Health inspection·December 11, 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. Based on observations, interview and record review the facility failed to implement the care plan of one of three sampled residents (Resident 3) to ensure placement of bolster pillows (a long firm and raised pillows placed on the edges of the bed) on the mattress while in bed to prevent the resident from recurrent fall. Resident 3 had a history of unwitnessed falls from bed on 8/17/2025 and 9/22/2025. As a result of this deficient practice Resident 3 had the potential for recurrent falls that could result in pain, major injuries and a decline in residents' wellbeing. Findings: During a review of the facility's P&P titled Fall Management, dated 5/26/2021, the facility's P&P indicated that residents who were determined to be at risk for falls will receive the appropriate interventions to reduce risk and minimize injury and the residents who experienced falls will receive the appropriate care and investigation of the case. During a review of the facility's P&P titled Care Plan Comprehensive, dated 8/25/2021, the facility's P&P indicated the facility will identify problem areas, their causes, and develop interventions that required careful data gathering, proper sequencing of events, and systematic clinical decision-making. During a review of Resident 3's admission Record (AR), the facility admitted Resident 3 on 1/30/2016 and readmitted Resident 3 on 9/9/2025 with diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) without dyskinesia (uncontrolled, involuntary muscle movements ranging from shakes, tics and tremors to full-body movements) and contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the bilateral hands and ankles. During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 8/17/2025, the MDS indicated Resident 3 had cognitive (a person's mental process) skills for daily decision making were moderately impaired (decisions poor; cues/supervision required). The MDS indicated Resident 3's was dependent (the helper does all the effort) on staff for all activities of daily living (ADLs, activities such as bathing, dressing, and toileting a person performs daily) and was dependent on staff for functional mobility such as repositioning left and right in bed and transferring from bed to chair. During a review of Resident 3's Change of Condition (CoC) evaluation, dated 8/17/2025, at indicated on 8/17/2025 at around 4:10 PM Resident 3 was found face down on the floor mat next to her bed and complained of right wrist acute pain 9/10 (pain scale 0-no pain and 10-severe pain). During a review of Resident 3's INTERACT Transfer Form, dated 8/17/2025, indicated Resident 3 was transferred to the General Acute Care Hospital (GACH) 1 for the facility's inability to complete x-rays (images of the bone structures in the body) due to Resident 3's tremors (involuntary shaking or trembling movements in one or more parts of the body). During a review of Resident 3's Radiology Reports from GACH 1, dated 8/17/2025, the reports indicated there was no fracture (broken bone) or dislocation (displacement of bones in the joint) in Resident 3's right shoulder and right upper arm and no brain bleeding. During a review of Nursing Documentation Evaluation indicated on 8/29/2025 at 10:29 PM, Resident 3 readmitted to the facility from GACH alert and Page 1 of 3 056487 056487 12/11/2025 Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few oriented without complain of pain, distress or discomfort. During a review of Resident 3's Nursing Documentation Evaluation document, dated 8/29/2025, the document indicated Resident 3 was at risk for fall due to a history of falls within the last 6 months, poor safety judgement, impaired balance, and unsteady gait. During a review of Resident 3's CoC evaluation, dated 9/22/2025, timed at 2:50PM, the CoC indicated Resident 3 reported she had fallen. The report indicated a CNA witnessed Resident 3 on the floor after an unwitnessed fall. The COC indicated Resident 3 had no complaints of pain after the fall, Xray was done and sustained no injury. During a review of Resident 3's care plan revised on 9/23/2025, the care plan indicated Resident 3 was at risk for falls and will have no falls injuries by the target date of 10/14/2025 and the interventions, revised included to place a floor mat on the left side of the bed, to ensure the bolster was attached to Resident 3's mattress to ensure Resident 3 was placed in the center of the bed when repositioning, and to monitor Resident 3's for non-stop movement of her upper body and intervene promptly. During a review of Resident 3's care plan, revised on 9/23/2025, the care plan indicated Resident 3 was at risk for recurrent fall because Resident 3 was found on the floor to the left side of the bed lying on her back on 9/22/2025. The care plan indicated Resident 3 had Parkinson Disease, intermittently and uncontrollable movement of her upper body, and episodes of scratching. The care plan's interventions included keeping a floor mat on the left side of the bed, moving the right side of the bed against the wall, and keeping the bed in the lowest position. During an interview on 10/2/2025 at 1:15 PM with Family Member (FM) 1, FM 1 stated Resident 3 had fallen off the bed in August and September of 2025. FM 1 stated, Resident 3 had Parkinson's disease and has bad tremors. During an observation on 10/2/2025 at 4:30 PM in Resident 3's room, Resident 3 was observed lying in bed calmly, her upper body from the waist to her head was tilted to the left side of the bed, and the pillows were halfway off the bed. There was no bolster pillows observed attached to Resident 3's mattress. During a concurrent observation and interview on 10/2/2025 at 4:50 PM in Resident 3's room with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 3 moved a lot in bed and does not have bolsters on either side of her bed. During an observation and interview on 10/3/2025 at 10:02 AM with Certified Nurse Assistant (CNA) 1, CNA 1 stated, Resident 3's body wiggles a lot. CNA 1 stated that Resident 3's wiggling movement would intermittently stop she start wiggling again and slides down in bed and should have the bolster pillow to prevent sliding in bed. During a concurrent interview and record review on 10/3/2025 at 12:00 PM with the Social Services Director (SSD), SSD stated, the IDT noted was the initial IDT meeting for Resident 3's fall on 8/17/2025. The SSD stated that Resident 3 was transferred to GACH 1 on 8/17/2025 and readmitted into the facility on 8/29/2025 after an unwitnessed fall on 8/17/2025. During a concurrent interview and record review on 10/3/2025 at 12:05 PM with the SSD, Resident 3's CoC, dated 9/22/2025 indicated Resident 3 had fallen and the IDT recommended to place a bolsters pillow that were well-attached to the mattress. During a review of Resident 3's IDT care conference note, dated 9/23/2025, the IDT note indicated Resident 3 had an unwitnessed fall on 9/22/2025. The IDT note indicated Resident 3 had a diagnosis of Parkinson's disease, which led to involuntary movements, The IDT note indicated the following interventions: keep the bed in low position, and ensure bolsters were well-attached to the mattress. During a concurrent observation and interview on 10/3/2025 at 12:30 PM with CNA 1, Resident 3's bed and environment were observed. CNA 1 stated that Resident 3 did not have a bolster pillow on the bed. During a concurrent interview and record review on 10/3/2025 at 4:15 PM with the Assistant Director of Nursing (ADON) 1, Resident 3's IDT care conference note, dated 9/4/2025 and care plan for fall were reviewed. ADON 1 stated, Resident 3's unwitnessed fall on 8/17/2025 and the care plan to prevent a fall was not revised. The ADON stated the IDT's recommendation to prevent a 056487 Page 2 of 3 056487 12/11/2025 Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few repeat fall was too vague. During a concurrent interview and record review on 10/3/2025 at 4:30 PM with ADON 1, Resident 3's IDT noted, dated 9/23/2025, was reviewed. The ADON stated, he was unaware Resident 3's bed did not have bolsters attached to the mattress. The ADON stated that Resident 3 had transferred to a different room a couple days ago, and the bolsters were not transferred to her new room. During a concurrent interview and record review on 10/3/2025 at 4:45 PM with ADON 1, Resident 3's care plans were reviewed. ADON 1 stated, Resident 3's care plan was not implemented to ensure the bolster was attached to the mattress to keep the resident in the center of the bed and to ensure the resident was monitored for frequent movement of the upper body to prevent recurrent falls. 056487 Page 3 of 3