Health inspection·May 30, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report a fall accident that happened on 5/15/2025 accordance of facility ' s policy for one (1) of 2 (two) sampled residents (Resident 1). This failure not only resulted in a delay of an onsite inspection by the California Department of Public Health (CDPH) to investigate incident of fall, but also lead to delay of prevent further falls to ensure safety of Resident 1 and other residents in the facility. Findings: During a review of Resident 1's admission Record indicated Resident 1 was initially admitted to the facility on [DATE], and readmitted to the facility on [DATE], with diagnoses that included but not limit to fracture of nasal bones subsequent encounter for fracture with routine healing (the patient is receiving aftercare and follow-up visits for the injury after initial active treatment and the fracture is healing normally), history of falling, chronic obstructive pulmonary disease [(COPD), a progressive lung disease that makes it difficult to breathe] and type II diabetes (a chronic disease where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels). During a review of the Minimum Data Set, [(MDS)- (a resident assessment tool)] dated 5/15 /2025, indicated Resident 1 had moderate impairment (decisions poor, cues/supervision required) for cognitive skills (the mental processes that allow people to think, learn, and solve problems) for daily decision making. Resident 1 need partial or moderate assistant, (helper does less than half the effort) with the eating, oral hygiene, personal hygiene, toileting, upper and lower body dressing. Resident 1 needs supervision or touching assistance, (helper provides verbal cues and /or touching/steadying and/or contact guard assistance as resident completes activity) for shower/bathe self, change of position, and transfer. During an interview on 5/29/2025 at 11:25 AM with Resident 1 at Resident 1 ' s room, Resident 1 stated she was trying to grab her wheelchair, and she was going to go to the activity room, she then lost her balance and landed face down and Resident 1 ' s nose got injured. Resident 1 stated it was early morning, her nose got injured, she did not remember she was sent to the hospital for further care after her nose injury from her fall. During an telephone interview on 5/29/2025 at 3:29 PM with Licensed Vocational Nurse 1(LVN1), LVN1 stated Resident 1 had an accident of unwitnessed fall on 5/15/2025 near 5:00 AM. LVN 1 stated he was the nurse for Resident 1 for that shift, he called physician, notified her conservator and he had Page 1 of 2 555338 555338 05/30/2025 Brighton Care Center 1836 N. Fair Oaks Ave Pasadena, CA 91103

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few obtained an order for x-ray for Resident 1 ' s nose (a type of radiation called electromagnetic waves) from her physician. I had also notified the Director of Nurses (DON) by following the chain of command of reporting to the DON and the administrator (ADM). During an interview on 5/30/2025 at 10:40 AM with Registered Nurse Supervisor (RNS), RNS stated she did the risk management, post fall assessment, neuro check was ordered, and transferring order had obtained for Resident 1 to go to the hospital for further care. RNS stated she had reported the accident to DON & ADM. RNS stated she did not know that the facility must report this fall accident to the department of public health. During an interview on 5/30/2025 at 10:30 AM with Director of Staff Development (DSD), DSD stated, Resident 1 ' s fall with nose fracture on 5/15/2025 was reportable. The facility ' s staffs included herself should have reported the accident to the department of public health and the appropriate agencies as required by the federal and state regulations. During an interview on 5/30/2025 at 11:10 AM with the ADM(administrator), ADM stated he did not report the accident to the department of public health as he thought Resident 1 ' s fall on 5/15/2025 AM was from a known origin. ADM stated he should have reported the accident to reinforce the facility ' s policy of reporting the unusual occurrence events so that staffs and employees will know they have to report to the appropriate agencies as required by the federal and state regulations within the required time intervals. During a concurrent interview and record review on 5/30/2025 at 11:15 AM with ADM, the facility ' s policy and procedure (P&P) titled, Unusual Occurrence Reporting, undated, revised December 2007 was reviewed. The P&P statement indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. 1. Our facility will report the following events to appropriate agencies: a. Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors. 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations. 4. The administration will keep a copy of written reports on file. 555338 Page 2 of 2