Health inspection·January 14, 2026

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure for one of three sampled residents (Resident 1), who was assessed as being at risk (likelihood) for elopement (leaving the facility unsupervised) and wandering (walking/ travelling from place to place, without any clear aim or purpose) out of the facility and being high risk for falls with a history of multiple falls, was monitored and whereabouts (location in the facility) checked. This failure resulted in Resident 1 wandering out from the facility on 1/9/2026 without the facility's knowledge and supervision leading to the resident's fall and sustaining left hand fourth (4th) and fifth (5th) fingers fracture (brake in bone), left frontal scalp hematoma (a collection or pool of blood that forms outside of blood vessels) and intracranial (within the cranium [skull] the bony dome that houses and protects the brain) hemorrhage (bleeding). Resident 1 was transferred to the General Acute Care Hospital (GACH) 1 on 1/10/2026 for further evaluation and treatment.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility from GACH 1 on 1/10/2026 with diagnoses including closed head injury (a type of brain injury where the brain sustained damage due to external forces, but the skull remains intact), left hand 4th and 5th fingers fractures, dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and generalized muscle weakness. During a review of Resident 1's care plan titled, Category: CAA9 Behavioral Symptoms, dated 1/18/2024, the care plan indicated Resident 1 was identified as being at risk for elopement and wandering out of the facility, wandering without purpose, had an exit-seeking behavior (a resident's attempts to leave a safe environment without regard of their safety or consequences of the actions) and searching behavior (a behavior that is goal-oriented, an expression of need, manifested as wandering, exit-seeking). The care plan goal was to decrease resident's risk of elopement and wandering out of the facility. The care plan interventions included allowing the resident to move around the hallways safely, gently redirecting the resident back to the supervised areas and checking resident's whereabouts. The care plan's additional intervention dated 3/11/2024 included to use wander guard bracelet (a safety device designed to monitor and manage residents who wander away from the care environment) on left wrist for elopement precautions, check alarm for functioning, monitor for proper placement and battery function every shift. During a review of Resident 1's care plan titled Category: CAA11 Falls, indicating problem start date of 1/18/2024, the care plan indicated Resident 1 had increased susceptibility (likelihood) to falling that may cause physical harm due to history of falls, balance problem, loss of muscle strength and wandering. The care plan indicated Resident 1 had a fall risk assessment score of 16 (indicating a high risk for fall). The care plan included documentation indicating Resident 1 had fallen on 12/13/2024, 6/12/2025, and 11/17/2025 without injuries. The interventions to achieve care plan goals in preventing Resident 1 from Page 1 of 6 055526 055526 01/14/2026 Inglewood Health Care Center 100 S. Hillcrest Blvd Inglewood, CA 90301

F 0689 Level of Harm - Actual harm Residents Affected - Few falling and sustaining injuries included: on 12/13/2024, educating resident and staff on safety precautions; on 1/18/2024, checking resident's whereabouts; and on 6/12/2025, incremental monitoring (unspecified) to address resident's needs and safety precautions. During a review of Resident 1's History and Physical (H&P), dated 6/7/2025, the H&P indicated Resident 1 could not make medical decisions and had the fluctuating capacity (unstable) to understand and make decisions due to dementia. During a review of Resident 1's Physical Therapy (PT) Discharge summary, dated [DATE], the summary indicated Resident 1 had history of falling and lacking insight (understanding) into her condition and risk factors (hazards). The summary indicated Resident 1 required supervision/touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as the resident completes the activity) in transferring from sitting to standing position and when walking 150 feet. The summary indicated walking ten feet on uneven surfaces and taking one step on curb (taking a step down) was not attempted due to Resident 1's medical condition or safety concerns. The summary indicated Resident 1 required 24-hour staff assistance with mobility and daily care tasks. During a review of Resident 1's Elopement Risk Assessment, dated 10/24/2025, the Elopement Risk