Health inspection·November 13, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify, document and communicate changes in condition for a resident following an unwitnessed fall for one out of three sampled residents (Resident 1) when the following occurred: 1. Certified Nursing Assistants (CNA) 1 and 2 observed new onset of shoulder pain and limited range of motion while assisting Resident 1 put on a sweater (on 11/3/2025 and 11/6/2025) but did not effectively communicate the change to the Licensed Vocational Nurse (LVN) and did not complete a Stop and Watch form (the facility CNA to LVN communication tool). 2. LVN 1 noted new skin redness to Resident 1's right shoulder on 11/6/2025 (three days after Resident 1's fall) but failed to document the finding, failed to assess for range of motion changes and failed to notify the physician or RN Supervisor. These failures resulted in a delay of physician notification and had the potential to result in missed opportunities to identify Resident 1's clavicle fracture (broken collarbone) and significant bruising to the shoulder, which was not discovered until 11/10/2025 (seven days after her fall), placing Resident 1 at risk for increased pain, functional decline and delayed treatment.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included history of falling, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) following a stroke (loss of blood flow to a part of the brain), aphasia (a disorder that makes it difficult to speak), dementia (a progressive state of decline in mental abilities), and mild intellectual disabilities. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 11/30/2025, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) for toileting, showering, lower and upper body dressing putting on footwear, and personal hygiene. During a review of Resident 1's History and Physical (H&P), dated 9/18/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make medical decisions. During a review of Resident 1's Pain Care Plan, dated 10/30/2025, the Care Plan indicated the nurses were to call the physician for any significant change of condition, find out the reason for pain and intervene, provide nursing measures that will promote comfort, and assess for nonverbal signs and symptoms of pain. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR-a communication tool used by healthcare workers when there is a change of condition among the residents) Note, dated 11/3/2025, the SBAR indicated, on 11/3/2025 at 11:00 a.m., Resident 1 was observed lying a supine position in the hallway, and stated she fell. The SBAR indicated Resident 1 sustained a hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) on the back of Resident 1's head. The SBAR indicated the physician was made aware and an x-ray (a type of medical imaging) of the skull (bony Page 1 of 5 555732 555732 11/13/2025 Santa Fe Heights Healthcare Center, LLC 2309 N Santa Fe Ave Compton, CA 90222

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few enclosure around the brain) was ordered. During a review of Resident 1's SBAR, dated 11/10/2025, the SBAR indicated Resident 1 complained of pain to her right shoulder when raising her right arm and had discoloration to her right shoulder. The SBAR indicated the physician was made aware and an x-ray of the right arm and shoulder was ordered. During a review of Resident 1's X-ray Report, dated 11/10/2025, the report indicated a displaced, acute communicated fracture (a severe type of bone fracture where the bone is broken into multiple pieces) of Resident 1's right clavicle (collarbone). During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] with diagnoses that included anemia (a condition where the body does not have enough healthy red blood cells), diabetes (poor blood sugar control) and chronic pain. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making were intact. During a concurrent observation and interview on 11/12/2025 at 1:40 p.m. with Resident 1, in Resident 1's room, Resident 1 was observed with two round, yellow, purple bruises on the back of her shoulder. Resident 1 stated she fell and could not recall how she developed her shoulder injury. 1. During an interview on 11/12/2025 at 2:21 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 recalled, on 11/6/2025, Resident 1 cried and complained of right arm pain while CNA 1 assisted Resident 1 with putting on a sweater. CNA 1 stated when a resident complained of a new onset of pain, the process was to immediately notify the charge nurse and complete a Stop and Watch form. CNA 1 stated she made Licensed Vocational Nurse (LVN) 1 aware but did not complete a Stop and Watch form. CNA 1 stated she should have completed the form to document that she made LVN 1 aware and could provide proper treatment and assessment. During a concurrent interview and record review on 11/12/2025 at 4:20 p.m. with LVN 1, all Stop and Watch forms, dated 11/3/2025 through 11/9/2025, were reviewed. There were no Stop and Watch forms that addressed Resident 1's new right arm pain. LVN 1 stated, on 11/6/2025, she did not receive any reports of pain or range of motion limitations in Resident 1's right arm. LVN 1 stated if she had known, she would have conducted a full assessment of Resident 1's shoulder and notified the physician to obtain orders for an x-ray. During an interview on 11/13/2025 at 7:53 a.m. with Resident 1's roommate, Resident 2, Resident 2 recalled, a few days after Resident 1's fall, she heard Resident 1 crying and moaning in pain when