Health inspection·April 16, 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 observation, interview, and record review, the facility failed to ensure the bed was in locked position for one (1) of two (2) sampled residents (Resident 1) who fell on 4/4/2025 around 9 am and was high risk for fall (to drop or descend under the force of gravity, as to a lower place through loss or lack of support) as indicated on the resident ' s care plan. This deficient practice had the potential to result in serious injuries or death in an event of another fall. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included but not limit tomuscle weakness, osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) and high blood pressure. During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool), dated 3/13/2025, the MDS indicated Resident 1 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 was dependent with shower and required substantial/maximal assistance (helper does more than half the effort) with toileting and personal hygiene, upper and lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with oral hygiene and setup assistance (helper sets up, resident completes activity) with eating. During a review of Resident 1 ' s Morse Fall Assessment (a tool that predicts the likelihood a Resident will fall) dated 3/13/2025, the Morse Fall Assessment indicated Resident 1 was a high risk for falls. A review of Resident 1 ' s Care Plan, initiated on 9/20/2025, the Care Plan indicated Resident 1 was at risk for fall related to cognitive impairment, unsteady gait (the manner or pattern of how someone walks, runs, or moves on foot), and poor safety awareness (not being mindful or attentive to potential dangers or risks). Resident 1 ' s Care Plan goal indicated to reduce the risk from injuries related to fall and an approach plan to keep the resident ' s bed locked. During a concurrent observation and interview on 4/16/2025 at 10:25 AM, Resident 1 was seen lying in bed with the left side of the bed against the wall and the 2 wheels on the right foot part of the Page 1 of 2 056080 056080 04/16/2025 The Bellefontaine Healthcare Center 150 Bellefontaine St Pasadena, CA 91105

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bed that was visible were unlocked and the bed was movable when pushed. Licensed Vocational Nurse 1 (LVN 1) confirmed Resident 1 ' s bed was unlocked and movable and stated the brakes on Resident 1 ' s bed should be locked to prevent risk for fall if the resident attempts to get up again. During an interview on 4/16/2025 at 10:40 AM, LVN 2 stated that on 4/4/2025 around 9AM she answered Resident 1 ' s roommate yell for help and when she approached the room, LVN 2 saw Resident 1 slid from the bed with the resident ' s right shoulder on top of the bottom metal part of the bedside table with her head up while trying to get up using her right elbow. During an interview on 4/16/2025 at 11:08 AM, Certified Nursing Assistant 1 (CNA 1) stated the bed should always be locked because it could move if Resident 1 tries to get up, causing the resident to fall again. During an interview on 4/16/2025 at 3:07 PM, Registered Nurse 1 (RN 1) stated to prevent the residents from fall, the bed should be locked since beds could move and residents could lose their balance when they try to get up by themselves. During a review of the facility ' s policy and procedure titled, Safety and Supervision of Residents, revised July 2017, indicated that the facility strives to make the environment as free from accident hazards as possible. The policy also indicated that the residents ' safety and supervision and assistance to prevent accidents are facility-wide priorities. During a review of the facility ' s policy and procedure titled, Falls and Fall Risk, Managing, revised March 2018, indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent from falling and to try to minimize complications from falling. The policy also indicated resident-centered (putting the individual ' s needs, preferences, and choices first when providing care) approach to managing falls and fall risk which included that the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 056080 Page 2 of 2