Health inspection·September 25, 2025

Regulation: CFR 483.25(d) Accidents. The facility must ensure that - CFR 483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and CFR 483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR 72521(a) Administrative Policies and Procedures. (a)Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. 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. 22 CCR 72311(a)(1)(A), (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 of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 8/5/25 at 9:40 a.m., an unannounced visit was conducted at the facility to investigate Facility Reported Incident: 2567443 which alleged Resident 1 sustained a left hip fracture after being left alone in the bathroom without staff assistance. The facility failed to ensure adequate supervision was provided to prevent accidents when Resident 1, who had unspecified dementia (a progressive state of decline in mental abilities), was assessed to be at risk for falls and had a history of falls on 9/7/23, 9/12/23, 1/3/24, and 8/29/24, and required staff assistance with toileting. On 7/20/25 Resident 1 was left alone sitting on the toilet after being assisted with walking to the bathroom by a staff member in violation of her care plan. As a result of this failure, Resident 1 fell and broke her left hip, which required an evaluation in the Emergency Department (ED) the same day. Resident 1 was ordered to be on bedrest, experienced increased pain, had a decline in her nutritional intake, and subsequently died on 7/26/25. Resident 1 was a 103-year-old female, admitted to the facility on 4/23/19. She had the following diagnoses: unspecified dementia, muscle weakness, abnormalities of gait and mobility (ability to move freely and easily), and repeated falls and was on hospice for comfort care measures (specialized care that focuses on a person's quality of life and dignity as they near the end of their life). During a review of Resident 1's "Minimum Data Set (MDS- a standardized assessment and care screening tool)," dated 5/12/25, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation and memory recall) indicated a score of 5 out of 15; a score of 0-7 would indicate Resident 1 had severe cognitive impairment. During an interview on 8/5/25 at 9:50 a.m. with the Director of Nursing (DON), the DON stated Resident 1 was on hospice with comfort measures prior to her fall. The DON stated Resident 1 was able to ambulate (walk) to the bathroom with assistance from a certified nursing assistant (CNA). The DON stated CNA 1 was Resident 1's assigned CNA when she fell in the bathroom. The DON stated the hospice company and Resident 1's physician were consulted and Resident 1 was sent to the acute care hospital because she continued to complain of pain and there was unevenness to the left leg. The DON stated Resident 1 was diagnosed at the hospital with a fracture (broken bone) of the left intertrochanteric femur (near the hip on the thigh bone). The DON stated Resident 1's Responsible Party (RP) was informed of the risks and benefits of surgery. The DON stated Resident 1's RP declined surgery due to Resident 1 being on hospice and she was not likely to survive surgery. The DON stated Resident 1 was brought back to the Skilled Nursing Facility (SNF- facilities which provide care to residents twenty-four hours a day, seven days a week) to continue hospice services and to be kept comfortable. The DON stated Resident 1 had new orders to be on bed rest, to keep the leg comfortable, and for pain control. The DON stated Resident 1's health declined after the fall because she did not want to eat. During a concurrent interview and record review on 8/5/25 at 10:45 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's MDS "Section GG- Functional Status (MDSGG)," dated 5/7/25 was reviewed. The MDSGG indicated, "...Mobility...Coding: ... If helper assistance is required because resident's performance is unsafe...score according to amount of assistance provided...03. Partial/moderate assistance- Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort...Toilet transfer The ability to get on and off a toilet or commode [portable toilet which enables a patient to sit comfortably]..." The MDSGG indicated a code of "03" was selected for Resident 1's toilet transfer mobility. LVN 1 stated the MDSGG indicated a code of "03" meant, Resident 1 required partial assistance from staff for toilet transferring, which was the ability to get on and off the toilet. LVN 1 stated prior to her fall, Resident 1 drank nutritional drinks as her main source of nutrition instead of eating food and rarely needed PRN (as needed) pain medications. LVN 1 stated Resident 1 had prior falls where she would suddenly and unexpectedly move and fall down. LVN 1 stated Resident 1 fell on 7/20/25 at 6:30 a.m. LVN 1 stated CNA 1 assisted Resident 1 to the bathroom, sat her on the commode and then CNA 1 left the bathroom to go to Resident 1's closet. LVN 1 stated CNA 1 saw Resident 1 standing up from the commode and witnessed her fall. LVN 1 stated Resident 