the CNAs tried to dress Resident 1. During an interview on 11/13/2025 at 9:09 a.m. with CNA 2, CNA 2 stated she was assigned to care for Resident 1 on the 11:00 p.m. to 7:00 a.m. shift on 11/3/2025 (the day of Resident 1's fall). CNA 2 stated, on 11/3/2025 (the night of the fall), Resident 1 could not raise her right arm to put on her sweater and Resident 1 complained of pain. CNA 2 stated Resident 1 usually only required partial help with upper body dressing, but, this time, Resident 1 could not assist with putting on her sweater. CNA 2 stated she notified LVN 3 right away. CNA 2 stated she was supposed to complete the Stop and Watch form to document the change of condition but had forgotten. During an interview on 11/13/2025 at 9:44 a.m. with Registered Nurse 1, RN 1 stated CNAs were expected to notify the charge nurse and complete a Stop and Watch form once a patient complained of a new onset of pain or exhibited any abnormalities. RN 1 stated if Resident 1 exhibited pain while the CNAs got her dressed, the pain should have been reported and addressed right away. RN 1 stated the Stop and Watch form was a way for the CNAs to keep the nurses accountable and to ensure patient-related changes were effectively relayed to the licensed nurses. RN 1 stated if Resident 1's pain was not effectively communicated to the licensed nurses, then it placed Resident 1 at risk for continued discomfort, delayed treatment and further issues with mobility. During an interview on 11/13/2025 at 10:20 a.m. with LVN 3, LVN 3 stated she was the assigned LVN to Resident 1 on the 11:00 p.m. to 7:00 a.m. shift on 11/3/2025. LVN 3 stated she was not made aware of CNA 2's report Resident 1's right shoulder 555732 Page 2 of 5 555732 11/13/2025 Santa Fe Heights Healthcare Center, LLC 2309 N Santa Fe Ave Compton, CA 90222

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pain. During a review of the facility's Policy and Procedure (P&P) titled, Acute Condition Changes, revised 3/2018, the P&P indicated direct care staff, including nursing assistants would be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse. Nursing assistants were encouraged to use the Stop and Watch Early Warning Tool to communicate subtle changes in the resident to the nurse. During a review of the facility's CNA Job Description (undated), the Job Description indicated CNAs were to ensure the following:1) Record all entries on flow sheets, notes, charts, etc., in an informative and descriptive manner.2) Report all changes in the resident's condition to the Nurse Supervisor/Charge Nurse as soon as practical. 2. During an interview on 11/12/2025 at 4:06 p.m. with LVN 2, LVN 2 stated, on 11/6/2025, he recalled Resident 1 presented with new skin redness to her right shoulder. LVN 2 recalled Resident 1 did not complain of pain to the shoulder. LVN 2 stated he did not perform any other assessments of Resident 1's shoulder, like mobility of the joint. LVN 2 stated he did not endorse this finding to any other licensed nurse and nor did he document the finding. LVN 2 stated he should have started a change of condition note to ensure the other nurses and the physician were made aware of the finding and to ensure the skin redness did not worsen, especially because Resident 1 had sustained a fall. LVN 2 stated he did not document the finding because he was busy passing medications during the shift. During an interview on 11/13/2025 at 9:44 a.m. with Registered Nurse (RN) 1, RN 1 stated changes of condition should be relayed to the physician and documented in a change of condition note. RN 1 stated if new skin redness (with or without pain) was observed on Resident 1's shoulder, the licensed nurse was to further the assess for pain, grimacing during a mobility assessment, monitor and document the finding. RN 1 stated it was important to complete a change of condition note so that the other licensed nurses could monitor for worsening symptoms especially because Resident 1 had suffered a fall. During a review of the facility's Charge Nurse Job Description (undated), the Job Description indicated charge nurses were to ensure the following:1) Observe, report and record findings/changes in resident condition (i.e., signs, symptoms, reactions, behavior, and complaints) to physician and nursing personnel2) Report changes of condition to physician, follow up on orders and document.3) Communicate residents' condition and nursing care to appropriate people i.e , supervisor, physician, family, etc. During a review of the facility's P&P titled, Charting and Documentation, revised 4/2008, the P&P indicated all services provided to the resident, or any changes in the resident's medical or mental condition, should be documented in the resident's medical record. During a review of the facility's Policy and Procedure (P&P) titled, Change in the Resident's Condition or Status, revised 11/2015, the P&P indicated the facility would promptly notify the Attending Physician of changes in the resident's medical/mental condition and/or status. 555732 Page 3 of 5 555732 11/13/2025 Santa Fe Heights Healthcare Center, LLC 2309 N Santa Fe Ave Compton, CA 90222

