Health inspection·December 14, 2023

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 develop and/or implement a care plan for one of three sampled residents (Resident 1) who was assessed at risk for elopement (leaving an institution without notice or permission). This deficient practice resulted in Resident 1 attempting to elope from the facility by climbing out of the facility s bathroom window and breaking her right leg when she fell to the ground outside that bathroom. 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 including dementia (progressive loss of memory), anxiety (extreme worry), depression (feeling unhappy and without hope) and a history of falling. During a review of Resident 1's Minimum Data Set ([MDS]) a standard assessment and care screening tool), dated 11/21/2023 Resident 1's cognitive (the ability to think, reason, and understood) skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 needed partial to moderate assistance with toileting, sit to stand and walking. During a review of Resident 1's Elopement Risk Evaluation, dated 11/16/2023, the Elopement Risk Evaluation indicated Resident 1 was at risk for elopement. During a review of Resident 1's clinical record, there was no Care Plan available for review related to Resident 1's risk for elopement. During a review of Resident 1's Change of Condition (COC) dated 12/8/2023, the COC indicated Resident 1 suffered a fall on the 12/7/2023. The COC indicated Resident 1 climbed through the bathroom window and was found outside the bathroom window. The COC indicated Resident 1 was holding her right leg and complained of pain. During an interview on 12/12/2023 at 12:05 p.m., Certified Nurse Assistant 1 (CNA 1) stated she saw Resident 1 get up from bed and walk towards the bathroom in her room and she (CNA 1) went to assist her (Resident 1) to the bathroom. CNA 1 stated Resident 1 closed the bathroom door and insisted that it remain closed. CNA 1 stated she respected Resident 1's request but left a crack in the door. CNA 1 stated a few minutes went by, she knocked on the bathroom door and saw through the opening of the door that the shower chair was positioned against the wall, the window in the bathroom was open (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056446 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 056446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paramount Convalescent Hosp. 8558 East Rosecrans Avenue Paramount, CA 90723 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)