Assessment indicated Resident 1 was at risk of elopement. The assessment indicated Resident 1 was able to propel (drive) her wheelchair and ambulate (walk). The assessment indicated Resident 1 was oblivious (not aware of) to her needs or safety and wandered without purpose.During a review of Resident 1's Fall Risk Data Collection form, dated 10/24/2025, the Fall Risk Data Collection form indicated Resident 1 was at high risk for falling due to poor decision making, incontinence (no control of bowel and bladder elimination), gait/balance (manner of walking) problem, multiple medications, and multiple medical conditions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/29/2025, the MDS indicated Resident 1 had severe cognitive impairment for daily decision making. The MDS indicated Resident 1 wandered four to six days within the previous week (unspecified). The MDS indicated Resident 1 was independent with sitting to standing position (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed), walking 10 feet, walking 50 feet with two turns. The MDS indicated Resident 1 used a manual wheelchair independently for mobility. During a review of Resident 1's care plan titled CAA11 Falls, dated 11/18/2025, the approach indicated to provide with bed alarm and wheelchair alarm (devices to notify staff when a resident attempts to get out of bed or wheelchair unassisted) to remind Resident 1 not to get up unassisted and alert staff of resident's attempts to get up unassisted, place the resident in a visible area (area where staff can view) after group activities, provide individualized activity to keep the resident engaged (occupied) and distracted from attempting to get up unassisted, encourage/ remind resident to ask for help when needed, if able and provide assistance as identified in transfer and mobility and keep environment free of hazards. Resident 1's care plan goal indicated to decrease resident's risk of fall and injury with the interventions, reduce risk of serious injury from falls and resident will relate the intent (purpose) to use safety measures to decrease risk of fall. During a review of Resident 1's Functional Abilities Assessment (an assessment to determine an individual's physical, cognitive and emotional capabilities in relation to their ability to perform work-related tasks), dated 1/7/2026, the assessment indicated Resident 1 required supervision or touching assistance to transfer from sitting to standing. The assessment indicated Resident 1's walking ten feet was not attempted due to medical condition or safety concerns. During a review of Resident 1's Physician Orders, dated 1/8/2026, the physician's order indicated Resident 1 to wear a wander guard bracelet on the left wrist for elopement precautions. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR-a communication tool used by healthcare workers when there is a 055526 Page 2 of 6 055526 01/14/2026 Inglewood Health Care Center 100 S. Hillcrest Blvd Inglewood, CA 90301

F 0689 Level of Harm - Actual harm Residents Affected - Few change of condition among the residents), dated 1/9/2026, the SBAR indicated on 1/9/2026 at 8:50 a.m., Resident 1 had an unwitnessed fall outside the facility. The SBAR indicated Resident 1 was confused following the fall. The SBAR indicated Resident 1 complained of mild pain and sustained abrasion ([scratch] body part not indicated). The SBAR indicated radiology (x-ray- process of taking pictures to diagnose and treat diseases) was ordered by the physician. During a review of Resident 1's Radiology Report dated 1/10/2026 at 10:40 a.m., the Radiology report indicated Resident 1 had an acute fracture of the left-hand 4th and 5th fingers with minimal angulation (a fracture where the broken ends of a bone are tilted or bent at an angle, deviating from the bone's normal alignment) and displacement (moved out of their normal alignment). During a review of Resident 1's Progress Notes dated 1/10/2026 at 12:33 p.m., the Progress Notes indicated the abnormal diagnostic results (unspecified) were reviewed and new orders (unspecified) were obtained. The Progress Notes indicated Resident 1 was transferred to a GACH 1 for evaluation and treatment. During a review of Resident 1's GACH 1 Emergency Department (ED) Physician Documentation, dated 1/10/2026 at 7:19 p.m., the Physician Documentation indicated Resident 1 presented to the ED due to a mechanical fall (a type of fall that occur due to an external force or interaction with a physical object or condition in the environment, not by an acute medical event) on 1/9/2026. The Physician Documentation indicated Resident 1 reported a swollen left hand but was unable to