Health inspection·February 11, 2026

The following reflects the findings of the California Department of Public Health during the investigation of: Facility Reported Incident: 2677785 Event ID: 1DCB58-H1 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)(2) 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 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 11/25/25, the California Department of Public Health (CDPH) received a facility reported incident regarding a fall with injury on 11/24/25 for Resident 1. An unannounced visit was conducted at the facility on 12/2/25 for a Recertification Survey. The Facility Reported Incident regarding Resident 1's status post fall with injury on 11/24/25 was investigated during the recertification survey. Resident 1 was sent out to the acute care hospital due to severe pain in her right hip and inability to bear weight to right leg for further evaluation and treatment. Resident 1was diagnosed with Periprosthetic fracture around internal prosthetic right hip (a broken bone around a hip replacement) and had a surgical procedure ORIF (open reduction internal fixation (is surgery used to stabilize and heal a broken bone) right femur (right thigh bone). The investigation found the facility failed to: 1. Ensure Resident 1 received adequate supervision and assistance to meet Resident 1's needs including safely performing activities of daily living, in violation of state and federal law and the facility's policy and procedures titled "Falls and Fall Risk, Managing and Red Sneaker Program (Fall Monitoring/Prevention)." 2. Implement effective fall 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 of attempting to self-transfer without using safe techniques, needing supervision during transfers, had unsteady gait, and suffered multiple falls on 11/18/25, 11/22/25,11/23/25 and 11/24/25. 3. Address medication regimen review status post fall on 11/18/25. Resident 1 was receiving anti-anxiety medication, pain medication and sleep medication that were related to the root causes of her falls. 4. Ensure Resident 1 was assessed by the Physical Therapy department after Resident 1 was identified having poor safety awareness and decline in functioning on 11/19/25. 5. Address the root cause of Resident 1's frequent falls related to self-transfers for a possible cause consistent with Resident 1's needs, goals and care. 6. Monitor effectiveness, modify and update fall interventions after each fall. These failures resulted in Resident 1 sustaining four unwitnessed falls on 11/18/25, 11/22/25, 11/23/25, and 11/24/25. After the fall on 11/24/25, Resident 1 was sent out to the acute care hospital due to severe pain in her right hip and inability to bear weight to right leg and was diagnosed with Periprosthetic fracture around internal prosthetic right hip (a broken bone around a hip replacement). During hospitalization, Resident 1 had a surgical procedure ORIF (open reduction internal fixation (is surgery used to stabilize and heal a broken bone) right femur (right thigh bone). Resident 1 experienced a significant change of condition after the fall on 11/24/25, suffered avoidable pain, injury to the right thigh, decreased mobility and decreased quality of life. Resident 1 is an 80-year-old female initially admitted to the facility on 1/27/22 with diagnoses which included Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), Protein Calorie Malnutrition (the state of inadequate intake of food (as a source of protein, calories, and other essential nutrients), Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), Sleep Disorder, Anemia (disease that occurs when the body doesn't have enough red blood cells to carry oxygen), Osteoarthritis (is a degenerative joint disease that can affect the many tissues of the joint) of Right Shoulder, Chronic Pain syndrome (is pain that persists or recurs for longer than 3 months, and, Scoliosis (is a side-to-side curve of the spine). Resident 1 was readmitted from acute hospital on 11/27/25 with a Periprosthetic fracture around an internal prosthetic right hip (a broken bone around a hip replacement), generalized muscle weakness, abnormalities of gait and mobility (an unusual walking pattern), spinal stenosis (a narrowing of the spine that causes pressure on the spinal cord and nerves and can cause pain), and repeated falls (experiencing two or more falls within a specific timeframe). During a concurrent observation and interview on 12/2/25 at 9:20 a.m. with Resident 1, in Resident 1's room, Resident 1 was awake, lying in bed with a white sheet covering her body. Resident 1's bed was at standard height position and a wheelchair was parked beside Resident 1's left side of the bed. Resident 1 was alert and oriented and able to state her name. Resident 1 was able to recall her recent fall on 11/24/25. Resident 1 stated she fell in