Health inspection·March 19, 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 interview and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) remain free from the accident hazards. * The facility failed to ensure Resident 1 was provided with two-person assistance for transfers. This failure had the potential to place the resident at risk for serious injuries. Findings: Medical record review for Resident 1 was initiated on 3/18/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Fall Risk Screen dated 3/7/25, showed Resident 1 was at high risk for falls and had a history of falls. Review of Resident 1's plan of care showed a care plan problem dated 3/8/25, addressing the resident's altered skin integrity. The interventions included to provide two-person assistance with transfers and positioning. Review of Resident 1's Nurse Weekly Progress Note dated 3/12/25, showed Resident 1 was dependent on the facility's staff for ADL care and required extensive assistance for transfers. On 3/17/25 at 0919 hours, CDPH, L&C Program received a complaint from Family Member 2. Family member 2 alleged CNA 2 forced Resident 1 to walk without using a wheelchair or walking aids on 3/13 and 3/14/25. On 3/18/25 at 1509 hours, an interview was conducted with CNA 2. CNA 2 was asked how she assisted Resident 1 to the bathroom on 3/13/25. CNA 2 stated she held Resident 1's arm while she ambulated to the bathroom. CNA 2 stated Family Member 1 was present and assisted her with taking the resident to the bathroom. On 3/19/25 at 1128 hours, an interview was conducted with Family Member 1. Family Member 1 stated on 3/13/25 at around 1700 hours, Resident 1 wanted to use the bathroom. CNA 2 came and assisted Resident 1 to use the bathroom. Family Member 1 stated CNA 2 held Resident 1's left arm as the resident ambulated to the bathroom. Family Member 1stated Resident 1 was unstable while ambulating with CNA 2 and almost fell. Family Member 1 stated she called the PT the next day and was told Resident 1 was not cleared to ambulate. Page 1 of 2 056271 056271 03/19/2025 Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683

F 0689 On 3/19/25 at 1505 hours, an interview and concurrent medical record review was conducted with DON for Resident 1. The DON was informed and acknowledged the above findings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056271 Page 2 of 2