Health inspection·November 4, 2024

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 observation, interview, and record review, the facility failed to install floor mats (a cushioned floor pad designed to help prevent injury should a resident falls) for one of three residents (Resident 1) who was a high risk for fall, as indicated on the resident ' s Care Plan. This failure had the potential to result in Resident 1 sustaining injuries such as fractures (broken bones) and brain hemorrhage (bleeding in the brain) from a fall. 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 on [DATE]. The admission Record indicated Resident 1 ' s diagnoses included metabolic encephalopathy (a disorder that affects brain function), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), dementia (a progressive state of decline in mental abilities) and cerebral infarction (loss of blood flow to the brain). During a review of Resident 1 ' s History and Physical (H&P), dated 7/5/2024, the H&P indicated Resident 1 did not have capacity to make medical decisions. During a review of Resident 1 ' s Fall Risk Observation/assessment dated , 7/4/2024, the Assessment indicated Resident 1 was a high risk for fall. During a review of Resident 1 ' s Fall Care Plan dated 10/20/2024, the Care Plan indicated Resident 1 had a fall with injury due to the resident getting out of bed unassisted, confusion, poor balance, poor communication/comprehension, and unsteady gait. The Care plan indicated nursing interventions included, to place floor mats on both sides of Resident 1 ' s bed. During a concurrent interview and record review on 11/4/2024 at 8:59 a.m. with Licensed Vocational Nurse (LVN 1), Resident 1 ' s Change of Condition (COC) and fall care plan dated 10/20/2024 were reviewed. LVN 1 stated Resident 1 fell out of bed and was transported to the hospital. LVN 1 stated the care plan indicated Resident 1 should have floor mats on both sides of the bed to minimize injury if Resident 1 fell again. During a concurrent observation and interview on 11/4/2024 at 9:08 a.m. with LVN 1 in Resident 1 ' s room, no floor mats were observed on both sides of Resident 1 ' s bed. LVN 1 stated, Resident 1 should have floor mats however there were no floor mats on both sides of Resident 1 ' s bed. LVN 1 Page 1 of 2 055608 055608 11/04/2024 Primrose Post-Acute 515 Centinela Ave. Inglewood, CA 90302

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated Resident 1 could fall again and suffer broken bones and brain hemorrhage because the pads were not in place. During an interview on 11/4/2024 at 2:35 p.m. with the Director of Nursing (DON), the DON stated nursing staff were responsible for implementing care plan interventions and ensuring floor mats were provided for Resident 1. During a review of the facility ' s undated policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, the P&P indicated care plans describe the services to be provided to maintain the residents ' highest practicable level of well-being. The P&P indicated residents had the right to receive the services and items included in the care plan. 055608 Page 2 of 2