Health inspection·November 18, 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 interview and record review, the facility failed to provide supervision during toilet use to one of six sampled Residents (Resident 1), who was assessed as high risk for falls. This failure resulted in Resident 1 falling from the toilet and sustaining a forehead laceration (a deep cut in the skin), which required five sutures (used to close wounds and hold tissues together) at a general acute care hospital (GACH). Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The Face Sheet indicated Resident 1 had diagnoses that included right femur fracture (a broken thighbone, a serious injury often requiring surgery and extensive rehabilitation, typically caused by high-impact trauma like falls), Alzheimer's (a disease characterized by a progressive decline in mental abilities), and osteoporosis (weak and brittle bones due to a lack of calcium and Vitamin D).During a review of Resident 1's Minimum Data Set (MDS, a Resident assessment tool), dated 9/18/2025, the MDS indicated Resident 1 had severely impaired cognition (the process of thinking). The MDS indicated Resident 1 required moderate assistance (the helper did less than half the effort) with eating and oral hygiene. The MDS indicated Resident 1 required maximal assistance (the helper did more than half the effort) with toileting hygiene. The MDS indicated Resident 1 was dependent (the helper did all the effort) on staff with toilet transferring.During a review of Resident 1's History and Physical (H&P), dated 9/13/2025, Resident 1's H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.During a review of Resident 1's Fall Risk Evaluation, dated 9/12/2025, the evaluation indicated Resident 1 was at high risk for falls.During a review of Resident 1's Post-Event Interdisciplinary Team (IDT, a group of healthcare professionals from different fields who worked together to plan and provide coordinated care for a Resident) Review, dated 10/7/2025, the IDT record indicated on 10/6/2025 Resident 1 had an unwitnessed fall in the room. The IDT record indicated Resident 1 was sitting on the toilet when Certified Nursing Assistant (CNA) 1 turned to inform another resident that she (CNA 1) was helping Resident 1. The IDT record indicated Resident 1 stood up from the toilet, fell on the floor, and sustained a cut on the forehead. The IDT record indicated Resident 1 had a history of a fall on 9/8/2025 which resulted in a right femur fracture.During a review of Resident 1's General Acute Care Hospital (GACH) records, dated 10/6/2025, the GACH records indicated Resident 1 was brought in by ambulance for an unwitnessed fall resulting in a head laceration and bruising on right side of the face. The GACH records indicated Resident 1 was awake, alert and oriented, and expressed experiencing pain to her right leg and head. The GACH records indicated Resident 1 stated she had fallen from the toilet and hit her head. The GACH records indicated Resident 1 was administered lidocaine (pain medication) and the resident's forehead laceration was repaired with five sutures (used to close wounds and hold tissues together).During a telephone interview on 10/16/2025 at 10:42 a.m. with CNA 1, CNA 1 stated that on 10/16/2025 around 10 a.m., Resident 1 was Page 1 of 3 055519 055519 11/18/2025 Downey Post Acute 13007 S. Paramount Blvd. Downey, CA 90242

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sitting on the toilet in the restroom. CNA 1 stated she left the restroom and informed another resident that she was assisting Resident 1. CNA 1 stated as soon as she reached the other resident, she heard Resident 1 screaming I fell in Spanish. CNA 1 stated Resident 1 was on the floor in the restroom with blood to the forehead. CNA 1 stated Resident 1 did not provide details on the fall. CNA 1 stated Resident 1 was confused and unaware of her surroundings. CNA 1 stated it was not safe to leave Resident 1 alone in the restroom because of fall risks. CNA 1 stated she should have asked another staff to stay with Resident 1 in the restroom to prevent falls.During an interview on 10/17/2025 at 10:44 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated for safety purposes staff should provide more supervision to high fall risk residents. LVN 1 stated supervision meant the staff should have residents within their visual field. LVN 1 stated it was standard nursing care to provide supervision and monitoring to residents as needed. LVN 1 stated he determined the level and type of supervision residents needed by collecting information from previous shifts, admission assessments, MDS assessments, and the plan of care. LVN 1 stated that he was not aware if the facility had any nursing manual or guidelines regarding resident supervision.During a concurrent interview and record review on 10/17/2025 at 10:44 a.m. with LVN 1, Resident 1's Care Plan titled Activities of Daily Living (ADL) self-care performance deficit related to right femur fracture and a history of falls, revised on 9/22/2025, was reviewed. The Care Plan indicated staff were to safely perform transfers and toilet use. The Care Plan interventions indicated staff were to participate with toilet use and transferring. LVN 1 stated the care plan interventions did not specify the types of assistance Resident 1 needed. LVN 1 stated the care plan interventions should be more specific so it would be clearer to communicate among staff. LVN 1 stated the non-specific care plan could increase the risks of avoidable mistakes and negatively impact on the quality of resident care.During an interview on 10/17/2025 at 12:04 p.m. with Registered Nurse (RN)1, RN 1 stated it was not safe to leave Resident 1 alone on the toilet due to the resident's history of falls and confusion. RN 1 stated CNA 1 should have stayed with Resident 1 for safety. RN 1 stated CNA 1 should have used the call light and asked for someone to supervise Resident 1 on the toilet before leaving to assist another resident.During an interview on 10/17/2025 at 1:34 p.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 1 was to be toe touch weight bearing (lightly touching the toes to the ground while walking or standing) on the right side after her fall on 9/8/2025. The DOR stated Resident 1 was not aware of safety measures and it was not safe to leave the resident lone in the restroom because of Resident 1's cognitive deficit and poor understanding of weight-bearing status and safety. The DOR stated Resident 1 was at risk of injury and possible worsening of the right femur fracture. The DOR stated Resident 1 needed cuing and redirection for activities. The DOR stated Resident 1 required assistance from two people with any kind of transfer due to the weight-bearing status. The DOR stated for safety staff had to stay and monitor Resident 1 while on the toilet. The DOR stated staff needed to make sure Resident 1 did not put weight on the right lower extremity.During an interview on 10/17/2025 at 2:18 p.m. with the Assistant Director of Nursing (ADON), the ADON stated Resident 1's fall on 10/6/2025 was preventable and due to a lack of staff supervision. The ADON stated if CNA 1 asked for help when she needed to attend the other resident or should have just stayed with Resident 1. The ADON stated staff should have kept Resident 1 safe and should not have left the resident unattended, especially residents who were at high risk for falls. The ADON stated she determined the level of supervision the residents required based on the fall risk assessments. The ADON stated residents at high risk for falls required more supervision. The ADON stated the facility did not have a nursing manual regarding resident supervision. The ADON stated the facility did not set guidelines for resident supervision and 055519 Page 2 of 3 055519 11/18/2025 Downey Post Acute 13007 S. Paramount Blvd. Downey, CA 90242

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few monitoring.During a review of the facility's policy and procedure (P&P) titled, Fall Management System, dated 4/2025, the P&P indicated the facility should provide an environment that remained as free of accident hazards as possible. The P&P indicated the facility should provide each resident with appropriate assessment and interventions to prevent falls and minimize the complications of falls. The P&P indicated high fall risk residents would have an individualized care plan developed. The P&P further indicated the care plan interventions would be developed to prevent falls by addressing the risk factors and would consider the particular elements of the evaluation that put the resident at risk. 055519 Page 3 of 3