Health inspection·February 5, 2026

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow through (follow up) on one of four sampled resident's (Resident 1), who was at risk for falls, fall that occurred on 1/9/2026, in accordance with the facility's policy and procedure (P&P) titled, Change of Condition. The facility failed to assess Resident 1 after the fall, report the fall to Resident 1's physician (Medical Doctor [MD] 1), and complete a change in condition (COC, an alteration in a resident's physical health that differs from their previous baseline) for Resident 1.This deficient practice had the potential to result in Resident 1 not receiving the necessary care and services affecting Resident 1's physical well-being.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including other abnormalities of gait (the pattern of walking) and mobility (ability to move freely), unspecified dementia (a progressive state of decline in mental abilities), and history of falling.During a review of Resident 1's Fall Risk Evaluation (FRE), dated 12/17/2025, timed at 6:40 PM, the FRE indicated Resident 1 was a risk for falls and to alert MD 1 if a fall occurred.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/5/2026, the MDS indicated Resident 1's cognition (the ability to think and process information) was moderately impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort) and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with activities of daily living (ADL).During a review of Resident 1's Progress Notes (PN), dated 1/9/2026, timed at 3:07 AM, the PN indicated, at approximately 3 AM, LVN 2 heard an alarm noise from the back hallway and entered Resident 1's room. LVN 2 noted Resident 1 to be on the floor, sitting on Resident 1's bottom in front of Resident 1's roommate's bed. LVN 2 asked Resident 1 what had happened and Resident 1 responded, I do not know, I just fell. The PN indicated Resident 1 had an abrasion (a superficial injury where the skin is scraped or rubbed off) on Resident 1's mid-back on the right side and LVN 2 notified Resident 1's primary nurse (LVN 3) who stated LVN 2 would resume follow-up. During a concurrent observation and interview on 2/5/2026 at 6:14 AM with Resident 1 and Certified Nursing Assistant (CNA) 1 in Resident 1's room. CNA 1 was monitoring Resident 1 at Resident 1's bedside. Resident 1 was lying in bed, confused (unable to answer most questions), and trying to get out of bed. Resident 1 had a pinkish colored linear scarring on the right forehead above the eyebrow. Resident 1 stated, Resident 1 had fallen a couple of times at the facility. CNA 1 stated, Resident 1 was a fall risk. CNA 1 stated, CNA 1 believed Resident 1 had fallen once in January 2026 during the evening shift (3 PM - 11 PM) and Resident 1 required stitches (special threads that doctors use to close a wound or cut).During an interview on 2/5/2026 at 10:01 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had advanced dementia with, a lot of confusion, and was a fall risk. LVN 1 stated Resident 1 had a fall (no date recollection) and Resident 1 had Residents Affected - Few (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: 555106 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 555106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732 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)