Health inspection·August 15, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to implement fall interventions in accordance with the care plan to frequently observe and place one of two Residents (Resident 1) who was assessed as high risk for fall in a supervised area while out of bed. This deficient practice resulted in a fall (unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force) on 5/10/2025, which placed Resident 1 at risk for serious injury like fractures (break in the bone) and head injury (injury that damages your head, including the skull [bony framework of the head, enclosing the brain and supporting the face] and brain), hospitalization and even death.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/25/2024 and readmitted on [DATE], with diagnoses including, but not limited to left sided hemiplegia (complete or severe paralysis of one side of the body) and hemiparesis (weakness or partial paralysis on one side of the body) following nontraumatic (without traumatic cause) intracerebral hemorrhage (bleeding within the brain tissue that extends into the ventricular system), epilepsy (a brain condition that causes recurring seizures), paroxysmal atrial fibrillation (type of irregular heartbeat where episodes of atrial fibrillation start and stop on their own), muscle weakness (actual decrease in muscle strength of one or more muscles, making it difficult to perform tasks that would normally be easy), and difficulty walking (abnormal walking pattern, often caused by an underlying medical issue, injury, or physical limitation). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 5/8/2025, the MDS indicated Resident 1 had modified independence (some difficulty in new situations only) with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with eating. The MDS indicated Resident 1 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts of holds trunks or limbs and provide more than half the effort) with upper body dressing and was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) with showering /bathing self, lower body dressing, putting on /taking off footwear, oral, toileting, and personal hygiene. The MDS indicated Resident 1 was also dependent with sit to lying (ability to move from sitting to lying flat on the bed), lying to sitting on the side of the bed (ability to move from lying on the back to sitting on the side of the bed), chair/bed to chair transfer (ability to transfer from a bed to a chair, and tub/shower transfer (the ability to get in and out of a tub/shower. The MDS indicated Resident 1 had three falls since admission on [DATE]. During a concurrent interview and record review on 8/13/2025 at 9:50 AM with Registered Nurse Supervisor (RN 1), the fall risk assessments for Resident 1, dated 10/25/2024, Page 1 of 3 555213 555213 08/15/2025 Cedar Pine Post Acute 1640 N. Fair Oaks Avenue Pasadena, CA 91103

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12/16/2024, 2/15/2025, 4/25/2025, and 5/10/2025 were reviewed. Resident 1 was assessed as high risk for fall as indicated on the following scores (The fall risk assessment score of 10 or higher was high risk and 0-9 was low risk):1. 10/25/2024 was 12. 2. 12/16/2024 was 16. 3. 2/15/2025 was 17.4. 4/25/2025 was 16.5. 5/10/2025 was 16. A review of Resident 1's Care Plan, initiated on 10/28/2024 and revised on 1/14/2025, the Care Plan indicated Resident 1 was at risk for fall/recurrent fall. Resident 1 had episodes of attempting to get up from bed/wheelchair unassisted. Resident 1 had history of falls dated 12/16/2024, 2/15/2025, 4/24/2025, and 5/10/2025. The staff interventions included were: May use floor mats on both sides of the bed for resident's safety Staff will observe frequently and place Resident 1 in a supervised area when out of bed such as in activity or close to nursing station. Provide resident with safety device/appliance for fall prevention program: low bed, wheelchair, according to physician (MD-Doctor of Medicine) order. Refer to the rehabilitation department for evaluation and possible treatment according to MD order. During a concurrent interview and record review on 8/13/2025 at 10:15 AM with RN 1, Resident 1's nurses' progress notes were reviewed, which indicated: On 12/16/2025 at 9:26 AM, Resident 1 was found on the floor in a sitting position. RN 1 confirmed that according to the progress notes dated 12/16/2025 at 10:35 PM, this was a witnessed fall. On 2/15/2025 at 5:15 PM, Resident 1 was heard yelling. Resident 1 was found lying on his back, on the floor. RN 1 confirmed that according to the progress notes dated 2/16/2025 at 4:52 AM, this was an unwitnessed fall. On 4/24/2025 at around 6:10 AM, Certified Nurse Assistant (CNA 1) found Resident 1 sitting on the floor when the bed alarm went off. According to the progress notes, Resident 1 stated he slid on the mat. RN 1 confirmed that this was an unwitnessed fall as documented on the notes. On 5/10/2025 at 6:25 PM, Resident was found by a housekeeper on the floor in the dining room. RN 1 stated this fall was avoidable if there was staff supervising the resident or residents remaining in the dining room. During an interview on 8/13/2025 at 10:30 AM with RN 1, RN 1 stated the fall incident on 5/10/2025 was avoidable. RN 1 stated it was the housekeeper that informed LVN 3 at the nurse's station that Resident 1 was on the floor. LVN 3 stated since Activity staff leave at 6 PM, they need to endorse to nursing staff if there are still residents