Health inspection·September 30, 2025

The following reflects the findings of the California Department of Public Health during the investigation of: Facility Reported Incident: 2564582 Event ID: 1D39ED Representing the California Department of Public Health HFEN #42123 State Citation A 42 C.F.R. 483.25(d)(2) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR 72311(a)(1)(A) Nursing Services-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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR 72523 (a) Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 7/17/2025, the California Department of Public Health (CDPH) received a facility reported incident regarding a fall with injury on 7/16/25 for Resident 1. An unannounced visit was conducted at the facility on 8/12/25, to investigate a Facility Reported Incident which alleged a resident fell with injury on 7/16/25. The resident sustained an intertrochanteric fracture (a type of hip fracture [broken bone] where the femur [upper thigh bone] meets the pelvis) of her left hip, decreasing mobility, becoming bedbound and caused increased pain. The resident was on hospice [specialized form of for end-of-life care] and the responsible party chose not to send the resident to the acute care hospital (ACH) for treatment and to provide comfort care only. The investigation found the facility failed to: 1. Ensure Resident 1 received adequate supervision and assistance to meet her needs, including anticipating toileting needs, in violation of state and federal law and the facility's policy titled . 2. Implement interventions to address Resident 1's high risk for falls when Resident 1 was assessed as having: a high fall risk, poor safety awareness having known behaviors of attempting to self-transfer, needing supervision during transfers, having urinary urgency and behaviors of asking to use the restroom within minutes of going. 3. To address the root cause of Resident 1's urinary urgency and frequent need to use the restroom. These failures resulted in Resident 1 attempting to self-transfer, leading to her falls on 5/19/25, 6/16/25 and 7/16/25 which resulted in the resident fracturing her hip on 7/16/25. Resident 1 became bedbound, was unable to attend activities and experienced increased pain that required routine pain medication. Resident 1 was an 89 year old female on hospice admitted to the facility on 3/24/25 with diagnoses that included fracture of superior rim (upper edge) of right pubis (pubic bone-a bone that makes up the pelvis), displaced intertrochanteric fracture of left femur, dementia (decline in mental ability severe enough to interfere with daily life), retention of urine (inability to completely empty the bladder), and anxiety disorder (feeling of unease, worry or fear). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive and physical function) assessment dated 7/3/25, it indicated Resident 1's Brief Interview of Mental Status assessment (BIMS-assessment of cognitive status for memory and judgement) scored 05 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment score indicated Resident 1 had severe cognitive impairment. During an interview on 8/12/25 at 8:42 a.m. with the Administrator in Training (AIT), the AIT stated Resident 1 was no longer in the facility because she had passed away on hospice on 7/27/25. During an interview on 8/12/25 at 9:26 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was a high fall risk and had behaviors of frequently getting up and trying to self-transfer while unsupervised. CNA 1 stated Resident 1 was not safe to transfer without assistance. CNA 1 stated Resident 1 had frequent urgency (sudden, compelling need to urinate) to go to the restroom because she felt like she needed to urinate (pass urine from the body). CNA 1 stated the staff would take Resident 1 to the restroom, and she would ask to go again within minutes of urinating. During an interview on 8/12/25 at 10:27 a.m. with CNA 2, CNA 2 stated she took care of Resident 1 while she was in the facility. CNA 2 stated "she would want to toilet all the time. We would take her to the bathroom often, then she would want to go again right away." CNA 2 stated even though staff frequently took Resident 1 to the bathroom, she would try to get up unassisted because she felt like she needed to go again, which increased her fall risk. During a concurrent interview and record review on 8/12/25 at 10:51 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was working when Resident 1 fell on 7/16/25. LVN 1 stated on 7/16/25 around 6:55 a.m., she had just arrived at the facility for her shift and saw Resident 1 in bed. LVN 1 stated she had walked to the nurse's station for report from the night shift and a CNA told her Resident 1 was on the floor. LVN 1 stated she assessed Resident 1 for injuries and Resident 1 complained of pain to her right leg from the back of her knee to her hip. LVN 