recall the fall. The ED Physician Documentation indicated Resident 1 was mildly distressed (upset) with raccoon's sign (dark bruising and swelling) on head/ eyes. The ED Physician Documentation indicated Resident 1's radiology report showed acute and minimally displaced fractures of the left 4th and 5th fingers and left frontal scalp hematoma (a collection or pool of blood that forms outside of blood vessels). The ED Physician Documentation indicated Resident 1's differential diagnoses (list of possible conditions or diseases) included intracranial hemorrhage, fracture, dislocation (a medical condition where the bones in a joint are pushed out of their usual place) and electrolyte abnormalities (occur when too much or not enough minerals are in the body). The GACH 1 diagnostic impression indicated Resident 1 had closed head injury and left-hand fingers fractures. During an interview on 1/13/2026 at 8:45 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 had unsteady gait and weakness prior to the fall on 1/9/2026 and required touching assistance in transferring in and out of wheelchair and walking to prevent falls. CNA 1 stated Resident 1 was not allowed to leave the building without staff supervision and assistance prior to, and since the fall on 1/9/2026. During a concurrent observation and interview on 1/13/2026 at 8:50 a.m., with Resident 1, in Resident 1's room, Resident 1 cried, stating she was angry and mad about her pain. Resident 1 could not remember leaving the facility or falling. During a concurrent interview and record review on 1/13/2026 at 11:22 a.m., with Licensed Vocational Nurse (LVN 1), Resident 1's Elopement Risk Assessment, dated 10/24/2025, Fall Risk Data Collection form, dated 10/24/2025, MAR for the month of January 2026, Resident 1's SBAR dated 1/9/2026, and Resident 1's Progress Notes dated 1/9/2026 to 1/11/2026, were reviewed. LVN 1 stated the Fall Risk Data Collection form indicated Resident 1 had an unsteady gait and frequently stood up from her wheelchair without asking for staff assistance and had a wheelchair alarm in place to alert staff when Resident 1 was trying to stand without assistance. LVN 1 stated prior to Resident 1's fall on 1/9/2026, Resident 1 used her wheelchair to go around the unit. LVN 1 stated on 1/9/2026, she did not hear the wheelchair alarm turned on. LVN 1 stated Resident 1's progress notes indicated the resident exited the facility unsupervised and fell on the sidewalk outside the facility. Resident 1 sustained abrasion on the forehead, mild pain and the left hand was red and mildly swollen after the fall. LVN 1 stated Resident 1 should have been continuously supervised when not in her room to avoid falls and elopements. During a concurrent 055526 Page 3 of 6 055526 01/14/2026 Inglewood Health Care Center 100 S. Hillcrest Blvd Inglewood, CA 90301

F 0689 Level of Harm - Actual harm Residents Affected - Few interview and record review on 1/13/2026 at 1:17 p.m., with the Director of Rehabilitation (DOR), Resident 1's Physical Therapy (PT) Discharge summary dated [DATE], Resident 1's Functional Abilities assessment dated [DATE], were reviewed. The DOR stated the discharge summary indicated Resident 1 required 24-hour staff assistance with mobility and daily care tasks. The DOR stated Functional Abilities assessment dated [DATE], indicated walking ten feet was not attempted due to Resident 1's medical condition or safety concerns and she did not know why it (walking ten feet) was not attempted. The DOR stated Resident 1 required supervision/touching assistance in transferring from sitting to standing position and when walking 150 feet. The DOR stated walking ten feet on uneven surfaces and taking one step on curb were not attempted for Resident 1 due to medical condition or safety concerns. The DOR stated the Rehabilitation Department performed Resident 1's quarterly screening on 10/13/2025 and there were no changes in her functional abilities. The DOR stated the Rehabilitation Department was not notified about Resident 1's change (unspecified) in walking abilities. During a concurrent interview and record review on 1/13/2026 at 1:50 p.m., with Registered Nurse (RN 1), Resident 1's care plan titled Category: CAA11 Falls dated 1/18/2024, care plan titled Category: CAA9: Behavioral Symptoms at risk for elopement and wandering out of the facility- wandering without purpose, searching behavior, and exit seeking behavior dated 1/18/2024, and Resident 1's Radiology Report, dated 1/9/2026, were reviewed. RN 1 stated Resident 1's fall care plan did not indicate required interventions to prevent falls and injury. RN 1 stated Resident 1's care plan for fall