her room and went to the acute care hospital. Resident 1 stated she fell while walking around the room and stated the fall happened in the morning. After the fall, Resident 1 stated she had no broken bones and showed her right arm with a dried skin tear. Resident 1 stated she is aware of her need to use the bathroom, and she was unable to walk by herself to go to the bathroom. Resident 1 stated, "not easy to move my leg..." Resident 1 stated she had a bandage on her right leg. Resident 1 stated she had shoulder discomfort and receiving pain medication, and stated, "just feel sore here (pointing to right shoulder)." During a review of Resident 1's "Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment)," dated 12/1/25, the "MDS" section C indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding which has a scale of 0-15 ) score of 3 out of 15, which suggested Resident 1 was severely cognitively impaired. During a review of Resident 1's progress note, dated 11/27/25, indicated, "Received a call from acute care hospital...Resident 1 was admitted on 11/24/25 for ground level fall, fracture of right femur. ORIF was done on 11/25/25..." During a review of hospital records titled, "Case Management Discharge Summary/Orders Report," dated 11/27/25, indicated, Resident 1 discharge diagnosis was a Periprosthetic fracture located around internal prosthetic right hip. Resident 1 had history of falls and Alzheimer's and had a fall on 11/23/25 and 11/24/25. Resident 1 was sent from the skilled nursing facility to Hospital A. It was reported that Resident 1 attempted to ambulate her after the fall this morning, patient reported pain in her right thigh and was then transported to Hospital A. Resident 1 continued with pain and after radiology exams she was positive for a right femur periprosthetic fracture. The plan for Resident 1 was to keep the resident hospitalized and perform surgery to the right femur (right thigh bone). During a concurrent observation and interview on 12/3/25 at 9:00 a.m. to 9:15 a.m. with Resident 1 in the hallway by Resident 1's room, Resident 1 was up in a wheelchair with a bandage wrapped around Resident 1's right lower extremity. Resident 1 was propelling her wheelchair slowly and stating she was lost. Resident 1 continuously self-propelled her wheelchair while waiting for staff to assist her. During an interview on 12/4/25 at 9:58 a.m. with the Restorative Nurse Assistant (RNA), the RNA stated she was familiar with Resident 1. The RNA stated Resident 1 was "very high risk for falls" because she's been falling multiple times and was sent out to the acute care hospital related to a fall. The RNA stated Resident 1 had been doing unsafe transfers from bed to wheelchair forgetting to lock the wheelchair. The RNA stated Resident 1 can stand and walk in her room with an unsteady gait (a shaky, wobbly, and unstable way of walking). The RNA stated she observed a decline in Resident 1's activities of daily living (ADL's - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and cognition when Resident 1 returned from the acute care hospital last week. The RNA stated Resident 1 had been on Fall Program Level 2 monitoring (every 15-minute check) and had been falling. The RNA stated someone should be with Resident 1 around the clock to prevent additional falls. During an interview on 12/4/25 at 10:00 a.m. with Certified Nurse Assistant (CNA) 3, outside Resident 1's room, CNA 3 stated Resident 1 had a red shoe sneaker picture by her name which indicated Resident 1 was high risk for falls. CNA 3 stated Resident 1 was confused (a state of mental uncertainty where you can't think clearly, feeling disoriented, and having trouble with memory, focus, or decision-making), and she does not use her call light. CNA 3 stated prior to Resident 1's injury related to the fall; Resident 1 always attempted to get up from bed and do self-transfer from bed to wheelchair without assistance from the staff. CNA 3 stated Resident 1 can propel her wheelchair. CNA 3 stated Resident 1 had a decline in function after the fall on 11/24/25, Resident 1 was wearing a brief for incontinence and oral intake was decreased to 25 percent and was provided a bed bath. CNA 3 stated that all residents with level 2 monitoring were documented in a binder. CNA 3 stated level 2 monitoring means Residents are checked every 15 minutes. During a concurrent interview and record review on 12/5/25 at 10:45 a.m. with the Registered Nurse Supervisor (RNS), the RNS stated Resident 1's Medication Regimen Review (MRR) for a fall on 11/18/25 was not in Resident EMR's and hard copy chart and stated, "if not in chart it was not done." The RNS stated Resident 1 was on antianxiety medication prior to hospitalization and it was discontinued at the acute hospital. The RNS stated Resident 1's MMR after the fall should be completed to address