1 stated Resident 1 appeared to be in pain, so she administered her pain medication. LVN 1 stated Resident 1 was able to move but complained of pain. LVN 1 stated Resident 1 was unable to bear weight on her right leg, so she called hospice and notified them Resident 1 had fallen. LVN 1 stated the hospice nurse came in around 7:30 a.m. for a routine visit and she asked the hospice nurse for an order to X-ray (a painless test that captures images of the structures inside the body) Resident 1's hip but was told to just keep the resident comfortable. LVN 1 stated she was informed by the hospice nurse that because hospice was for end-of-life care, they did not routinely perform X-rays on patients. LVN 1 stated Resident 1's pain continued to worsen, and she had facial grimacing [facial expression that show pain], so they requested an X-ray order from hospice a second time and received an order. Resident 1's X-ray report titled "Right Hip, Unilateral [one side] W/ [with] Pelvis," dated 7/16/25 was reviewed, it indicated, "... Acute intertrochanteric fracture with impaction [broken ends of a bone are driven into each other] and varus angulation [deviation of the bone towards midline of the body] ... Soft tissue swelling [abnormal buildup of fluid] around the right hip." LVN 1 stated the Director of Nursing (DON) had contacted Resident 1's responsible party and they did not want the resident sent to the hospital and requested the resident be kept comfortable at the facility. LVN 1 stated Resident 1 had increased pain, and her morphine sulfate (a powerful pain medication) was changed from as needed to routine for pain control. LVN 1 stated Resident 1 had fallen before the 7/16/25 fall, twice on 5/19/25 and once on 6/16/25. Resident 1's care plan dated 7/16/25 indicated, "... at risk for fall related to actual fall on 7/16/2025 ... 72-hour alert monitoring ... X-ray ... Communicated X-ray findings to MD [physician]/hospice/IDT [interdisciplinary team-involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities for the best interest of the resident] ... Manage resident fall risk through facility red sneaker program ..." LVN 1 stated the Red Sneaker Program was the facility's fall prevention program and was used for all residents with high fall risk and was not specific to Resident 1. LVN 1 stated Resident 1 needed increased supervision because she had behaviors of getting up to transfer without assistance because she felt like she needed to use the restroom frequently. LVN 1 stated Resident 1 had the urge to urinate frequently causing her to try and transfer herself. LVN was unable to find interventions that addressed urinary frequency and attempts to self-transfer. Resident 1's "Fall Risk Assessment," dated 7/3/25, was reviewed. The assessment indicated, "... High Risk for Falls ..." LVN 1 stated Resident 1 fell because she did not have enough supervision and would have required one on one (direct, individualized supervision) to prevent her from falling. During a review of the facility's "Red Sneaker Program," the program indicated, "... Criteria for Inclusion in the Red Sneaker Program... Resident had had a fall in the last 90 days ... has a Fall Risk Assessment Score of above 10 ... Care Plan Implementation ... Anticipate toileting needs of High Risk for Fall Residents ... Focus on residents who are High Risk for Falls that may be attempting to ambulate independently ... DON and IDT will make sure appropriate individualized CPs [care plans] and interventions are in place ..." During a concurrent interview and record review on 8/12/25 at 11:33 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 1's MDS "Section GG [functional status]," dated 7/3/25 was reviewed and indicated, "... sit to stand [code 02-substantial/maximal assistance- helper does more than half the effort] ... Chair/bed-to-chair transfer [code 02] ... Toilet transfer [code 02] ..." The MDSC stated Resident 1's MDS indicated the resident required the assistance of two people to safely transfer between the bed and chair and the chair to toilet. Resident 1's fall risk care plan dated 3/25/25, was reviewed. The care plan indicated, "... functioning deficit related to: Mobility impairment, ROM [range of motion] limitations r/t fracture to right superior/inferior pubis ramus ... Interventions ... Bed mobility assistance ... Call bell within reach ... Toileting Assistance ... Transfer Assistance ..." Resident 1's fall care plan dated 5/19/25, was reviewed and it indicated, "... At risk for delayed trauma r/t actual fall on 5/19/25 at 12:30 PM 1st and 2nd fall at 5:03 PM ... 