Health inspection·December 17, 2025

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some floor and landed on his buttocks. During a review of the admission Record indicated Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including abnormalities of gait and mobility, type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and heart failure (a condition in which the heart does not pump blood as well as it should).During a review of the MDS dated [DATE], the MDS indicated Resident 9's cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 9 was totally dependent from staff for ADLs. During a review of Resident 9's FRA, dated 1/25/2026, the FRA indicated, Resident 9 had a score of 17 (total score above 10 represents high risk [of fall]). During a review of Resident 9's BCP, dated 12/15/2025, the BCP indicated Resident 9 safety precautions information was blank and no information if resident have any safety precautions such as history of falls/or at risk of falls CP in placed. During a review of Resident 9's SBAR dated 1/25/2026, the SBAR indicated, Resident (9) was found sitting on floor outside bathroom door.During a review of the admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy, heart failure and lack of coordination.During a review of the MDS dated [DATE], the MDS indicated Resident 9's cognitive skills for daily decisions were mildly impaired. The MDS indicated Resident 10 required maximal assistance from staff for ADLs. During a review of Resident 10's FRA, dated 2/1/2026, the FRA indicated Resident 10 had a score of 10 (total score above 10 represents high risk [of fall]). During a review of Resident 10's BCP, dated 2/1/2026, the BCP indicated Resident 10's safety precautions information was blank and no information if resident have any safety precautions such as history of falls/or at risk of falls CP in placed. During a review of Resident 10's SBAR dated 1/23/2026, the SBAR indicated, Found Resident (10) on the floor next to the bed, on the left side.During a concurrent interview and record review with Minimum Data Set Nurse 1 (MDSN 1) and Minimum Data Set Nurse 2 (MDSN 2) on 2/4/2026 at 2:06 p.m., MDSN 1 stated, resident's BCP must be developed and completed when residents get admitted and/or readmitted which is completed by the whole IDT team.During a concurrent interview and record review with Director of Nursing (DON) on 2/4/2026 at 3:32 p.m., DON reviewed Resident 7, Resident 8, Resident 9 and Resident 10's BCP and stated, the BCP were not completed and were not documented accurately. DON stated, if the BCP were not accurate, they would not know if residents were at risk for fall or not. DON stated, Residents 7, 8, 9 and 10 were evaluated as high risk of falls during their readmission assessment but the BCP were not developed, and no interventions were included to address their history of fall and/or risk of accidents due to falls.During a review of facility's policy and procedure (P&P) titled, Care Plans - Baseline, revised 1/2026, the P&P indicated, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. The interdisciplinary team will review the healthcare practitioner's orders and implement a baseline care plan to meet the resident's immediate needs including, but not limited to the following: a. initials goals based on admission orders; physician's orders, dietary orders; therapy services; social services; and PASARR recommendation, if applicable.During a review of facility's P&P titled, admission Assessment and Follow Up: Role of the Nurse, revised 1/2026, the P&P indicated, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS. Conduct an admission assessment including: a summary of the individual's recent medical history, including hospitalizations, acute illnesses, and overall status prior to admission; relevant medical, social, and family history; a list of active medical diagnoses and patient problems (such as recurrent falling or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056195 If continuation sheet Page 2 of 8 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 056195 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Brea Rehabilitation Center 505 N. LA Brea Avenue Los Angeles, CA 90036 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)

F 0655 impaired mobility). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056195 If continuation sheet Page 3 of 8 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 056195 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Brea Rehabilitation Center 505 N. LA Brea Avenue Los Angeles, CA 90036 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)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow professional standards of practice by failing to manage, assess and monitor resident and implement the facility policy and procedure (P&P) titled, Nursing Care of the Older Adult with Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), for one of three sampled residents (Resident 2), when resident had a hyperglycemia (high blood sugar, occurs when there's too much glucose in the blood, often because the body lacks enough insulin or can't use it properly).This deficient practice placed Resident 2 at risk of developing complications due to inadequate monitoring of blood glucose.Findings:During a review of the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type II DM, DM, End Stage Renal Disease (ESRD - irreversible kidney failure), and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of the Minimum Data Set (MDS - resident assessment tool) dated 9/27/2025, indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 2 required supervision from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 2's Order Summary Report (OSR), dated 11/25/2025, the OSR indicated, insulin glargine (a long-acting insulin used to manage blood sugar