medications that can be contributing to the falls to prevent additional falls. During a review of Resident 1's Electronic Medication Administration Record (EMAR- an electronic daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 11/2025, the EMAR indicated, "...Melatonin 3 mg (milligrams- metric unit of measurement, used for medication dosage and/or amount) give 1 tablet by mouth at bedtime for dietary supplement start date: 9/10/24; D/C (discontinue) date: 11/27/25...Clonazepam 0.5 mg give 1 tablet by mouth three times a day related to Anxiety Disorder, start date: 8/20/25 D/C date: 11/27/25..." During a concurrent interview and record review on 12/4/25 at 2:40 p.m. with Licensed Vocational Nurse (LVN) 3, the facility's fall program monitoring was reviewed. The monitoring form indicated Resident 1 was on Level 2 monitoring or every 15-minute check started on 11/27/25 and discontinued on 11/30/25. LVN 3 stated Resident 1 Level 2 monitoring ended on 11/30/25 and she was informed by Interdisciplinary Team (IDT) to start every 15-minute checks today (12/4/25). LVN 3 stated she was the nurse of Resident 1 and was aware of her repeated falls. LVN 3 stated Resident 1 is high risk for falls due to frequent falls on 11/18/25, 11/22/25 and 11/24/25, unsafe self-transfers and impaired safety awareness (the practice of finding and recognizing risks and hazards). LVN 3 stated level 2 monitoring for Resident 1 was not effective due to increasing number of falls. LVN 3 stated she believed that Resident 1 should be on level 3 monitoring which provides one on one supervision to prevent further falls and to minimize injuries related to falls. During an interview on 12/4/25 at 2:41 p.m. with CNA 7, CNA 7 stated the Red Shoe Sneaker Program is a Fall Program in which residents with a recent fall are placed on Level 2 monitoring (every 15-minute check) for 72 hours to prevent further falls. CNA 7 stated she was assigned to Resident 1, and she will be responsible for 15-minute check monitoring and responsible in providing care to other residents in their assignment. CNA 7 stated she could not do every 15-minute check monitoring consistently when she was providing care to another resident. CNA 7 stated Resident 1 attempted to stand up and transfer herself from wheelchair to toilet without calling for assistance. CNA 7 stated Resident 1 was a fall risk and requires assistance from staff for transfers. During a concurrent interview and record review on 12/5/25 at 3:27 p.m. with the RNS, Resident 1's oral intake dated 11/28/25-12/5/25, and ADLS care plan, dated 11/27/25 were reviewed. The oral intake indicated multiple refusals and percentage of 0-25. The ADLs long term care plan care plan indicated, Resident 1 had a physical functioning deficit related to mobility impairment, self-care impairment secondary to dx of Alzheimer's Disease with a goal to maintain current level of physical functioning. Resident 1's ADL's long term care plan interventions/tasks indicated, Resident 1 requires supervision with bed mobility, wheelchair mobility, ambulation, toileting and transfers. The RNS indicated had a decline in oral intake in the past week with multiple refusals and some 0-25 percent of oral intake. The RNS stated Resident 1's ADLs care plan indicated, Resident 1 requires supervision with bed mobility, walking, transfers and toileting. The RNS stated Resident 1 had a decline in physical functioning and nutrition when she returned from the acute care hospital on 11/27/25. The RNS stated Resident 1's care plan should be revised according to Resident 1's significant change of condition. The RNS stated Resident 1's ADLs care plan should reflect current level of function for staff to follow safely. During an observation on 12/5/25 at 7:45 a.m.-8:00 a.m. with Resident 1, in Resident 1's room, Resident 1 was lying asleep in bed. There were no staff who went to Resident 1's room to check Resident 1. During concurrent interview and record review on 12/5/25 at 10:45 a.m. with the RNS, Resident 1's Electronic Medical Records (EMR- a digital version of a patient's paper chart) titled "Risk for Fall Assessment," dated 11/18/25, 11/22/25, and 11/24/25, and Quarterly Fall Assessments dated 11/1/23 and 2/1/24 were reviewed. The "Risk for Fall Assessments" indicated, Resident 1 scored as a high fall risk. The RNS stated Resident 1's fall risk assessment scores were 11 which indicated risk for falls and 13 which indicated Resident 1 was high risk for falls. The RNS stated Resident 1 had an impaired safety awareness and unsteady gait that placed her at increased risk of falling. During concurrent interview and record review on 12/5/25 at 11:00 a.m. with the RNS, Resident 1's "SBAR (Situation-Background-Assessment-Recommendation) post Fall," dated 11/18/25, 11/22/25, and 11/24/25 were reviewed. The "SBAR post Fall," indicated Resi