72 hour alert monitoring ... Floor mat next to bed ... evaluation of the resident's condition ... activity programs ... low electric bed ... Manage resident fall risk through facility Red Sneaker Program ..." Resident 1's fall care plan dated 6/17/25 was reviewed and it indicated, "... At risk for delayed injury r/t actual fall on 6/16/25 ... Assist with toileting q [every] 2 hrs [hours], at bed time and as needed ... floor mats to side of bed ... level 2 [every 15 minute checks] monitoring x 72 hours ... Notify hospice ... Encourage activities ..." Resident 1's fall risk care plan dated 7/16/25, indicated, "... At risk for unavoidable falls and related injury ... Rt. [right] Hip fracture R/T [related to] Osteoporosis/Diffuse Osteopenia ... Resident is on Hospice care ... Bed in low position ... Fall Mat... Turn and reposition Q [every] 2 hours ..." The MDSC stated the care plan interventions were not personalized to Resident 1's needs. The MDSC stated rounding on residents and offering to toilet the residents every two hours was standard care and did not specifically address Resident 1's frequent urination or attempts to self-transfer. During a concurrent interview and record review on 8/1/25 at 11:55 a.m. with the DON, the DON stated Resident 1 was at high risk for falls and was admitted with fractures from falling prior to admission. The DON stated Resident 1 was not compliant with care and would try to transfer herself because she felt like she needed to use the restroom frequently. The DON stated Resident 1 was anxious, had behaviors of repeatedly requesting to use the restroom and attempting to self- transfer without assistance because she had urinary urgency, increasing her fall risk. The DON stated the CNAs would take Resident 1 to the bathroom and five minutes later she would get restless and want to go again. The DON stated Resident 1 had been seen by a psychologist (a professional who studies mental processes and behavior) to address the behavior of anxiety causing repeated requests to use the toilet. The DON reviewed Resident 1's electronic medical record and stated Resident 1 did not have a urinalysis (U/A-laboratory test that examines a person's urine to detect and assess various health conditions) to rule out a possible infection as a cause for her urinary urgency. The DON stated a U/A was not tested because Resident 1 was on hospice. The DON reviewed Resident 1's fall care plans and stated the resident sustained four falls while at the facility. The DON was unable to find interventions indicating how the plan of care addressed Resident 1's urinary urgency and frequency and her attempts to self-transfer. Resident 1's "General Note," dated 6/17/25, was reviewed. The note indicated, "... LATE ENTRY ... Writer was notified by staff that resident was sitting on the floor ... Resident stated I slid from bed and fell. I wanna go to the bathroom, I need to pee ..." Resident 1's "SBAR [situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents] Post Fall," dated 6/16/25 at 11:30 p.m., indicated, "... Resident fell in Resident room... Unwitnessed fall ..." The DON stated the root cause of Resident 1's 6/16/25 fall was the resident's attempt to transfer unassisted because she needed to go to the bathroom. The DON was unable to state if any new, personalized interventions were put into place after the fall on 6/16/25. Resident 1's "SBAR Post Fall," dated 7/16/25 at 3:46 p.m. was reviewed and indicated, "... Prior to fall resident was Attempt to self transfer ... Resident fell in Resident room ... Injury ... Unwitnessed fall ... Fall details: Other Unable to describe ..." from 7/16/25 was reviewed and indicated, "..." The DON stated Resident 1's fall was unwitnessed. The DON stated a new intervention was put into place after the fall and Resident 1 was moved into a different room with a CNA assigned in the room for the day and evening shifts. During a review of Resident 1's "Psychologist Consultation," dated 6/23/25, "... Treatment & compliance ... demanding ... Affect ... Anxious ... anxious [with] frequent requests to use restroom ..." During a review of Resident 1's "Post Fall IDT Analysis," Dated 6/19/25, the note indicated, "... Fall Date and Time ... 6/16/25 ... LN was notified by staff that resident was sitting on the floor. LN went to res. room assessed resident, noted this res sitting on the floor leaning her back against the bed ..." During a review of Resident 1's "Psychologist Consultation," dated 7/15/25, "... Treatment & compliance ... repetitive requests ... Affect ... Anxious ... anxious, forgetful, has frequent requests to use toilet is otherwise cooperative with care & Tx [treatment]..." During a review of Resident 1's "Post Fall IDT Analysis," dated 7/16/25, the IDT note indicated, "... Fall Date and Time ... 7/16/25 at 06:15 [a.m.] ... Immediate interventions post fall ... Placed on level 2 monitoring. Hospice Nurse Came New orders for pain meds [medication]. Xray Rt. [right] Leg and Rt. Hip ... C/O [complains of] pains Room Change offered for close supervision ... At 06:15 AM staff found resident sitting on the floor mat. At 06:05 AM CNA made rounds & res. [resident] was on her bed with her call light wit