Other·December 19, 2025

F689 §483.25(d) Accidents The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR §72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. Based on observation, interview, medical record review, facility document review, and facility P&P (Policy and Procedure) review, Resident 1 fell from bed onto a floor mat and sustained a lower left leg fracture. The facility: 1. Failed to ensure Resident 1's environment remains as free of accident hazards as possible, and to provide adequate supervision and assistance devices to prevent accidents, when it failed to maintain Resident 1's bed in the prescribed low position. 2. Failed to implement Resident 1's plan of care according to the methods indicated when it did not implement the low bed position necessary for mitigating the possibility of Resident 1's injury. These failures raised the risk of impact injury as a result of Resident 1's fall from a bed-level fall. As a result, Resident 1 sustained an avoidable lower leg fracture resulting in pain, hospitalization, quality of life impairment, and further risk of complication. Findings: Review of the facility's P&P titled Falls Prevention dated 02/2023 showed patients identified at risk for falls would have appropriate interventions. Each resident fall, the facility would implement actions to reduce the incidence of falls and minimize potential injury from fall. The CDPH, L&C (California Department of Public Health, Licensing and Certification) Department received a Letter from the facility dated 11/3/25, to report an Unusual Occurrence (fall with fracture). The facility Letter showed on 10/31/25 at approximately 1500 hours, Resident 1 sustained an unwitnessed fall. The report showed Family Member 1 was present at the facility and observed Resident 1 fall from the bed. The Letter further showed Resident 1 was transferred to the acute care hospital and returned at 0045 hours with a fracture to the left lower extremity. On 11/6/25 at 1015 hours, an observation of Resident 1 and concurrent interview was conducted with Family Member 1 at bedside. Resident 1 was observed in bed as awake, alert and able to respond by gestures. Resident 1 was observed with a cast on the left lower leg with skin discoloration above the cast. Family Member 1 stated on 10/31/25 at around 1500 hours, he visited Resident 1 in the facility. Family Member 1 stated he looked at Resident 1's bed but Resident 1 was not in bed, and he noticed the bed was elevated high. Family Member 1 stated he thought maybe the staff got Resident 1 up in the wheelchair to attend the holiday party in the activity room. Family Member 1 stated when he was about to go to the activity room, he heard someone was calling for help. Family Member 1 found Resident 1 on the floor, on the left side of the bed, lying on her left side in a "curl-ball-like" position, crying, and in a lot of pain. Family Member 1 stated he yelled for assistance from the staff. Family Member 1 stated he accompanied Resident 1 to the hospital and was informed Resident 1 had a fracture on her lower left leg in three different bones. Family Member 1 further stated Resident 1 had fallen hard from the bed and suffered pain and broken bones. Medical record review for Resident 1 was initiated on 11/6/25. Resident 1 was admitted to the facility on 5/3/25. Review of Resident 1's H&P (History and Physical) examination dated 5/5/25, showed Resident 1 had a diagnosis of Alzheimer's (a neurogenerative disease affecting the decline of cognitive function) Dementia (loss of mental functions such as thinking, memory and reasoning skills) and a history of fall, and had no capacity to understand and make decisions. Review of Resident 1's Fall Risk Evaluation dated 7/21/25, showed Resident 1 was at risk for falls and had a history of fall in the past three months. Review of Resident 1's Physician Order Summary showed the following physician's orders: - dated 7/21/25, for the use of bilateral bolster pillows (a long, thick pillow placed under other pillows for support) while in bed for postural support and proper body alignment, and - dated 10/6/25, for the use of bilateral floor mats to minimize risk of injury. Review of Resident 1's MDS (Minimum Data Set- a standardized tool for resident assessment) assessment dated 9/29/25, showed Resident 1 had severe cognitive impairment, dependent on staff on all ADLs (Activities of Daily Living), and had a history of fall. Review of Resident 1's Care Plan Report showed a care plan problem initiated on 5/4/25, addressing the risk for falls related to late effects of nontraumatic intracerebral (within the brain) hemorrhage (bleeding), generalized body weakness, left hemiplegia (paralysis on one side of the body), seizure disorder (sudden burst of electrical activity in the brain), impaired vision, Alzheimer's disease and medication side effects. The interventions included were to place the floor mats to minimize risk of injury and place the bed in low position. Review of Resident 1's Progress Notes dated 10/31/25 at 1608 hours, showed at around 1515 hours, Family Member 1 informed the licensed nurse Resident 1 was on the floor. The note further showed during the assessment Resident 1 complained of pain to the left lower extremity, noted with bump on top of anterior (front) part of the ankle, and light blue discoloration to the left side of foot. Review of Resident 1's Change of Condition Evaluation showed the following: - dated 7/21/25, Resident 1 had a fall; and - dated 10/31/25, Resident 1 had a fall. The Review Findings And Provider Notification - Summary section showed the nurse was notified Resident 1 was on the floor, and Resident 1 was side lying on the left side of the bed. The documentation further showed "bump on left ankle noted, Resident 1 expressed pain to Family Member 1, 911 protocols initiated." Review of Resident 1's After Visit Summary from the acute care hospital dated 10/31/25, showed Resident 1 was diagnosed to have tibia (lowed leg bone), fibula (lower leg bone) and foot fractures. On 11/6/25 at 1400 hours, an interview for Resident 1 was conducted with CNA (Certified Nursing Assistant) 1. CNA 1 stated Resident 1 was dependent on staff on ADLs. CNA 1 stated she heard Family Member 1 was yelling for help on 10/31/25. CNA 1 stated the nurses attended Resident 1 immediately and found the resident on the floor. CNA 1 verified and acknowledged she observed Resident 1's bed was elevated, "hip high." On 11/6/25 at 1600 hours, an interview for Resident 1 was conducted with LVN (Licensed Vocational Nurse) 1. LVN 1 stated on 10/31/25, she immediately attended Resident 1 when summoned for help by Family Member 1. LVN 1 stated Resident 1 was found on the floor, curled up close to the dresser, crying and in distress. LVN 1 verified and acknowledged she observed Resident 1's bed was elevated, "hip high" when she assisted Resident 1 on the floor. On 11/10/25 at 1020 hours, an interview for Resident 1 was conducted with LVN 2. LVN 2 stated Resident 1 had a history of fall. LVN 2 verified Resident 1 had bolster pillow in bed, floor mat on both side of the bed and kept the bed in lowest position. LVN 2 stated she attended Resident 1 immediately when Family Member 1 was asking for assistance on 10/31/25. LVN 2 stated Resident 1 was found lying on the floor. LVN 2 stated during the transfer of Resident 1 back to bed, LVN 2 observed a "bump" on Resident 1's shin and ankle area of the left leg. LVN 2 verified and acknowledged she observed Resident 1's bed was elevated when she assisted Resident 1 on the floor. On 11/10/25 at 1050 hours, a telephone interview for Resident 1 was conducted with LVN 3. LVN 3 stated Resident 1 was found on the floor on 10/31/25. LVN 3 verified and acknowledged the bolster pillows in bed and floor mat was in place. However, LVN 3 observed Resident 1's bed was "hip high" when he assisted Resident 1 on the floor. On 11/10/25 at 1415 hours, an interview was conducted with the DON (Director of Nursing). The DON stated on 10/31/25 at around 1500 to 1515 hours, when Family Member 1 was asking for assistance, she attended right away and found Resident 1 on the floor. The DON verified and acknowledged she noticed Resident 1's bed was elevated and was not aware why the bed was elevated. The DON further stated the bed should have been in lowest position when not providing care. This violation had a direct or immediate relationship to the health, safety or security of the patients.