levels) subcutaneous (SQ - a shot given into the fatty layer right under the skin, not into a muscle, using a small needle for slow, steady medicine absorption) solution 100 unit/millimeter (ml unit of measurement) - inject four unit SQ in the morning.During a review of Resident 2's Medication Administration Record (MAR), dated 11/26/2025 at 6:30 a.m., the MAR indicated, Resident 2's blood sugar (BS) level was 348 milligram per deciliter (mg/dl - unit of measurement).During a review of Resident 2's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 11/26/2025 at 1:05 p.m., the SBAR indicated, Resident 2 was found unresponsive, lethargic (decrease in consciousness), not easily arose, breathing noted to be labored. blood pressure (BP - measures the force of blood against artery walls) 156/90 (a BP of 156/90 is considered high BP), pulse (heart beat counted per minute) 86 beats per minute (bpm), temperature 97.2 degrees Fahrenheit (F - temperature scale) and respiration (RR - breathing rate) 20.During a concurrent interview and record review with Licensed Vocational Nurse (LVN 3) on 12/16/2025 at 1:23 p.m., LVN 3 stated, in the morning of 11/26/2025, Resident 2 was sleeping and did not touch his (Resident 2) breakfast, but he usually was up early in the morning and would eat his breakfast. LVN 3 stated, Resident 2 struggled waking up and he was unable to open his eyes. LVN 3 reviewed Resident 2's MAR on 11/26/2025 at 6:30 a.m., and stated, she was not made aware of Resident 2's BS of 348 mg/dl. LVN 3 stated, there was no report given to her during hands-off from Licensed Vocational Nurse 6 (LVN 6) in the morning of 11/26/2025. LVN 3 further stated, she checked Resident 2's BS upon assessment that he was lethargic, and he had a BS of 70 mg/dl which means hypoglycemic (low blood sugar). LVN 3 reviewed SBAR on 11/26/2025 and stated, she did not document the BS of 70 mg/dl and she should have documented it.During an interview with LVN 6 on 12/16/2025 at 3:12 p.m., LVN 6 stated, she checked Resident 2's BS on 11/26/2025 at 6:30 a.m. and he had a high BS. LVN 6 stated, she administered glargine insulin, but she did not recheck his BS after administering the insulin. LVN 6 stated, she also did not give any hand-off report to the oncoming nurse regarding Resident 2's high BS and she did not document what her interventions upon assessing Resident 2's high BS. LVN 6 Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056195 If continuation sheet Page 4 of 8 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 056195 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Brea Rehabilitation Center 505 N. LA Brea Avenue Los Angeles, CA 90036 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)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete further stated, I honestly don't remember what I did but I should have rechecked his (Resident 2's) BS and notify the physician and the oncoming nurse and documented it.During an interview with Director of Nursing (DON) on 12/17/2025 at 2:26 p.m., DON stated, if resident has a high BS and license nurse administered insulin, they need to recheck the BS because residents who are given insulin are at risk of hypoglycemia. DON stated, Resident 2's had symptoms of hypoglycemia on 11/26/2025 as he was lethargic, unable to be aroused and unresponsive. DON further stated, the facility staff failed to document the interventions and did not notify the physician upon assessment of BS of 348 mg/dl.During a review of the facility's P&P titled, Nursing Care of the Older Adult with Diabetes Mellitus, revised on 12/2024, the P&P indicated that, The target range for healthy older adults is considered 90-130 mg/dl. The provider will order the frequency of glucose monitoring and establish appropriate glycemic targets for individual residents. Establish provider notification protocols, for example:a. Call provider immediately if resident is hypoglycemic {<70 mg/dL).b. Call as soon as possible when:(1) blood glucose values are regularly 70-100 mg/dL (for possible regimen adjustment);(2) blood glucose values are >250 mg/dL more than once within a 24-hr period;(3) blood glucose values are >300 mg/dL more than once over two consecutive days;(4) reading is too high for glucometer; or(5) the resident is vomiting, has symptomatic hyperglycemia or poor oral intake.Medication Management:5. Closely monitor the diabetes management of cognitively impaired residents.Documentation:b. Level of consciousness, change in orientation;c. Dose and time of most recent anti-hyperglycemic given; Event ID: Facility ID: 056195 If continuation sheet Page 5 of 8 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 056195 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Brea Rehabilitation Center 505 N. LA Brea Avenue Los Angeles, CA 90036 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)

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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed as high risk for falls and dependent in Activities of Daily Living (ADLs), did not experience multiple falls, one resulting in injury, by failing to: 1. Initiate an individualized plan of care upon admission on [DATE] when Resident 1 was identified as having a high fall risk. 2. Update the care plan and interventions when Resident 1 had an unwitnessed fall on 11/16/2025. 3. Ensure staff adhered to the facility's policy and procedure titled Falls - Clinical Protocol (revised 12/2024), which requires staff and physicians to identify and implement interventions to prevent falls and mitigate clinically significant consequences. 