in the dining room waiting to be brought back to their rooms. RN 1 stated Resident 1 was a high fall risk and should not be left unattended or unsupervised RN 1 stated there were no staff in the dining room when Resident 1 fell on 5/10/2025. RN 1 added that if there was a staff present in the dining room at that time, Resident 1's fall could have been prevented. During an interview on 8/13/2025 at 12 PM with Licensed Vocational Nurse (LVN 2), LVN 2 stated Resident 1 would try to get up from his wheelchair and stand, placing him at high risk for fall. LVN 2 stated there should have been an MD order for one-to-one observation (continuous monitoring by a staff member, like a nurse or patient sitter, to ensure the safety of patients at risk of self-harm or harm to others or falls due to cognitive impairment or physical health issues) to prevent Resident 1 from falling. During an interview on 8/14/2025 at 9:25 AM with LVN 3, LVN 3 stated she was at the nurse's station on 5/10/2025 when the housekeeper notified her that Resident 1 was found on the floor in the dining room. LVN 3 stated she cannot recall how many residents were still in the dining room at that time. LVN 3 stated, after the residents on wheelchairs are done eating in the dining room, they are wheeled back to their respective rooms by the CNAs. LVN 3 stated she recalls the facility policy indicating high fall risk residents should always be in an area where they can be supervised. If there was a staff in the dining room with the remaining residents, Resident 1 would have been under supervision of that staff, and fall could have been prevented. LVN 3 stated the facility policy was not followed since Resident 1 was able to attempt standing up from his wheelchair and subsequently fell. During a concurrent interview and record review on 8/15/2025 at 11:25 555213 Page 2 of 3 555213 08/15/2025 Cedar Pine Post Acute 1640 N. Fair Oaks Avenue Pasadena, CA 91103

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few AM with the Physical Therapist (PT-a healthcare professional specializing in evaluating, diagnosing, and treating movement disorders [neurological conditions that cause disruptions in motor control] and musculoskeletal injuries (damage to any part of the body's framework that supports movement, including the muscles, bones, joints, ligaments, tendons, and nerves), the PT treatment encounter notes dated 5/9/2025 and 5/12/2025 were reviewed. The encounter notes on 5/9/2025 indicated: for wheelchair mobility, Resident 1 required minimal assistance with distance of 40 feet (a unit of length). PT stated Resident 1 needed help when propelling the wheelchair, so staff need to be propelling Resident 1's wheelchair. Resident 1 was able to walk on level surfaces of 40 feet with moderate assistance The PT stated that PT and Occupational Therapist (OT-helps people perform daily tasks by restoring or improving skills needed for living and working, or by providing adaptive equipment [a tool, device, or machine that helps people with disabilities or impairments perform everyday tasks, such as dressing, eating, or moving, which they might otherwise struggle with] and strategies to help them achieve independence and participate in meaningful activities), evaluated Resident 1 on initial admission on [DATE]. PT stated Resident 1 had a functional mobility decline (gradual loss of a person's ability to move independently and safely to perform daily tasks). The PT stated that Resident 1 was always a fall risk secondary to Resident 1's hemiplegia and hemiparesis from his stroke and poor safety awareness. During an interview on 8/15/2025 at 12:26 PM with the MDS Nurse, the MDS Functional Abilities section dated 5/8/2025 was reviewed. The Functional Abilities section indicated Resident 1 was wheelchair bound, was dependent on chair to bed, sit lying, tub/shower transfer. The MDS Nurse stated that according to the assessment, Resident 1 needed staff to assist with Activities of Daily Living (ADLs-tasks a person does to take care of the body and overall well-being) all the time. The MDS nurse stated that if Resident 1 was not assisted, it could lead to possible falls that could possibly cause harm and injury to the resident. The MDS nurse stated Resident 1 was assessed as having memory problems and with episodes of confusion. The MDS nurse stated Resident 1 should not have been left unattended or unsupervised on 5/10/2025. The MDS nurse stated that with supervision from staff, the falls could have been prevented. During a review of the facility's Policy and Procedures (P&P) titled, Fall Risk Assessment, revised 3/2024, the P&P indicated: The nursing staff, in conjunction with the Attending MD, consultant pharmacist, therapy staff and others, will seek to identify and document resident risk factors for falls and establish a resident-centered fall prevention plan based on relevant assessment information.During a review of the facility's P&P, titled Fall Risk Intervention and Monitoring, revised 12/2024, the P&P indicated: If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of falling is identified as unavoidable. For monitoring subsequent falls and fall risk, the staff will monitor and periodically document the resident's response to interventions intended to reduce falling or the risks of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. The MD may help the staff reconsider possible causes that may not previously have been identified. 555213 Page 3 of 3