview and record review, on 8/28/2025, at 10:09 AM, with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), Resident 1 care plan with 055480 Page 2 of 3 055480 08/28/2025 The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few focus on Resident 1's actual fall and risk for further falls, dated 8/10/2025 was reviewed. The DON stated Resident 1 was confused, had poor safety awareness, and tried to get out of bed numerous times. The DON stated on 8/12/2025 at approximately 6:15 PM, LVN 1 was charting on the computer inside the Nurse's Station when he heard a sound in the hallway. The DON stated LVN 1 stood up and saw Resident 1 on the floor. The DON stated LVN 1 was not able to catch Resident 1 before she fell on the floor. The DON stated Resident 1's care plan for fall did not include resident-specific interventions on how to supervise and what type of monitoring Resident 1 needed to prevent further falls. The DON stated the purpose of a care plan was to provide interventions for facility staff to follow in order to tackle residents' needs and meet specific goals. The DON stated the IDT recommendation from 8/11/2025 for ongoing monitoring of Resident 1 should have been included in Resident 1's interventions to prevent falls. During a concurrent interview and record review, on 8/28/2025, at 10:09 AM, with the DON and the ADON, Resident 1's care plan for risk for further falls and injuries related to (r/t) balance problem, gait abnormality (unusual pattern of walking), poor trunk control (difficulty maintaining upright posture, balance, and performing daily activities) , bowel/bladder incontinence (involuntary and unexpected passage of urine or stool), poor communication/comprehension, dated 8/10/2025 was reviewed. The DON stated the care plan was not resident-specific and did not and should have included supervision and monitoring as an intervention to prevent Resident 1 from falling. During a concurrent interview and record review, on 8/28/2025, at 10:50 AM, with the DON, the facility's Falling Star Program policy was reviewed. The DON stated the Falling Star Program did not indicate what type of supervision or monitoring a resident receives once added to the program. The DON stated both the facility's Falling Star Program and Resident 1's care plan for falls did not indicate what type of supervision and monitoring Resident 1 needed to prevent falls. During a review of the facility's undated Policy and Procedure titled, Falling Star Program, the P&P indicated The IDT is responsible for implementing individualized interventions for each resident's fall risks. During a review of the facility's P&P, titled, Managing Falls and Fall Risk, , revised 03/2018, the P&P indicated the following:1. The staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. 2. The staff, with the input of the attending physician, will implement a Resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. During a review of the facility's P&P, titled, Safety and Assistance of Residents, revised 02/2021, the P&P indicated the following:1. Our facility strives to make the environment as free from accident hazards as possible. Our residents' safety and needs to prevent accidents are facility-wide priorities.2. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including assisting the residents as needed and assisting on any assistive devices. During a review of the facility's P&P, titled, Care Plans, Comprehensive Person-Centered, undated, the P&P indicated the following:1. A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 2. The comprehensive, person-centered care plan describes services that are to be furnished to attain or maintain the Resident's highest practicable physical, mental, psychosocial well-being. 055480 Page 3 of 3