Other·June 11, 2026

Sage Post Acute The following reflects the findings of the California Department of Public Health during the investigation of one Facility Reported Incident number 2802504. Event ID: 231A77-H1 Representing the Department, HFEN # 38534 State Citation (B) was written. 72311(a)(1)(A)(B)(C)(2) §72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 5/11/26 at 11:30 am, an unannounced visit was conducted at the facility to investigate a Facility Reported Incident of resident (Resident 1) injury. The facility failed to provide adequate supervision to Resident 1 when she was left unattended on shower chair. This deficient practice resulted in Resident 1 falling out of shower chair, sustaining L5 (5th lumbar- lower back bone) compression fracture (broken bone due to a collapse). Resident 1 was admitted to the facility in March 2016, with multiple diagnosis including muscle weakness, dementia (decline in cognitive function), osteoarthritis of knees (chronic degenerative joint disease). During a review of Resident 1's Minimum Data Set (MDS, an assessment to plan care) assessment dated 12/22/25 indicated, Resident 1's Brief Interview for Mental Status (BIMS, an evaluation for mental status) score was eight (8) out of 15, indicating Resident 1's mental status was moderately impaired. The assessment indicated Resident 1 required facility staff supervision or touching assistance, where staff provided verbal cues and/or touching/steadying as she completed upper body dressing, lower body dressing, showers and personal hygiene. During a review of Resident 1's "fall risk assessment" (an evaluation to determine likelihood of falling) dated 6/24/25, indicated Resident 1 was at moderate risk for falls related to use of medications to control blood pressure, impaired recall ability, impaired vision, incontinence of bladder (involuntary leakage of urine), and her being confined to bed. During a review of Resident 1's fall risk care plan dated 9/13/24 indicated Resident1 was at moderate risk for falls due to gait/balance problems, vision loss, her preference to perform self-care and mobilization with walker and wheelchair. The care indicated for all facility staff to anticipate and meet her needs. During an observation and interview with Resident 1 on 5/11/26 at 1:25 p.m., Resident 1 was standing in her room, trying to get her walker. Resident 1 stated she was "almost blind" and it was hard for her to see things. Resident 1 stated she could not remember how she fell. During an interview on 5/12/26 at 9:29 a.m., with Certified Nursing Assistant (CNA 1, who was the assigned staff when Resident 1 fell on 3/4/26), CNA 1 stated that she helped Resident 1 to take the shower, took Resident 1 back to her room in a shower chair. CNA 1 stated Resident 1 asked her to bring water for her, CNA 1 left room while Resident 1 was still in the shower chair (unsupervised and unattended) to bring water. CNA 1 stated when she went back to the room after a minute, she saw Resident 1 was on the floor next to the bed. CNA 1 stated she did not know Resident 1 was at risk for falls. During a review of Resident 1's nursing progress notes dated 3/4/26 indicated, [Resident 1] found on the floor in sitting position next to shower chair in her room after being left to dress independently following a shower. [Licensed nurse] assessed the resident immediately after the fall. [Resident 1] was alert and oriented and complained of neck pain and back pain. Rectal (anus) bleeding was noted during assessment. No other visible external bleeding noted.... [Resident 1] assisted back to bed with staff assistance...Due to complaints of pain and noted bleeding 911 activated and [Resident 1] transferred to [Acute Care Hospital Emergency Room] for further evaluation. During a review of Resident 1's Acute Care Hospital- History and Physical progress notes dated 3/4/26, indicated Resident 1 had L5 (the fifth lumbar vertebra [lower back]) compression fracture after the ground level fall at the facility. During an interview on 5/11/26 at 2:10 p.m. with the Director of Nursing (DON), the DON stated CNAs should make sure to transfer residents to their bed after shower to make sure they are safe and secure before leaving the resident's room. A review of facility's policy and procedure titled "Bath, Shower/Tub" revised Feb 2018, indicated "...31. Assist with dressing and grooming as needed. 32. Assist the resident into bed or chair. 33. Place the call signal within easy reach of the resident..." A review of the facility's policy and procedure "Fall and Fall Risk Managing" revised December 2007, indicated "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling..." The facility failed to supervise one of three sampled residents (Resident 1), when Resident 1 was left unsupervised and unattended in a shower chair in her room. This deficient practice resulted in Resident 1 falling out of shower chair, sustaining L5 (5th lumbar- lower back bone) compression fracture (broken bone due to a collapse). This violation presented imminent danger that resulted in a serious physical harm including but not limited to Resident 1 sustaining L5 compression fracture after falling out of shower chair when she was left unattended and unsupervised.