Rosemead Healthcare Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
photosensitivity, weight gain for use of Escitalopram Oxalate.4. Anti-psychotic: Monitor side effects such as sedation, drowsiness, dry mouth, constipation, blurred vision, weight gain, edema, sweating, loss of appetite, urinary retention for the use of Haloperidol and Quetiapine Fumarate. During a review of Resident 2's Change of Condition (COC)/Interact Assessment Form (SBAR, a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains), dated 4/19/25, the COC indicated on 4/19/25 Resident 2 suffered an unwitnessed fall, found on the floor inside bedroom. Resident 2 stated he slipped out of the wheelchair while leaning forward. The COC further indicated the recommendation from the primary care physician was to perform neuro checks for 72 hours.During a
review of Resident 2's Fall Risk (Morse) Assessment (a nursing tool that uses a scoring system to evaluate resident's risk of fall), dated 4/19/25, the assessment indicated Resident 2 scored a 35 (moderate risk for falling).During a review of Resident 2's Neuro Check List (NCL), the NCL indicated Resident 2 was monitored from 4/19/25 at 00:20 to 4/22/25 at 24:05.During a review of Resident 2's Change of Condition (COC)/Interact Assessment Form, dated 4/22/25, the COC indicated on 4/22/25 Resident 2 had a fall with a pain score of 3 out of 10 pain scale for the left parietal area [where the parietal lobes are located near the back and top of the head. They are important for processing and interpreting somatosensory input].During
a review of Nursing Progress Notes, dated 4/22/25, the notes indicated Resident 2 was found lying on the floor in front of his wheelchair at 22:30. A body check was completed and Resident 2 had a 2.5 x 2.5 cm bump on the left parietal area and complained of pain on a scale of 3 out of 10. Resident 2 stated he was sitting in his wheelchair and wanted to catch the urinal, but lost balance and was laying on the floor.
Resident 2 was provided with an ice pack, and the MD was notified with no new order.During a review of Resident 2's Neuro Check List (NCL), the NCL indicated Resident 2 was monitored from 4/22/25 at 22:30 to 4/25/25 at 22:15.During a review of Resident 2's Fall Risk (Morse) Assessment, dated 4/22/25, the assessment indicated Resident 2 scored a 60 (high risk for falling).During an interview on 8/13/25 at 9:40 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the fall skin assessment by the treatment nurse is completed at the time of the fall or next day if it occurred at night. When the resident is on an anticoagulant medication, or there is an unwitnessed fall, then it's automatic that the resident is sent out to
the hospital unless the resident refuses to go. LVN 1 further stated the change of condition is completed by
the nurse and the MD, RP/family are notified about the fall.During an interview on 8/13/25 at 11 a.m. with
the Director of Nursing (DON), the DON stated the facility does not have an IDT documentation note for Resident 2's falls that occurred on 4/19/25 and 4/22/25. The DON stated the IDT met as a group, but the DON could not find any IDT note in Resident 2's medical record indicating the falls were evaluated and discussed by the IDT. The DON stated he could only provide IDT notes for 3/31/25 (IDT after Resident 2 was admitted on [DATE REDACTED]) and IDT notes for 6/26/25 (discharge planning for anticipated discharge on [DATE REDACTED]). The DON stated the process per the Fall Management Program Policy is the IDT meets within 72 hours of a fall and reviews the cause of the fall(s) and plans interventions and updates the care plan. The DON stated the facility missed the opportunity to evaluate Resident 2's falls that occurred on 4/19/25 and 4/22/25 and update the care plan with interventions to mitigate or prevent future falls.During a review of the facility's current Policy & Procedure (P&P) titled, Fall Management Program, date implemented 10/1/23, the P&P indicated Post-Fall: The IDT-Falls Committee will meet within 72 hours of a fall. The IDT-Falls Committee will review and document: 1) Summary of event following a fall; 2) Root cause analysis; 3) Referrals, as necessary; and 4) Interventions to prevent future falls.
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ROSEMEAD HEALTHCARE CENTER in EL MONTE, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EL MONTE, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ROSEMEAD HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.