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.
Based on interview and record review, the facility failed to ensure that a wheelchair sensor pad alarm (a
weight-sensitive sensor pad that is connected to a monitor unit and activates an alarm if a patient leaves
the chair or the bed) was placed on the wheelchair (a mobility device that helps a person with mobility
impairment to move around) of one of three sampled residents (Resident 1).
This deficient practice had the potential to result in multiple falls with injuries for Resident 1 who was
assessed as high riskfor falls.
Findings:
During areview of Resident 1 ' s admission Record, the admission Record indicated that the facility
admitted the resident on 07/01/2019 and readmitted the resident on 09/19/2024 with diagnoses that
included difficulty in walking, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the
body), and hemiparesis (a condition that causes weakness or an inability to move on one side of the body).
During areview of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated
09/25/2024, indicated that the resident ' s cognition (mental action or process of acquiring knowledge and
understanding through thought, experience, and senses) was severely impaired and that the resident was
dependent (helper does all the effort) on a person to transfer from a chair to the bed and vice versa.
During a review of Resident 1 ' s Fall Risk Evaluation dated 09/19/2024 indicated that the resident was
assessed as a High Risk for fall.
During a review of Resident 1 ' s Physician Order dated 09/19/2024 indicated that the physician ordered to
use a sensor pad in bed and in a wheelchair to remind the resident not to get up unassisted.
During areview of Resident 1 ' s care plan, dated 09/19/2024, indicated that the resident was at risk for falls
and one of the interventions indicated on the care plan was to include the use of a sensor pad when the
resident was in the wheelchair for safety precaution.
During areview of Resident 1 ' s Progress Notes dated 11/01/2024 at 04:50 PM indicated that the resident
was found lying on the floor in the dining room on his left side by a Certified Nurse Assistant (CNA) and
was assisted back to his wheelchair.
During a telephone interview with Family 1 (FAM 1) on 11/22/24 at 1:45 PM, FAM 1 stated that
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
555796
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555796
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mission Care Center
4800 Delta Avenue
Rosemead, CA 91770
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Resident 1 had an unwitnessed fall in the facility on 11/01/2024 while in his wheelchair. FAM1 stated that
on four (4) separate occasions, she found Resident 1 ' s wheelchair sensor pad unplugged to the alarm.
FAM 1 also stated that when she visited Resident 1 on 11/15/2024, the wheelchair sensor pad was missing
from Resident 1 ' s wheelchair.
During an interview with the Director of Staff Development (DSD) on 11/25/2024 at 12:12 PM, the DSD
stated that FAM 1 asked DSD on 11/15/2024 why Resident 1 did not have the wheelchair sensor alarm
applied to Resident 1 ' s wheelchair and confirmed that Resident 1 did not have the wheelchair sensor
alarm applied to the wheelchair, while Resident 1 was seated in the wheelchair in the dining room.
During an interview with the Director of Nursing (DON) on 11/25/24 at 3 PM, she stated that the facility
conducted a fall risk evaluation on residents during admission, quarterly, annually, and during a change of
condition. She stated that if a resident was assessed as a high risk for fall, the facility created a care plan
with interventions that included a wheelchair sensor pad alarm to aid in the prevention of falls. The DON
stated that if the facility did not carry out the interventions according to the plan of care, the resident could
be exposed to accidents, such as a fall, that could result to serious injuries.
During a review of the facility ' s undated policy titled; Fall Management System revised in 03/2024
indicated that the facility is committed to promoting resident autonomy by providing an environment that
remains free of accident hazards as possible. Each resident is assisted in attaining or maintaining their
highest practicable level of function through providing the resident adequate supervision and assistive
devices to prevent accidents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555796
If continuation sheet
Page 2 of 2