1 was diagnosed with a left hip fracture at the hospital. LVN 1 stated Resident 1 was in pain, so nurses administered PRN pain medications more frequently. LVN 1 stated Resident 1's PRN medications were changed to be administered routinely to keep her as comfortable as possible due to the increased pain she was experiencing. LVN 1 stated Resident 1 became more tired, possibly from the side effects of taking pain medications more frequently. LVN 1 stated Resident 1's food intake declined, and she was not drinking her usual nutritional drinks. LVN 1 stated Resident 1 passed away on 7/26/25, which was 6 days after she fell. LVN 1 stated it was important to provide Resident 1 with the supervision necessary to prevent accidents because it could have prevented her fall, injury, pain, and death. LVN 1 stated Resident 1 was living an uneventful life and this fall changed that for her. During a phone interview on 8/5/25 at 11:22 a.m. with CNA 1, CNA 1 stated Resident 1 was confused at times, but could say her preferences and liked a usual routine. CNA 1 stated Resident 1 could transfer with the assistance of one person. CNA 1 stated on 7/20/25 at 6:30 a.m. CNA 1 noticed Resident 1 was attempting to get up to use the bathroom. CNA 1 stated she assisted Resident 1 to walk to the bathroom located inside Resident 1's room. CNA 1 stated she assisted Resident 1 to sit down on the commode and then stepped out of the bathroom but left the door open. CNA 1 stated Resident 1 had a commode located over the toilet in the bathroom. CNA 1 stated Resident 1 was adjusting herself on the toilet, got up too quickly, lost her balance and fell. CNA 1 stated she could not get to Resident 1 quickly enough before she fell. CNA 1 stated the door to Resident 1's bathroom was too narrow for her to reach Resident 1 before she fell. CNA 1 stated she was unable to quantify how far away she was from Resident 1 when she fell. CNA 1 stated she left Resident 1 in the bathroom to give her privacy. CNA 1 stated Resident 1 fell on her left side straight down on her left hip and was complaining of pain. CNA 1 stated Resident 1 appeared to be scared after the fall. CNA 1 stated Resident 1 was sent to the hospital due to the significant pain. CNA 1 stated Resident 1 came back from the hospital and stopped being able to get up to use the bathroom due to being bed bound. CNA 1 stated Resident drank less of her nutritional drinks after the fall and then passed away. CNA 1 stated it was important to provide Resident 1 with the necessary supervision to prevent accidents because the staff did not want her to get injured or to fall. During an observation on 8/5/25 at 11:34 a.m. in Resident 1's former bathroom, a commode was positioned over the toilet with silver hand railing noted to the left of the toilet and in front of the toilet. The space between the toilet and the wall in front of the toilet appeared to be approximately 3 feet. During an interview on 8/5/25 at 11:39 a.m. with CNA 2, CNA 2 stated Resident 1 had fallen in the past and did not have good balance. CNA 2 stated Resident 1 required one person to assist her. CNA 2 stated she would bring Resident 1 to the hallway bathroom when she needed to use the bathroom because it was more spacious. CNA 2 stated Resident 1 required one person to stay with her while toileting. CNA 2 stated CNA 1 told CNA 2 that Resident 1 was in the bathroom when CNA 1 left to get something for Resident 1 to put on and then Resident 1 fell. CNA 2 stated Resident 1 went to the hospital. CNA 2 stated Resident 1 was in pain when staff would reposition her, was on bedrest, received bed baths and could not get up to use the toilet. CNA 2 stated Resident 1's intake of her nutritional drinks declined until it stopped, it was difficult to understand what Resident 1 was trying to say and then she passed away. CNA 2 stated it was important to provide Resident 1 with the supervision necessary to prevent accidents because she was not able to recover after breaking her hip and subsequently passed away. CNA 2 stated CNA 1 should have stayed with her at all times and not stepped away for a second in order to prevent Resident 1's fall. During a phone interview on 8/5/25 at 11:59 a.m. with LVN 2, LVN 2 stated Resident 1 had prior falls and was a fall risk. LVN 2 stated Resident 1 fell in the bathroom and was lying with her legs towards the inside of the bathroom, head positioned towards the bathroom door and was lying on her left side. LVN 2 stated she did an assessment on Resident 1, and she was complaining of left hip pain with a skin tear to her left elbow. LVN 2 stated the hospice company was notified of Resident 1's fall, hospice informed Resident 1's family and the family desired for Resident 1 to be sent to the hospital. LVN 2 stated CNA 1 did not have enough time or space to catch Resident 1 as she fell. LVN 2 stated in the days following Resident 1's fall, she began declining, talking less, not drinking her nutritional drinks anymore and then passed away. LVN 2 stated it was important to provide Resident 1 with the supervision