Health inspection·May 29, 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. Based on observation, interview, and record review, the facility failed to prevent fall () for one (1) of three (3) sampled residents (Resident 1), assessed as high risk for falls when Resident 1 was not provided assistance when getting up from the bed to go to the bathroom and failing to initiate a fall care plan (a document created for a resident receiving healthcare, personal care, or other forms of support) , as indicated on the facility policy and procedure. This deficient practice resulted to Resident 1 ' s fall on 5/19/2024 and transfer to General Acute Care Hospital (GACH 1). Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 5/9/2024 with diagnoses which included muscle weakness, history of falling, and abnormality of gait and stability. A review of Resident 1 ' s Fall Risk Evaluation, dated 5/9/2024 indicated Resident 1 ' s score was 11 which indicated high risk of fall. Resident 1 ' s risk factors included were history of falls in the past 3 months, change of condition in the last 14 days, and balance problem while walking. A review of Resident 1 ' s History and Physical (H&P),dated 5/10/2024, indicated Resident 1 had the capacity to understand make decisions. It indicated Resident 1 ' s diagnosis of subdural hematoma (SDH, a clot of blood that develops between the surface of the brain and the dura mater [brain ' s tough outer covering], usually due to stretching and tearing of veins on the brain ' s surface. These veins rupture when a head injury suddenly jolts or shakes the brain) and was status post craniotomy (an operation in which a small hole is made in the skull or a piece of bone from the skull is removed to show part of the brain). A review of Resident 1 ' s Minimum Data Set (MDS, standardized care and screening tool), dated 5/16/2024, indicated Resident 1 ' s cognitive (processes of thinking and reasoning) skills for daily decision making was intact. Resident 1 required substantial maximal assistance (helper does more than half the effort, helper lift or hold trunk or limb) with toileting, shower, and lower body dressing. Resident 1 required partial / moderate assistance (helper does less than half the effort. Helper lift, holds, support trunk or limbs) with sit to stand (ability to come to standing position from sitting in a chair, wheelchair, or on the side of the bed), toilet transfer (ability to get off a toilet commode), and walking 10 feet (once standing ability to walk at least 10 feet in the room, corridor, or similar space). (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055760 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055760 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)