4. Evaluate and analyze hazards and risks following repeated unwitnessed falls. As a result of these failures, Resident 1 had multiple unwitnessed falls (11/16/2025, 11/23/2025) and on 12/1/2025 Resident 1 slid from the bed, landing face down on the floor, resulting in a three cm laceration to the left forehead. Resident 1 was transferred to a General Acute Care Hospital (GACH) 1 on 12/2/2025 for generalized pain following the fall, with diagnoses of thoracic spine strain (discomfort in the mid-back, between the shoulder blades and lower ribs, often caused by muscle strain, poor posture, overuse, or joint issues, though more serious causes like nerve compression or fractures exist) and left shoulder contusion (bruise from direct impact, causing pain, swelling, stiffness, and discoloration [black-and-blue] as blood vessels leak under the skin). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnosis that included acute respiratory failure with hypoxia (severe, sudden condition where the lungs can't get enough oxygen into the blood), other lack of coordination, and other abnormalities of gait (a manner of walking or moving the foot) and mobility (ability to move arounds freely and easily). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/17/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills were severely impaired. The MDS indicated Resident 1 was dependent on oral hygiene, toileting, bathing and dressing. The MDS indicated Resident 1 was also dependent with mobility, helper does all of the effort, with Resident 1 laying on back to roll left and right side, sit on side of bed to lying flat on the bed, lying on the back to sitting on the side of the bed and with no back support, come to a standing position from sitting and transfer to and from a bed to chair. The MDS also indicated Resident 1's ability to get on and off a toilet commode was not attempted due to medical conditions or safety concerns. During a record review of Resident 1's fall risk assessment dated [DATE], the fall risk assessment indicated score of 14. According to the falls assessment tool, if the total score is above 10, the resident should be considered high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. During a record review Resident 1's admission care plan, for the admission date 11/11/2025, unable to locate documentation of a high risk for fall care plan, no care plan initiated and no intervention in place. During a review of Resident 1's Situation, Background, Assessment, Request (SBAR-communication framework widely used in healthcare to ensure clear, concise, and organized information exchange among team members.) Communication Form, dated 11/16/2025 timed at 4:16 a.m., the SBAR indicated Resident 1 slid out of bed and found sitting on the floor at bedside with no visible injuries or bruises noted and Resident 1 denied any acute pain. During a record review of Resident 1's fall risk assessment dated [DATE], indicated score of 19.During a review of review of the care plan titled Resident 1 noted sliding out of bed, dated 11/16/2025, the care plan intervention indicated fall precautions implemented such as bed at lowest locked position and frequent visual (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056195 If continuation sheet Page 6 of 8 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 056195 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Brea Rehabilitation Center 505 N. LA Brea Avenue Los Angeles, CA 90036 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few checks done by staff to ensure safety and monitoring. During review of Resident 1's care plan titled, Risk for fall initiated 11/17/2025, the care plan indicated anticipate and meet Resident 1's needs, Resident 1 needs prompt response to all request for assistance and follow facility fall protocol. During review of Resident 1's Occupational Treatment (OT) Encounter Notes, dated 11/17/2025, the notes indicated Resident 1's functional status as total dependence with dressing, toileting and bathing and unable to sit or stand during ADL. The notes indicated Resident 1 required extra time to initiate and complete given task. The notes also indicated that Resident 1's cognitive status and nursing care required were complexities and barriers impacting OT therapy session. During a review of Resident 1's SBAR Communication Form, dated 11/23/2025 timed at 9:06 p.m., the SBAR indicated Resident 1 was found on the floor by his bedside. During a review of Resident 1's SBAR Communication Form, dated 12/1/2025 timed at 10:30 p.m., the SBAR indicated a loud sound came from Resident 1's room and Resident 1 was found lying on the floor on his left side faced down. The SBAR further indicated Resident 1 had been attempting to use urinal on the edge of his bed until he slipped off the bed. The SBAR also indicated Resident 1 sustained a laceration on his left forehead above the eyebrow and reported a pain level of 7/10 and when assessed using the two-finger test, stated he were seeing 4 fingers(double). During an interview on 12/16/2025 at 4:02 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 depends totally on assistance with ADL's including toileting. LVN 1 stated Resident 1 was incontinent and able to tell the staff when he is wet. LVN 1 stated Resident 1's uses the urinal only when his spouse is present. LVN 1 stated that after Resident 1 fell on [DATE], the care plan should be floor mat, frequent (every hour and a half) visual checks and addressing why Resident 1 fell. Since there is no care plan done none of this intervention was implemented. LVN 1 said when Resident 1 fell again, the nurse needed to determine why he fell, review his medications, and assess whether confusion, attempts to get up, or anxiety caused the fall. LVN 1 said finding the cause of the second fall is necessary to change the care plan and prevent more falls. LVN 1 said, If the care plan stays the same with no changes to interventions Resident 1 can get hurt and it means we are not doing our job properly. LVN 1 said the LVN assigned to the resident