Health inspection·May 6, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure an extended floor mattress (a thicker safety mat [a floor pad designed to help prevent injury should a person fall] designed to provide cushion and protection in the event of a fall) was placed on the floor next to the bed for one of three sampled residents (Resident 1) who was assessed at high risk for falls and who had a history of falling, per Resident 1 ' s Care Plan dated 3/5/2025 This deficient practice resulted in Resident 1 experiencing an unwitnessed fall (4/25/2025) and being found on the floor without an extended floor mattress in place as care planned (3/5/2025). This deficient practice had the potential to result in Resident 1 sustaining aninjury. Findings During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a slight paralysis or weakness on one side of the body). During a review of Resident 1 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 2/2/2025, the MDS indicated Resident 1 ' s cognition (the process of knowing, understanding, and thinking) was severely impaired and Resident 1 required substantial/maximal assistance (helper does more than half the effort) from facility staff to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1 ' s Care Plan revised 3/5/2025, the Care Plan indicated Resident 1 had a fall on 3/4/2025. The Care Plan ' s goals included Resident 1 would resume usual activities without further incident. The Care Plan ' s interventions included using an extended mattress on the floor due to Resident 1 ' s history of falls. During a review of Resident 1 ' s Nurses Notes dated 4/25/2025, the Nurses ' Notes indicated licensed staff responded to Resident 1 ' s bed alarm and found Resident 1 lying on the floor on the right side of her bed. The Nurses Notes indicated there was no extended mattress on the floor on the right side of Resident 1 ' s bed because of Resident 2 ' s (Resident 1 ' s roommate) safety precautions to keep the room and [ During an interview on 5/6/2025 at 12:58 p.m., Licensed Vocational Nurse (LVN) 1 stated the extended floor mattress could not be placed on the floor on the right side of Resident 1 ' s bed because Page 1 of 2 056283 056283 05/06/2025 Bixby Towers Post-Acute Rehab 3747 Atlantic Avenue Long Beach, CA 90807

F 0656 Resident 2 was ambulatory (could walk) and she (Resident 2) might trip over the extended mattress. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/6/2025 at 4:30 p.m., the Director of Nursing (DON) stated Resident 1 was a high risk for falls, the intervention in her Care Plan (3/5/2025) that indicated to use an extended mattress should have been implemented and if that was not appropriate, other interventions should have been attempted. Residents Affected - Few During a review of the facility ' s policy and procedure (P/P), titled Falls and Fall Risk, Managing dated 3/2018, the P/P indicated the staff, with input of the attending physician, will implement a resident centered fall prevention plan to reduce the specific risk factor of falls for each resident at risk or with a history of falls. 056283 Page 2 of 2