Health inspection·November 21, 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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had poor safety awareness (a resident's inability to recognize physical dangers and follow safety instructions, which puts them at risk for injury - especially during mobility and self-care activities), a history of a falls, and was a moderate risk for falls, was supervised by the nursing staff while seated in her wheelchair. The facility failed to:1. Ensure the nursing staff promptly provided redirection and cueing (the use of verbal, visual, or tactile prompts to guide a resident's behavior or actions in a safe and appropriate manner) to prevent Resident 1 from getting up from her wheelchair unattended.2. Ensure the nursing staff followed the facility's Policy and Procedure (P&P) titled, Safety and Supervision of Resident, indicating the importance of ensuring interventions are implemented correctly and consistently.This deficient practice resulted in Resident 1 getting up from her wheelchair and falling to the floor. 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 unspecified mood disorder (mental health condition characterized by significant and prolonged changes in mood, impacting a person's ability to function daily), cognitive communication deficit (problem with thinking and communicating, often caused by brain injuries, strokes, or other neurological conditions) and displaced intertrochanteric fracture of right femur (break in the upper part of the thigh bone [femur], near the hip joint).During a review of Resident 1's History and Physical (H/P), dated 9/4/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 9/9/2025, the MDS indicated Resident 1's cognitive skill for daily decision-making were severely impaired. The MDS indicated Resident 1 was fully dependent on staff for toileting hygiene, showering, upper and lower body dressing. During a review of Resident 1's Fall Observation Assessment (standardized method used to identify a resident's risk of falling, based on specific risk factors), dated 9/3/2025, the assessment indicated Resident 1 was a moderate risk for falls.During a review of Resident 1's Occupational Therapy Evaluation and Plan of Treatment, dated 9/4/2025, indicated Resident 1 had impairments in mobility, strength, attention, follow-through, planning and problem-solving, resulting in limitations in areas of self-care and mobility.During a review of Resident 1's Care Plan initiated 9/4/2025, the Care Plan indicated Resident 1 was at risk for falls with or without injury related to cognitive impairment, history of fall, right hip fracture, anemia (condition where your blood doesn't have enough healthy red blood cells to carry oxygen to the body's tissues), mood disorder and episodes of attempting to get up unassisted. The Care Plan indicated the following goal will minimize complications related to fall to extent possible. The Care Plan interventions indicated the following, place resident in the nurses' station for supervision. During a review of Resident 1's Change of Condition ([COC] significant shift in a person's health or functional abilities) Page 1 of 3 555375 555375 11/21/2025 Sunset Villa Post Acute 3232 E. Artesia Blvd. Long Beach, CA 90805

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Evaluation, dated 9/25/2025, indicated while in bed, Resident 1 attempted to stand up without assistance using the over the bed TV mount for support causing resident to fall and hit her forehead.During a review of Resident 1's Interdisciplinary Team ([IDT] team of healthcare professionals who work together to develop and implement a resident's care plan) note, dated 9/25/2025, the note indicated the IDT met to discuss ongoing behavioral concerns which included Resident 1's repeated episodes of attempting to get up unassisted and behaviors have persisted despite redirection efforts. The note indicated Resident 1's Responsible Party (RP) was present during the IDT meeting. During a review of the facility's Witness Fall Report, dated 9/26/2025, indicated Registered Nurse (RN) 1 stated on 9/26/2025 at approximately 3:15 p.m., while at the nurses' station, she heard Certified Nurse Assistant (CNA) 1 in the hallway telling Resident 1 to sit down. RN 1 then saw Resident 1 had fallen to the floor as CNA 1 approached her (Resident 1).During a continued review of the facility's Witness Fall Report, dated 9/26/2025, indicated CNA 1 stated on 9/26/2025, she was walking down the hallway when she saw Resident 1 stand up from her wheelchair. CNA 1 reported that she ran toward Resident 1 while shouting for her to stop but was unable to reach her in time. CNA 1 stated Resident 1 fell to the floor and landed on her right side.During a review of Resident 1's COC Evaluation, dated 9/26/2025, the COC indicated Resident 1 was sitting in a wheelchair in the hallway when she stood up unassisted from her wheelchair, took a step and fell to the floor and landed on her right side. The COC indicated Resident 1 was transferred to the GACH for further evaluation.During an interview on 11/19/2025, at 11 a.m., RP 1 stated on 9/25/2025, Resident 1 hit herself on the head with the TV mount during an attempt to get out of bed unassisted. RP 1 stated on 9/26/2025, she was notified that Resident 1 attempted to get out of her wheelchair unassisted resulting in a fall. RP 1 stated during her meeting with the IDT on 9/25/2025 she was informed by the facility that they would ensure Resident 1 was supervised to prevent further falls.During an interview on 11/20/2025, at 12:22 p.m., the Director of Rehabilitation (DOR) stated Resident 1 had poor safety awareness but was able to sit in a wheelchair with supervision. The DOR stated Resident 1 required verbal cues, redirection, and tactile cues to ensure she was safe while sitting in the wheelchair.During an interview on 11/20/2025, at 2:53 p.m., CNA 1 stated she was walking down the hallway when she saw Resident 1 trying to get up from her wheelchair. CNA 1 stated Resident 1 was approximately five to six feet in front of her when she saw Resident 1 trying to get up, she shouted at Resident 1 to stop and not to get up several times, but Resident 1 did not listen to her. CNA 1 stated she ran to Resident 1 but was unable to reach her in time and Resident 1 fell to the ground and landed on her right side. CNA 1 stated RN 1 was seated at the nurses' station and did not have access to Resident 1 when she fell. During an interview on 11/20/2025, at 3:16 p.m., RN 1 stated on 9/26/2025, she was seated at the nurses' station while Resident 1 was in a wheelchair approximately four feet away, on the opposite side of the desk and not within arm's reach. RN 1 stated she was not actively observing Resident 1 when she heard CNA 1 shouting. RN 1 stated from the corner of her eye, she saw Resident 1 fall to the floor. RN 1 stated she was unable to intervene in time to prevent the fall.During an interview on 11/21/2025, at 2 p.m., the Director of Nursing (DON) stated Resident 1's care plan required her to remain at the nurses' station for supervision due to previous attempts of attempting to get out of bed unassisted and Resident 1's poor safety awareness. The DON stated that staff needed to keep Resident 1 in their view to redirect her from trying to get out of her wheelchair. The DON stated methods to redirect Resident 1 to maintain safety would include speaking to her clearly and directly, using tactile cues and distraction. The DON stated this was the first time she was aware of Resident 1 attempting to get out of her wheelchair unassisted. The DON stated that despite CNA 1 shouting for Resident 1 to stop, neither CNA 1 555375 Page 2 of 3 555375 11/21/2025 Sunset Villa Post Acute 3232 E. Artesia Blvd. Long Beach, CA 90805

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nor RN 1 were able to reach Resident 1 in time to prevent her from falling to the ground.During a review of the facility's Policy and Procedure (P&P) titled, Fall and Fall Risk Managing, dated 2001, the P&P indicated the staff with the input of the attending physician, will implement a resident centered -fall prevention care plan to reduce the specific risk factors of falls for each resident at risk or with the history of falls.During a review of the facility's P&P, titled, Safety and Supervision of Resident, dated 2001, the P&P indicated the following, our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents, the interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific hazards or risks for individual residents, the care team shall target interventions to reduce individual risks related to hazards in the environment including adequate supervision and assistive devices. The P&P indicated the importance of monitoring the effectiveness of interventions shall include ensuring that interventions are implemented correctly and consistently. 555375 Page 3 of 3