prevention was not followed because Resident 1 was outside the facility, unsupervised and was not in a visible area by the facility staff. RN 1 stated Resident 1's behavioral care plan intervention indicating to check the resident's whereabouts was vague (unclear) and stated she (RN1) did not know how to implement that intervention. RN 1 stated the behavioral care plan intervention indicated to allow Resident 1 to move around the facility safely was not implemented, because without supervision at the lobby and exit door, the hallway was unsafe when she [RN 1] left the lobby. RN 1 stated Resident 1 had history of dementia, Alzheimer's disease, and generalized weakness that increased Resident 1's risk of falling. RN 1 stated on 1/9/2026 at around 8:45 a.m., Receptionist 1 asked her (RN 1) to observe the front door and lobby, and ensure residents' safety, prevent residents from leaving, and to greet/assist visitors because Receptionist 1 had to go on break. RN 1 stated she did not see Resident 1 or any residents at the lobby, so she left the lobby area to access her bag in the Medication room [ROOM NUMBER]. RN 1 stated the lobby and exit area could not be viewed from Medication room [ROOM NUMBER] for supervision. RN 1 stated she did not assign another staff member to supervise the lobby and exit door, while she went to Medication room [ROOM NUMBER]. RN 1 stated on 1/9/2026 at 9 a.m., she heard the Wander Guard alarm went off (activated) by the front door less than one minute after she entered Medication room [ROOM NUMBER]. RN 1 stated she left Medication room [ROOM NUMBER] to investigate the Wander Guard alarm but did not see any residents in the lobby or near the front door. RN 1 stated she ran outside the facility, passing the lobby, through the front door, and observed Resident 1 falling on the sidewalk, hit her head, hands, and knees before she (RN 1) could reach Resident 1. RN 1 stated, when she observed Resident 1 on the sidewalk, Resident 1's wheelchair was not observed near Resident 1, and she did not hear the wheelchair alarm. RN 1 stated outside the facility was hazardous (dangerous) due to uneven sidewalks, hard surfaces, presence of cars and unknown people were present. RN 1 stated Resident 1 had wandered outside the facility through the lobby area, where there was no facility staff to redirect Resident 1 back inside the facility so that staff can provide supervision to the resident. RN 1 stated Resident 1 could have stood up by herself, got out of her wheelchair, and walked without staff's assistance or supervision on the sidewalk. RN 1 stated Resident 1 was placed 055526 Page 4 of 6 055526 01/14/2026 Inglewood Health Care Center 100 S. Hillcrest Blvd Inglewood, CA 90301

F 0689 Level of Harm - Actual harm Residents Affected - Few at risk of getting hit by a car, tripping (walking/ fall) on an uneven sidewalk, and suffered exposure to the external elements (severe cold weather condition, rape, vehicular accident) when the resident left the facility without staff supervision. RN 1 stated because of the fall, Resident 1 fractured the two fingers on her left hand as indicated in the radiology report 1/9/2026. RN 1 stated on 1/10/2026, Resident 1 was transferred to GACH 1 for further evaluation of the left hand and head injury she suffered after the fall on 1/9/2026. RN 1 stated Resident 1's fall and injuries on 1/9/2026 could have been avoided if staff supervision was provided to implement interventions according to the fall care plan. RN 1 stated fall care plan intervention to provide incremental monitoring was not specific and not measurable. RN 1 stated she did not know how to implement that intervention (provide incremental monitoring). RN 1 stated Resident 1's wandering outside on 1/9/2026 could have been prevented if the interventions in the behavioral care plan were implemented. During an interview on 1/13/2026 at 2:43 p.m., with LVN 2, LVN 2 stated he was the second responder on 1/9/2026 when Resident 1 went outside the facility unsupervised and fell. LVN 2 stated Resident 1's wheelchair was outside the facility when he responded to the wanderguard alarm. LVN 2 stated he did not hear Resident 1's wheelchair alarm on prior to the fall. During an interview on 1/13/2026 at 4:41 p.m., Receptionist 1 stated RN 1 should not have left the lobby and front door to ensure residents who come to the lobby will be supervised. During a concurrent interview and record review on 1/14/2026 at 1:37 p.m., with the Director of Nursing (DON), Resident 1's care plan titled Category: CAA11 Falls, dated 1/18/2024, and the facility's undated P&P titled Safety Supervision of Residents, were reviewed. The DON