necessary to prevent accidents to ensure her safety and to prevent falls. During a concurrent interview and record review on 8/5/25 at 12:19 p.m. with the DON, Resident 1's "MDSGG," dated 5/7/25 was reviewed. The MDSGG indicated, "...Mobility...Coding: ...If helper assistance is required because resident's performance is unsafe...score according to amount of assistance provided...03. Partial/moderate assistance- Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort...Toilet transfer The ability to get on and off a toilet or commode..." The MDSGG indicated a code of "03" was selected for Resident 1's toilet transfer mobility. The DON stated Resident 1 required partial assistance from one person to assist her with toilet transferring according to her MDSGG. The DON stated Resident 1 fell on 7/20/25. The DON stated Resident 1 was confused, complaining of pain, and had decreased appetite after her fall. The DON stated Resident 1's pain medication changed from PRN to routine in an attempt to keep her comfortable. The DON stated Resident 1 passed away on 7/26/25. During a phone interview on 8/7/25 at 1:47 p.m. with the Hospice Clinical Supervisor (HCS), the HCS stated Resident 1 was placed on hospice in November 2023 with a diagnosis of heart disease (group of conditions affecting the heart and blood vessels). The HCS stated Resident 1's condition was fairly stable during this time, although Resident 1 had some falls. The HCS stated Resident 1 was confused intermittently (not happening regularly) but was able to make her needs known. The HCS stated Resident 1 did not require many PRN pain medications prior to her fall on 7/20/25. The HCS stated Resident 1 required 1 person assistance and should not have been left alone to use the bathroom on 7/20/25. During a phone interview on 8/12/25 at 11:47 a.m. with CNA 2, CNA 2 stated she had taken care of Resident 1 during the month when Resident 1 fell. CNA 2 stated her usual practice was to take Resident 1 to the bathroom in the hallway because she would take Resident 1 to the bathroom in a wheelchair, and it could fit Resident 1's wheelchair inside the hallway bathroom. CNA 2 stated Resident 1 was not safe to be left alone in the bathroom and needed to stay in close proximity to her. CNA 2 stated Resident 1 could make her preferences known, like if she wanted privacy or independence in the bathroom, but Resident 1 had never expressed to CNA 2 she wanted privacy or independence. During a phone interview on 8/12/25 at 3:44 p.m. with CNA 1, CNA 1 stated Resident 1 was able to ambulate to the bathroom with a CNA guiding her by hand. CNA 1 stated Resident 1 could not pivot (to turn or rotate) after standing up from the toilet. CNA 1 stated she did not observe a decline in Resident 1's mobility and function (transfer and ambulation, including walking) prior to her falling. CNA 1 stated if a resident required partial assistance, she would be really close to them in proximity. CNA 1 stated if a resident was attempting to stand up, she would be right next to them. CNA 1 stated Resident 1 needed assistance with activities which required greater movement, like using the bathroom. CNA 1 stated she left Resident 1's bathroom on 7/20/25 because she thought Resident 1 wanted independence. CNA 1 stated Resident 1 did not tell her on 7/20/25 prior to her fall she wanted to be independent. CNA 1 stated in the past, she would occasionally take Resident 1 to the bathroom in the hallway. CNA 1 stated on 7/20/2025, she took Resident 1 to the bathroom in her room because it was closer and more convenient. During a concurrent phone interview and record review on 8/15/25 at 10:45 a.m. with the DON, Resident 1's "Fall Risk Evaluation (FRE)," dated 5/12/25 was reviewed. The FRE indicated, "...Score: 11...Category: At Risk...Level of consciousness [a person's state of awareness and responsiveness to their surroundings]/mental state...Intermittent confusion...Ambulation/ elimination [removal of waste from the body] status...Chair bound...assist with elimination...Gait/balance...Balance problem while standing...Balance problem while walking..." The DON stated Resident 1 started hospice on 11/17/23. The DON stated Resident 1 had a history of multiple falls. The DON stated since starting hospice, Resident 1 had falls on 9/7/23, 9/12/23, 1/3/24, 8/29/24, and 7/20/25. The DON stated according to Resident 1's FRE, her score of 11 meant she was at risk for falls. The DON stated CNA 1 said she could not fit in Resident 1's bathroom with Resident 1 while Resident 1 was voiding. The DON stated the expectation was CNA 1 should have been with Resident 1 while she used the bathroom and to assist as needed. The DON stated there was no known decline in Resident 1's abilities prior to her fall on 7/20/25. The DON stated CNA 1 was outside Resident 1's bathroom and could not get to her quickly enough before Resident 1 fell. During a review of Resident 1's "Care Plan Report (CPR)," dated 7/15/21, the CPR indicated, "...Resident has history of falling [related to] unsteady gait...Interventions...Ask any other