initiates care plan changes, and the RN completes the assessment, follows up with the physician, and revises the care plan further. LVN 1 said the goal is to prevent Resident 1 from falling again and getting injured. During an interview on 12/17/2025 at 11:06 a.m. with LVN 2, LVN 2 stated Resident 1 responds verbally with episodes of confusion, especially at night. LVN 2 stated Resident 1 tries to get out of bed by pulling his upper body using the side rails. LVN 2 stated while assisting CNA 1 with another resident room, LVN 2 and CNA 1 heard a loud bang sound that came from Resident's 1 room. When they went to Resident 1's room, they found Resident 1 on the floor with the urinal next to him and urine on the floor. LVN 2 stated that Resident 1 told him, on 12/1/2025 after Resident 1 fell, he was at the edge of the bed trying to use the urinal and slipped out of bed. LVN 2 said he cannot confirm if Resident 1 slipped as described because Resident 1's cognition is impaired. LVN 2 said he forgot to update the care plan after the fall on 12/1/2025 and learned about it from Medical Records staff the next day. LVN 2 said he completed the care plan on paper the day after the fall and gave it to Medical Records. LVN 2 said he did not verify whether Medical Records received the care plan he submitted. During a concurrent interview and record review on 12/17/2025 at 12:07 p.m., with RN 1, Resident 1's care plan dated 11/10/2025 and 11/17/2025 and fall risk assessment dated [DATE] and 11/16/2025 were reviewed. The fall risk assessment dated [DATE] showed a score of 14. The admission care plan dated 11/10/2025 indicated no documented safety concern and did not address the risk of falls. RN 1 stated Resident 1 was high risk for falls based on fall assessment on 11/10/2025 and staff should have initiated a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056195 If continuation sheet Page 7 of 8 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 056195 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Brea Rehabilitation Center 505 N. LA Brea Avenue Los Angeles, CA 90036 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete care plan for risk for falls. The fall risk assessment dated [DATE] S/P fall showed a score of 19. RN 1 said staff did not initiate care plan for actual fall on 11/16/2025. RN 1 stated she was the RN on duty when Resident 1 had another fall on 12/1/2025. RN 1 stated care plan should have been revised with changes in the interventions based on findings why Resident 1 keeps falling. RN 1 stated there should be a care plan addressing Resident 1's behavior with interventions such as frequent safety reminders and hourly check on Resident 1. RN stated it is important to have an updated, current care plan to prevent falls from recurring of which could result in injury or possible death. During an interview on 12/17/2025 at 2:40 p.m., with Director of Nursing (DON), DON stated a care plan is done on admission and reviewed and revise it as needed. The DON stated staff should have revised Resident 1's care plan after the fall on 11/23/2025 and completed a fall risk assessment. The DON stated it is important to assess what was missing from the initial care plan and change or add interventions based on their effectiveness. The DON stated staff must determine why the fall occurred and identify factors that explain the resident's behavior that increases fall risk so they can address them. The DON stated after a fall, staff must review the care plan, identify needed changes, and determine additional interventions. The DON said the care plan guides the care provided to the residents, and if staff fail to update it, the facility is not taking steps to prevent another fall. The DON further stated the plan of care becomes ineffective when staff do not update the care plan. The DON said failing to include a known issue in the care plan can lead to more falls and potentially cause injuries. During review of the GACH 1 records titled Emergency Department Reports (EDR) dated 12/2/2025, the EDR indicated Resident 1's presented for the GACH Emergency Department with generalized body pain after a fall and laceration to the left eyebrow. The EDR indicated Resident 1's visit diagnosis as forehead laceration, closed injury, cause of injury - accidental fall, thoracic spine strain and left shoulder contusion. During a review of the facility's policy and procedure (P&P) titled, Falls - Clinical Protocol, dated 2/2024, the P&P indicated, For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. If the fall is unclear.or if the individual continuous to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. The P&P also indicated, Based on preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls to address the risks of clinically significant consequences of falling.The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. During a review of the facility's fall prevention potential intervention dated 12/2024 nursing measures indicated toileting schedule, proper positioning, and use of non-slip material to prevent sliding. During a review of facility's P&P titled, Care Plans - Baseline, dated 12/2024, the P&P indicated, to assure that a resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of admission. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 12/2024, the P&P indicated, The Care Planning process will facilitate resident and/or representative involvement, include an assessment of the resident's strengths and needs, and incorporate the resident's personal and cultural preferences in developing the goals of care. During a review of the facility's P&P titles, Care Planning - Interdisciplinary Team, dated 12/2024, the P&P indicated, our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. Event ID: Facility ID: 056195 If continuation sheet Page 8 of 8