stated the fall care plan intervention indicating to place Resident 1 in a visible area was not implemented. The DON stated the fall care plan intervention indicating incremental monitoring to address Resident 1's needs and safety was unclear. The DON stated she guessed that (incremental monitoring) meant to monitor Resident 1's location, safety, and needs every two hours. The DON stated this intervention (incremental monitoring) was not documented and there was no proof this was implemented. The DON stated she could have implemented a written log to monitor Resident 1's incremental monitoring to ensure that intervention was implemented. The DON stated Resident 1 was not provided with fall prevention measures because Resident 1 was outside the facility without staff's knowledge and was unsupervised. The DON stated on 1/9/2026 at 9:00 a.m., when she heard and responded to Resident 1's wanderguard alarm, the lobby and exit door were not supervised because there was no staff present to gently redirect Resident 1 back to a supervised area as indicated in Resident 1's behavioral care plan. The DON stated Resident 1 was on her wheelchair outside the facility and did not hear Resident 1's wheelchair alarm prior to the fall. The DON stated the Safety Supervision of Residents P&P indicating interventions should be implemented correctly and consistently (always), was not implemented on Resident 1. The DON stated Resident 1's fall on 1/9/2026 and injuries sustained was a major accident caused by lack of staff supervision and assistance. During a concurrent interview and record review on 1/14/2026 at 3:30 p.m., with the Administrator, the State Operations Manual (SOM) Appendix PP- Guide to Surveyors for Long Term Care Facilities, dated 7/23/2025, was reviewed. The Administrator stated the SOM Appendix PP indicated alarms, such as the wander guard and chair alarms, do not replace staff supervision. The Administrator stated a system-wide approach to prevent resident elopements and falls involve active supervision of the lobby and exit door whenever the automatic-opening exit is unlocked. During a review of the facility's undated P&P titled Safety Supervision of Residents, the P&P indicated the facility strive to make the environment as free from accident hazards as possible. The P&P indicated resident safety and supervision and assistance to prevent accident are company-wide priorities. The P&P indicated the interdisciplinary care team (group of healthcare professionals, 055526 Page 5 of 6 055526 01/14/2026 Inglewood Health Care Center 100 S. Hillcrest Blvd Inglewood, CA 90301

F 0689 Level of Harm - Actual harm Residents Affected - Few including physician, nurses, resident/ resident representative, working together to develop a plan of care for the residents) should analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The P&P indicated the care team should target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The P&P indicated the facility should ensure interventions are implemented correctly and consistently, evaluate the effectiveness of interventions, modify or replace interventions as needed and evaluate the effectiveness of new or revised interventions. The P&P indicated due to the complexity and scope; certain resident risk factors and environmental hazards should be addressed in dedicated P&P including falls and unsafe wandering. During a review of the facility's undated P&P titled, Comprehensive Care Plan, the P&P indicated the comprehensive care plan must describe the services provided to the resident to attain or maintain the residents highest practicable, physical, mental and psychosocial well-being. The P&P indicated the facility must conduct a functional assessment of the resident by completing the MDS and Care Area Assessment (CAA) and the CAA triggered must be considered for care plan development. The P&P indicated to re-evaluate and modify care plans as necessary to reflect changes in care, service and treatment. During a review of the facility's undated P&P titled, Fall Management, the P&P indicated if falling recurs despite initial interventions, staff should implement additional or different interventions or indicate why the current approach remains relevant. The P&P indicated if underlying causes cannot be readily identified or corrected and, will try various interventions based on assessment of the nature or category of falling, until falling is reduced or stopped or until the reason for the continuation of the falling is identified as unavoidable. The P&P indicated the MDS/Interdisciplinary Care conference team should also update the resident's care plan accordingly. 055526 Page 6 of 6