Health inspection·July 23, 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 was assessed at risk for falls, and who had Care Plan interventions indicating Resident 1's bed to be in a low position, did not fall. This failure resulted in Resident 1 having an unwitnessed fall from her bed on 7/13/2025 and because of the fall, Resident 1 sustained an abrasion (wound caused by rubbing or scraping the skin against a rough surface) and redness to her forehead, and bilateral knee. Resident 1's bed was found at medium height level (approximately three feet from the floor) per the facility's Post Fall Evaluation dated 7/13/2025, upon her fall. Resident 1 was subsequently transferred to a General Acute Hospital (GACH) for evaluation of her injuries on 7/13/2025 via 911 (emergency transportation). This failure had the potential for Resident 1 to sustain greater injuries.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental activities), muscle weakness and encephalopathy (brain disease, damage, or malfunction).During a review of Resident 1's History and Physical (H&P) dated 1/18/2025, the H&P indicated Resident 1 did not have the capacity to understand and make medical decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 4/23/2025, the MDS indicated Resident 1's cognition (ability to register and recall information) was severely impaired and was sometimes understood and was sometimes able to be understood by others. The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half of the effort) from staff for rolling left to right (ability to roll from lying on back to left and right side, and return to lying on back on the bed), sit to lying (ability to move from sitting on side of the bed 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 with no back support), and sit to stand (ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed). The MDS indicated Resident 1 was incontinent (involuntary voiding of urine and stool) in both her bowel and bladder functions). During a review of Resident 1's Fall Risk Evaluation, dated 1/17/2025, the Fall Risk Evaluation indicated Resident 1 was at risk for falls. During a review of Resident 1's Care Plan, revised 1/18/2025, the Care Plan indicated Resident 1 is at risk for falls related to gait and balance problems. The Care Plan interventions included always keep the environment clear of clutter and hazards and position Resident 1's bed in a low position.During a review of Resident 1's Change of Condition (COC) Evaluation, dated 7/13/2025, the COC Evaluation indicated Resident 1 had an unwitnessed fall and was found by Certified Nursing Assistant (CNA) 1, next to her bed, face down on the floor, with her knees on the floor. The COC Evaluation indicated Resident 1 hit her forehead on the floor and had a small abrasion (measurement unknown) and redness on her forehead, and redness on both of her knees.During a review of Resident 1's Order Summary Report Page 1 of 2 555706 555706 07/23/2025 Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (Physician's Orders), dated 7/13/2025, the Physician's Orders indicated to transfer Resident 1 to a GACH via 911 due to an unwitnessed fall with head trauma (an injury to the head, including the scalp, skull, brain and underlying tissues). During a review of Resident 1's Post Fall Evaluation, dated 7/13/2025, the Post Fall Evaluation indicated Resident 1 sustained an unwitnessed fall in her room on 7/13/2025 at 5:40 p.m. The Post Fall Evaluation indicated Resident 1's activity at the time of the fall was unknown, and her bed was found at medium height at the time of her fall. During a review of the Emergency Department (ED) documents dated 7/13/2025, the ED documents indicated Resident 1 was transferred to the ED on 7/13/2025 at 6:42 p.m.During a review of Resident 1's GACH History and Physical (H&P), dated 7/14/2025, the H&P indicated Resident 1 was found to have forehead abrasions (unknown measurement). During an interview on 7/22/2025 at 3:05 p.m., Registered Nurse (RN) 1 stated she was called into Resident 1's room on 7/13/2025 at approximately 5 p.m. by Licensed Vocational Nurse (LVN) 1. RN 1 stated when she entered Resident 1's room she (RN 1) saw Resident 1 on the floor next to her bed. RN 1 stated Resident 1 appeared to be kneeling face down with her forehead on the floor. RN 1 stated she assessed Resident 1 and observed redness on Resident 1's forehead and bilateral knees and an abrasion (unknown measurement) to Resident 1's forehead. RN 1 stated she observed Resident's 1 bed being at a medium height, measuring approximately three feet from the ground. RN 1 stated Resident 1's bed height should have been positioned at the lowest level, as Resident 1 was at risk for falls. RN 1 stated the bed positioned at medium height placed Resident 1 at risk for injuries.During an interview on 7/22/2025 at 3:20 p.m., Licensed Vocational Nurse 1 (LVN 1) stated she was called into Resident 1's room by Certified Nurse Assistant (CNA) 1 on 7/13/2025 at approximately 5 p.m. LVN 1 stated she saw Resident 1 on the floor next to her (Resident 1's) bed. LVN 1 stated Resident 1 was face down, with her knees bent under her and her hands to her side. Resident 1's bed was not at the lowest level. LVN 1 stated the bed must be at the lowest level due to Resident 1 being at risk for falls and injury.During an interview on 7/23/2025 at 1:30 p.m., the Director of Nursing (DON) stated the nursing staff should have implemented safety measures as indicated in Resident 1's Care Plan which was to position Resident 1's bed height at a low position. The DON stated failure to ensure Resident 1's bed was positioned to the lowest level placed Resident 1 at risk for falls which could lead to severe injuries, including death. During a review of the facility's policy and procedure (P&P) titled, Free of Accident Hazards/Supervision/Devices, revised 1/2025, the P&P indicated the facility provides an environment that is free from accident hazards over which the facility had control, and each resident receives adequate supervision and assistive devices for each resident to prevent avoidable accidents. The P&P indicated factors which may result in resident falls include but are not limited to incorrect bed height or width.During a review of the facility's P/P titled Quality of Care, revised 1/2025, the P&P indicated the facility ensures that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person -centered care plan and resident's choices based on the comprehensive assessment of the resident. 555706 Page 2 of 2