Health inspection·April 30, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 2 ' s Change of Condition (COC) dated 4/1/2025 at 10:46 a.m., the record indicated Resident 2 had a witnessed fall when Resident 2 had a witnessed fall. During a review of Resident 2 ' s Care Plan titled Resident 2 had a fall with no injury with no injury, revised 4/1/2025, the interventions indicated to check range of motion and report mental changes. Residents Affected - Few During a concurrent interview and record review on 4/30/2025 at 9:36 a.m. with LVN 1, Resident 2 ' s Care Plan, revised 4/1/2025, LVN 1 stated the record did not include interventions did not address when Resident 2 sled off his wheelchair. LVN 1 stated the interventions should have included elevating the resident ' s legs with pillows to prevent the resident from sliding down the wheelchair. LVN 1 stated there was no IDT meeting conducted after the fall. LVN 1 stated Resident 2 ' s care plan was not individualized and did not focus on the causes why Resident 2 sled down his wheelchair. 2). During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses of difficulty walking and low back pain. During a review of Resident 3 ' s Care Plan titled Resident 3 had an actual fall with no injury, poor balance, poor communication/comprehension, unsteady gate, dated 1/26/2025, one of the interventions indicated to provide floor mat and determine and address causative factor for the fall. During a review of Resident 3 ' s fall risk assessment after the fall on 1/26/2025, the fall risk assessment did not reflect the fall Resident 3 had on 1/26/2025. During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 was able to understand and be understood by others. The MDS indicated Resident 3 required supervision for eating, and upper body dressing and substantial assistance (helper lifts, holds, or supports trunk or limbs, and provides more than half the effort) with oral hygiene, and upper dressing. The MDS indicated Resident 3 was dependent with showers, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 3 required supervision with rolling left to right, moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) sit to lying, lying to sitting on side of bed and substantial assistance with sitting to standing, chair/bed-to-chair transfer, and walking 10 feet. During a review of Resident 3 ' s COC dated 2/7/2025 at 12:00 a.m., the COC indicated Resident 3 was observedon the floor, on his back, next to his bed. The COC indicated that Resident 3 verbalized he rolled over and fell on the floor. During a review of Resident 3 ' s Rehabilitation Service Screening Tool dated 2/7/2025 at 1:50 p.m., the notes indicated Resident 3 reported he fell out of bed two times. The notes indicated the resident reported he tried to stay off his wound, but he felt he was at risk of falling because his bed had no barriers. The notes indicated recommendations for bed railings, and cushion pad along the bedside to reduce the risk of falls and soften fall. During a concurrent interview and record review on 4/30/2025 at 9:36 a.m. with Licensed Vocational Nurse (LVN 1), Resident 3 ' s Fall Risk Evaluation dated 1/26/2025 at 6:45 a.m. was reviewed. LVN 1 stated the fall risk evaluationdid not reflect the fall Resident 3 had on 1/26/2025. LVN 1 stated Resident 3 had a poor balance and did not reflect in the fall risk assessment which resulted in the resident being a medium risk for falls. LVN 1 stated Resident 3 was on Lasix (water pill that may (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056267 If continuation sheet Page 2 of 3 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 056267 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camino Healthcare 13922 Cerise Avenue Hawthorne, CA 90250 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 - Minimal harm or potential for actual harm Residents Affected - Few reduce blood pressure), Lisinopril (medication that lowers blood pressure), and Amitriptyline (medication used for low mood and to help sleep) which could cause drowsiness and increase the resident ' s risk of falling. LVN 1 stated if the fall risk evaluation was conducted correctly, the assessment would have indicated Resident 3 was at a higher risk for falls. LVN 1 stated that it was important to have a correct fall evaluation to identifyResident 3 ' s risk for falling and i appropriate interventions will be implemented. LVN 1 stated there was no care plan created after the fall on 2/7/2025, and placedResident 3 at higher risk of falls because there were no interventions to prevent him from falling. During a concurrent observation, interview, and record review on 4/30/2025 at 12:54 p.m., with Physical Therapy (PT), Resident 3 ' s Rehabilitation Service Screening Tool dated 2/7/2025 at 1:50 p.m., PT stated the record indicated Resident 3 rolled off the bed and the recommendation was to place bed railings, and cushion pad along bedside to reduce the risk of falls and soften fall. PT stated there were no bed railings, no cushion pads and no floor mats noted in Resident 3 ' s room. PT stated not implementing interventions could lead to additional falls and they could lead to injury and hospitalization. During a review of the facility ' s policies and procedures (P&P) titled, Fall Management System, dated 11/2021, the P&P indicated the facility should provide residents with appropriate assessments and interventions to prevent and to minimize falls and complications. The P&P indicated that the IDT would review and updated care plan and would reassess resident for fall risks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056267 If continuation sheet Page 3 of 3