Health inspection·October 28, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review, the facility failed to ensure the environment remained as free of accident hazards possible and residents received adequate supervision for two of three sampled residents (Residents 2 and 3) when:a. Resident 2's bed sensor pad alarm (an assistive electronic device that makes alerts/sounds to warn caregivers when the resident tries to get up from the bed) did not sound when Resident 2 got up from Resident 2's bed unassisted by staff and walked to the bathroom.b. The facility's licensed nursing staff (in general) failed to conduct a fall risk assessment (an evaluation to determine a resident's likelihood of falling) or inaccurately assessed Resident 3 as low risk for fall following Resident 3's falls on 5/31/2025, 8/4/2025, and 10/4/2025. c. The facility's Interdisciplinary Team (IDT, a group of health care professionals who work together toward the goals of the resident) failed to conduct a comprehensive root cause analysis (systematic process to identify the underlying reasons a fall occurred, which can then be used to prevent future incidents) of Resident 3's falls on 5/31/2025, 8/4/2025, and 10/4/2025 and update Resident 3's care plan interventions to prevent Resident 3 from falling again.These failures had the potential for Resident 2 to sustain injury and/or harm due to falling while in care of the facility. In addition, these violations resulted in Resident 3 falling on 5/31/2025, 8/4/2025, and 10/4/2025 and sustained lacerations (a pattern of injury in which skin and underlying tissues are cut or torn) to the head on 5/31/2025 and 8/4/2025. Findings: a. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 4/4/2025 with diagnoses including transient cerebral ischemic attack (TIA, a temporary interruption of blood flow to the brain), dysphagia (difficulty swallowing foods or liquids), and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 10/12/2025, the MDS indicated Resident 1 had moderately impaired cognition (ability to make daily decisions). The MDS indicated Resident 1 required supervision or 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 intermediately) from staff for toileting, personal hygiene, and dressing. The MDS indicated Resident 2 required supervision or touching assistance from staff for walking. During a review of Resident 2's Order Summary Report (OSR) dated 10/27/2025, the OSR indicated a physician order dated 9/15/2025 for nursing staff to apply bed sensor pad alarm to Resident 2 every shift for safety due to history of falls and to monitor placement every shift. During an observation on 10/27/2025 at 11:22 AM, in Resident 2's room, Resident 2 got up from Resident 2's bed and walked alone while using a front wheel walker (FWW, a device used to assist individuals with balance and mobility problems). Resident 2 walked to the restroom on the other side of the room from Resident 2's bed. Staff (in general) did not come to Resident 2's room. The sensor alarm for Resident 2 did not sound. Resident 2 shut the bathroom door behind her. During a Page 1 of 3 055541 055541 10/28/2025 Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some follow-up interview on 10/27/2025 at 11:41 AM with Resident 2, Resident 2 stated Resident 2 had fallen multiple times at the facility. Resident 2 stated Resident 2 gets dizzy due to chemotherapy (a drug-based medical treatment that uses powerful chemicals to kill or slow the growth of cancer cells). Resident 2 stated Resident 2 was not supposed to walk by herself to the bathroom. Resident 2 stated Resident 2 had walked by herself earlier (when surveyor observed) without assistance from staff (in general) because staff did not always come right away when Resident 2 needed to use the toilet. b. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 1/22/2025 and readmitted on [DATE] with diagnoses including encounter for surgical aftercare following surgery on the digestive system, metabolic encephalopathy (brain disease that alters brain function or structure), and seizures (a sudden, uncontrolled electrical disturbance in the brain). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 was severely impaired in cognitive skills. The MDS indicated Resident 3 required supervision or touching assistance from staff for personal hygiene, bathing and dressing. The MDS indicated Resident 3 required supervision or touching assistance from staff for walking. During a review of Resident 3's General Acute Care Hospital 1 (GACH 1) Emergency Trauma Documentation (ETD) dated 5/31/2025, the ETD indicated Resident 3 presented to GACH 1 Emergency department (ED) on 5/31/2025 with chief complaint of a fall. The ETD indicated Resident 3 hit Resident 3's head when Resident 3 fell in the facility. The ETD indicated Resident 3 had a 3-centimeter (cm-unit of measurement) scalp laceration. The ETD indicated the physician repaired Resident 3's laceration with three staples (specialized staples that are used instead of sutures to mend skin wounds). During a review of Resident 3's GACH 2 ED Provider Note (ED Note), dated 8/4/2025, the ED Note indicated Resident 3 presented to GACH 2 ED on 8/4/2025 with a 4 cm laceration to the head due to an unwitnessed fall at the facility. The ED Note did not indicate any treatment for Resident 3's laceration. During a concurrent interview and record review on 10/27/2025 at 2:20 PM with the Director of Nursing (DON), Resident 3's Change in Condition Evaluation (CIC) dated 5/31/2025, 8/4/2025, and 10/4/2025 were reviewed. The DON stated Resident 3 had fallen at the facility on five separate occasions since being admitted to the facility. The DON stated Resident 3 had fallen three times, (5/31/2025, 8/4/2025, and 10/4/2025) since the facility's last recertification survey. The CIC dated 5/31/2025 indicated on 5/31/2025 at 1:20 PM, Resident 3 was found on the floor lying on the right side. The CIC indicated Resident 3 had a right head hematoma (bruising) and a laceration measuring around 3 cm. long. The CIC indicated Resident 3's physician instructed the facility to send Resident 3 via 911 (emergency response) to a General Acute Care Hospital (GACH) due to unwitnessed fall and to treat Resident 3's hematoma and laceration on Resident 3's head. The CIC indicated 911 was called and that emergency medical services (EMS) took Resident 3 to GACH 1. The CIC dated 8/4/2025 indicated on 8/4/2025 at 1:00 PM, Resident 3 was observed on the floor face down, and had a 5 cm long laceration on the forehead with bleeding. Resident 3 was transferred to (GACH 2) via 911 for further evaluation. The CIC dated 10/4/2025 indicated on 10/4/2025 at 1:20 PM, Resident 3 had an unwitnessed fall and was discovered on the floor. The CIC indicated, Resident 3 verbalized feeling dizzy and fell. The CIC indicated Resident 3's physician instructed the facility to send Resident 3 to GACH 3 for further evaluation. During a concurrent interview and record review on 10/28/2025 at 9:49 AM with the DON, Resident 3's Nursing-Fall Risk Evaluation (FRE) dated 5/22/2025 and 10/4/2025 were reviewed. The DON stated the FRE dated 5/22/2025 inaccurately indicated Resident 3 had no falls in the last 90 days. The FRE dated 10/4/2025 inaccurately indicated Resident 3 was at low risk of falling. The DON stated the FRE dated 5/22/2025 incorrectly indicated Resident 3 was at low risk of falling instead of accurately indicating Resident 3 was at high risk of falling again. The DON stated an FRE was 055541 Page 2 of 3 055541 10/28/2025 Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some required after each fall to help identify risks of falls prior to the resident falling again. The DON stated if an FRE is completed inaccurately, then residents had the potential to fall again. The DON also stated an FRE was not completed after Resident 3 fell on 5/31/2025. c. During a concurrent interview and record review on 10/28/2025 at 9:49 AM with the DON, Resident 3's Progress Notes (PN) dated 10/27/2025 was reviewed. The PN indicated the IDT fall review committee met following Resident 3's falls on 5/31/2025, 8/4/2025 and 10/4/2025. The DON stated the IDT did not conduct a thorough root cause analysis for Resident 3 for each fall. The DON stated the IDT did not focus on Resident 3's diagnoses as being a contributing factor to Resident 3's repeated falls. The DON stated the IDT did not change interventions to prevent Resident 3 from falling but still expected the current interventions to prevent Resident 3 from falling again. The DON stated if the IDT did not conduct a thorough root cause analysis, Resident 3 would likely fall again. During a concurrent interview and record review on 10/28/2025 at 9:49 AM with the DON, Resident 3's undated Care Plan Report (CPR) was reviewed. The CPR indicated the facility failed to initiate or update Resident 3's care plan to address Resident 3's risk of falling again, following Resident 3's falls on 5/31/2025, 8/4/2025, and 10/4/2025. The DON stated the IDT did not review Resident 3's care plan following the falls. The DON stated if a resident (in general) had repeated falls then interventions used to prevent the falls must be changed since the current interventions were not working to prevent the falls. The DON stated if resident's care plan was not updated following a fall, the resident would be more likely to fall again. During a review of the facility's policy and procedure (P&P) titled, Fall Management & Prevention Policy, undated, the P&P indicated, the purpose of the fall management and prevention policy was, To minimize the risk of patient/resident falls and fall-related injuries by implementing assessment, prevention, and management strategies . The P&P indicated the responsibility of the facility's Clinical and Nursing staff (in general) was to: Conduct fall risk assessment on admission, transfer, after a fall, or when there is a significant change in condition. Develop and implement individualized fall prevention plans. Document interventions and patient/resident responses in the care record. Educate patients/residents and families on fall risks, prevention measures and safe mobility. Report all falls and near-falls immediately according to facility incident reporting procedures.The P&P indicated the responsibility of all staff was to . Maintain a safe physical environment: clear walkways, adequate lighting, safe flooring, proper use of equipment and assistive device. The P&P indicated Post Fall (after a resident falls at the facility) Management included: . Update the individual's care plan and risk status if needed. Convene a multidisciplinary fall review committee (e.g., nursing, PT/OT, risk management, quality/safety) to analyze:- The event's chain of events and contributing factors- Whether existing interventions were in place and effective- Recommend and implement corrective actions (e.g., change in intervention plan, staff education, environment modification) . 055541 Page 3 of 3