Santa Fe Heights Healthcare Center, Llc

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

or responsible family. RN 1 stated licensed nurses must obtain the Verification of Informed Consent form

before administering the medication.During a concurrent interview and record review on 10/15/2025 at 2:35 p.m. with RN 1, Resident 1's MAR, dated 7/1/2025 - 7/31/2025, was reviewed. The MAR indicated Resident 1 started receiving quetiapine fumarate 50mg, valproic acid 250mg/5ml, and Zyprexa 10mg on 7/17/2025.

RN 1 stated Resident 1 received psychotropic medications before obtaining an informed consent and Resident 1 should not have received the medication until the informed consent had been obtained. RN 1 stated administering medication without a verification of Informed consent was an unsafe practice.During a

review of facility's Policy and Procedure (P&P) titled Psychoactive Medication Informed Consent, dated 3/2024, the P&P indicated its purpose was to ensure an informed consent was obtained and verified prior to the initiation of psychoactive (a chemical substance that alters psychological functioning, such as mood, perception, and consciousness) medication use. The P&P indicated before initiating treatment with psychotherapeutic drugs, facility staff shall verify that residents' health records contain written informed consent with the required signatures.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Santa Fe Heights Healthcare Center, LLC

2309 N Santa Fe Ave Compton, CA 90222

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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure licensed nursing staff revised a fall care plan for one of two sampled residents (Resident 1) after Resident 1's fall on 1/4/2025, 7/28/2025, 4/30/2025, and 7/28/2025.These deficient practices resulted in Resident 1 not having effective interventions in place to minimize future falls and injuries, placing Resident 1 at risk for future falls. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE REDACTED] with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).During a review of Resident 1's History and Physical (H&P), dated 10/3/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 8/28/2025, the MDS indicated Resident 1's cognitive skills for daily decision making were moderately impaired (ability to think and reason). The MDS indicated Resident 1 required supervision from staff for activities of daily living such as eating, oral hygiene, toileting hygiene, dressing, shower/bathing and personal hygiene.During a review of Resident 1's fall care plan, dated 12/3/2024, the care plan indicated Resident 1 fell on 1/4/2025, 1/10/2024, 4/30/2025, and 7/28/2025. The care plan indicated the interventions were not revised after Resident 1's falls.During a review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 7/28/2025, the SBAR form indicated Resident 1 had a witnessed fall on 7/28/2025.During a concurrent interview and record

review on 10/15/2025 at 12:27 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's care plan for falls, dated 12/3/2024, was reviewed. The care plan indicated on 1/4/2025, 1/10/2025, and 4/30/2025, the care plan's interventions were not revised after Resident 1 had a fall. LVN 1 stated care plans must be revised

after every fall and new interventions must be developed. LVN 1 stated if a care plan was not revised after a fall, there would be no additional interventions to minimize Resident 1's falls.During a concurrent interview and record review on 10/15/2025 at 1:10 p.m. with Registered Nurse (RN) 1, Resident 1's care plan for falls, dated 7/28/2025, was reviewed. The care plan indicated Resident 1 had a fall on 7/28/2025 and interventions were not developed. RN 1 stated the care plan was incomplete because interventions were not developed to minimize falls or injuries from a fall.During a concurrent interview and record review on 10/15/2025 at 3 p.m. with RN 1, Resident 1's care plan for falls, dated 12/3/2024, was reviewed. The care plan indicated on 1/4/2025, 1/10/2025 and 4/30/2025, Resident 1 had a fall, and the care plan interventions were not revised. RN 1 stated interventions had to be developed after every fall because the last intervention did not work. RN 1 stated this practice was unsafe for Resident 1 because the previous interventions did not work to prevent another fall and Resident 1 needed new interventions to minimize falls.During a review of facility's Policy and Procedure (P&P) titled Falls and Fall Risk, Managing, dated 4/2018, the P&P indicated if a fall reoccurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. The P&P indicated staff would implement a resident centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. The P&P indicated if the resident continues to fall, staff will re-evaluate the situation and determine if whether it is appropriate to continue or change current interventions.

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