Health inspection·January 16, 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 implement its policy and procedure on resident safety by failing to provide supervision to one of two sampled residents (Resident 1) who were at high risk for falls. This deficient practice resulted to Resident 1 having an acute subdural hematoma (a blood clot that forms between the brain's surface and its tough outer covering) after he had a fall when he attempted to stand up from a sitting position at the facility's patio without staff supervision. Findings: During a review of the facility ' s investigation summary report, dated 1/7/2025, indicated that on the evening of 1/2/2025, a staff who was in the patio observed Resident 1 sitting on the patio ' s brick seating area. At around 9 PM, Resident 1 stood up using his front-wheeled walker and fell on his right side. The staff who immediately responded to the fall assessed Resident 1 and found a bump and a cut on the resident ' s right forehead. The facility called 911 (a universal emergency number) and sent Resident 1 to a general acute care hospital (GACH) for further evaluation per physician ' s order. During a review of Resident 1 ' s admission Record indicated that the facility admitted Resident 1 on 1/11/2011 and readmitted the resident on 1/5/2025 with diagnoses that included nontraumatic subdural hemorrhage (a rare condition that occurs without head trauma). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 3/27/2024, indicated that Resident 1 ' s cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated that Resident 1 required supervision or touching assistance (helper provides verbal cues and touching or contact guard assistance as resident completes the activity) from a person when standing from a sitting position. During a review of Resident 1 ' s Change in Condition Evaluation report, dated 12/30/2024, indicated that he fell in the patio prior to the fall incident on 1/2/2025, but did not sustain any injury. During a review of Resident 1 ' s Fall Risk Evaluation, dated 12/30/2024, indicated that Resident 1 had a history of falls in the past three (3) months and had problem maintaining his balance while standing and has a decreased muscular coordination (a condition that causes a loss of muscle control and unsteady movements). During a review of Resident 1 ' s Physical Therapy Evaluation, dated 12/31/2024, indicated that Page 1 of 2 555897 555897 01/16/2025 Monterey Healthcare & Wellness Centre, LP 1267 San Gabriel Blvd Rosemead, CA 91770

F 0689 Resident 1 required supervision or touching assistance when transferring sitting to standing. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1 ' s Physical Therapy Discharge summary, dated [DATE], indicated that Resident 1 required supervision or touching assistance when transferring from chair to bed and vice-versa. Residents Affected - Few During a review of Resident 1 ' s care plan, initiated on 6/23/2021, indicated that Resident 1 was at risk for falls related to psychoactive drug use (substances that include alcohol, caffeine, nicotine, marijuana, and certain pain medicines), had poor safety judgement, and lacked coordination. The care plan ' s interventions included to anticipate and meet the needs of the resident. During a review of Resident 1 ' s GACH Emergency Notes records, dated 1/2/2025, indicated that Resident 1 had a post-fall acute subdural hematoma with a large scalp hematoma overlying the right frontal bone with no depressed skull fracture. During a telephone interview with Certified Nurse Assistant (CNA) 4 on 1/16/2025 at 1:10 PM, CNA 4 stated that he heard a resident fall on the ground when he and CNA 1 were passing cigarettes to the residents in the patio on 1/2/2025 at around 9 PM. CNA 4 stated that he and CNA 1 were far from Resident 1 when he saw Resident 1 on the floor. During an interview with the facility ' s physical therapist (PT 1) on 1/16/2025 at 12:15 PM, PT 1 stated that they evaluated Resident 1 for PT treatment on 12/31/2024 due to a fall incident Resident 1 had on 12/30/2024 and determined in the evaluation that Resident 1 required supervision when standing from a sitting position. The PT stated, Supervision means that a person needs to be close enough to the resident being supervised so that the resident could be caught if he if he loses his balance. During a review of the facility ' s undated policy titled, Resident Safety, version 1.0, revised on 4/15/2021 indicated that the purpose of the policy is to provide a safe and hazard free environment for the residents by establishing a person-centered observation or monitoring system for the resident to address the identified risk factors. 555897 Page 2 of 2