Health inspection·September 17, 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. Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with a proper functioning bed pad alarm (an alerting device intended to monitor a resident's movement) as ordered by the physician.This deficient practice had the potential to place Resident 1 at an increased risk for further falls, accidents, and injuries.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 12/19/2024 with diagnoses that include fracture (break in a bone) of right femur (thigh bone), hemiplegia (one-sided paralysis [complete or partial loss of muscle function]) following cerebral infarction (stroke- loss of blood flow to a part of the brain) affecting left non-dominate side, morbid obesity (excessive body fat), dementia (a progress state of decline in mental abilities), and history of falling.During a review of Resident 1's History and Physical (H&P) dated 12/21/2024, the H&P indicated Resident 1 had capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 6/27/2025, the MDS indicated Resident 1's cognition (ability to think and make decisions) was moderately impaired. The MDS further indicated that Resident 1 required set up assistance with eating, moderate assistance with oral hygiene, maximum assistance with upper body dressing and personal hygiene and dependent on staff for toileting hygiene, showering and lower body dressing.During a review of Resident 1's physician order dated 9/8/2025, the physician order indicated the use of a bed pad alarm to decrease potential for injury.During a concurrent observation and interview on 9/17/2025 at 2:15 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 attempted to demonstrate that Resident 1's bed pad alarm was working. CNA 1 pressed the bed pad alarm and no alert was heard. CNA 1 stated that she (CNA 1) did not believe the bed pad alarm was working properly.During a concurrent observation and interview on 9/17/2025 at 2:17 p.m., with the Director of Nursing (DON), the DON confirmed the observation by stating that the bed pad alarm for Resident 1 was not currently operating properly.During an interview on 9/17/2025 at 2:55 p.m., with the Central Supply Manager (CSM), the CSM stated that normally the CSM will check all the position change alarms on a daily basis to make sure they are operating properly. The CSM stated that at times the nursing staff will inform the CSM of a position change alarm not functioning properly and the CSM will fix the existing one or change it with a new one. The CSM stated that the CSM did not check Resident 1's bed pad alarm today.During an interview on 9/17/2025 at 3:20 p.m., with the DON, the DON confirmed that the bed pad alarm should be in working order at all times. The DON stated that Resident 1's bed pad alarm was not working at the time of inspection. The DON stated that a non-working bed pad alarm for Resident 1 could lead to increased risk of fall, accident, or injury.During a review of the facility's policy and procedure (P&P) titled, Personal Alarm dated 3/15/2025, the policy indicated this facility will use, as indicated, a sensor pad that conveniently sounds an audible alarm when the sensor detects a patient rising out of the bed/wheelchair reminding the resident to return to a safe position while alerting staff to a Page 1 of 2 056412 056412 09/17/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0689 potential fall.If fall risk associated with fall from bed/chair is identified, physician orders will be obtained for assessment by appropriate staff.Check alarm system everyday for proper functioning. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056412 Page 2 of 2