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 interview and record review, the facility failed to ensure a registered nurse (RN) supervisor completed the post-fall incident report per facility Policy and Procedure (P&P), titled, Assessing Falls and Their Causes, for a resident who suffered an unwitnessed fall that resulted in the identification of right shoulder bruising and a clavicle fracture (broken collar bone) seven days after the fall for one of three sampled residents (Resident 1). This failure had the potential to result in a delay in an RN- level, thorough post-fall assessment of Resident 1's condition and had the potential to lead to missed opportunities to identify a developing injury. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included history of falling, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) following a stroke (loss of blood flow to a part of the brain), aphasia (a disorder that makes it difficult to speak), dementia (a progressive state of decline in mental abilities), and mild intellectual disabilities. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 11/30/2025, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) for toileting, showering, lower and upper body dressing putting on footwear, and personal hygiene. During a review of Resident 1's History and Physical (H&P), dated 9/18/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make medical decisions. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR-a communication tool used by healthcare workers when there is a change of condition among the residents) Note, dated 11/3/2025, the SBAR indicated, on 11/3/2025 at 11:00 a.m., Resident 1 was observed lying a supine position in the hallway, and stated she fell. The SBAR indicated Resident 1 sustained a hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) on the back of Resident 1's head. The SBAR indicated the physician was made aware and an x-ray (a type of medical imaging) of the skull (bony enclosure around the brain) was ordered. During a review of Resident 1's Fall Incident Report (undated), the report indicated Licensed Vocational Nurse (LVN) 1 prepared the report. The Fall Incident Report indicated, on 11/3/2025, a skin check was completed, a hematoma was observed (on the back of Resident 1's head) and no visible skin cuts or abrasions were observed. During a review of Resident 1's SBAR, dated 11/10/2025, the SBAR indicated Resident 1 complained of pain to her right shoulder when raising her right arm and had discoloration to her right shoulder. The SBAR indicated the physician was made aware and an x-ray of the right arm and shoulder was ordered. During a review of Resident 1's X-ray Report, dated 11/10/2025, the report indicated a displaced, acute communicated fracture (a severe type of bone fracture where the bone is broken into multiple pieces) of Resident 1's right clavicle (collarbone). During a concurrent interview and record review on 11/13/2025 at 11:01 a.m. with Quality Assurance Nurse (QAN), the facility's P&P, titled, Assessing Falls and Their Causes, revised 3/2018, and Resident 1's Fall Incident Report (undated) were reviewed. The P&P indicated the nurse supervisor on duty was to complete the Fall Incident Report within 24 hours after the fall occurred. The Fall Incident report indicated LVN 1 completed the report. QAN stated, according to the policy, the registered nurse (RN) supervisor on duty during the time of the fall (RN 1) was supposed to complete the Fall Incident Report. QAN stated the facility did not follow their own policy and had the licensed staff followed the policy, RN 1 would have been prompted to complete RN 1's own physical, post-fall assessment or re-verify Residents Affected - Few 555732 Page 4 of 5 555732 11/13/2025 Santa Fe Heights Healthcare Center, LLC 2309 N Santa Fe Ave Compton, CA 90222

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LVN 1's post-fall assessment. QAN stated Resident 1 would have benefited from an RN- level post-fall assessment to ensure there were no range of motion issues, injuries, neurological deficits (injury to the brain), and skin issues missed during LVN 1's assessment. During an interview on 11/13/2025 at 11:46 a.m. with RN 1, RN 1 stated he was the assigned RN supervisor during Resident 1's fall on 11/3/2025. RN 1 stated the fall occurred during his lunch break and he was unable to conduct Resident 1's initial post-fall assessment. RN 1 stated he should have completed Resident 1's Fall Incident Report and did not do so because he was unaware of the facility's policy. RN 1 stated if he had been aware, he would have completed the incident report by conducting his own partial post-fall assessment in conjunction with LVN 1's documented assessment. During an interview on 11/13/2025 at 12:59 p.m. with the Director of Nursing (DON), DON stated it was the expectation of the RN Supervisor to conduct a thorough musculoskeletal, neurological, mobility assessment of the resident after a fall. The DON stated RN 1 should have conducted his own assessment even though LVN 1 had already completed an assessment because he was responsible for all residents on his shift, and an RN held more clinical knowledge. The DON stated that if RN 1 did not complete the fall incident report, per policy, and did not conduct RN 1's own post-fall assessment, there was a potential for injuries to be missed, like a fracture. During a review of the facility's RN Supervisor Job Description (undated), the Job Description indicated the RN Supervisor was to supervise the day-to-day clinical activities of the facility to ensure that the highest quality of care is maintained at all times. During a review of the facility's P&P titled, Assessing Falls and Their Causes, revised 3/2018, the P&P indicated the nurse supervisor on duty was to complete the Fall Incident Report within 24 hours after the fall occurred. 555732 Page 5 of 5