Health inspection·March 12, 2026

CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices §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 § 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: (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. (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 § 72523. 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. §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). On 2/10/26 at 9:20 A.M., an unannounced onsite visit to the facility was conducted related to a reported resident's fall. The facility failed to: 1. Ensure Resident 1 received adequate supervision and assistance when she was positioned in her wheelchair and left alone in the facility's activities room. (Resident 1 was assessed by the facility as a high risk for falls when she scored 13. A score of 10 or higher is high risk ).While unattended, Resident 1 stood up and fell from her wheelchair which resulted in a head injury. 2.Develop an individualized written care plan for Resident 1, who had a known history of falls, in accordance with the facility's own fall policy and procedures. Resident 1 sustained a fall on 2/5/2026 which resulted in a head injury. 3. Implement an individualized written care plan for Resident 1, who had a known history of falls, in accordance with the facility's own fall policy and procedures. Resident 1 sustained a fall on 2/5/2026 which resulted in a head injury. These failures resulted in or created a substantial probability of Resident 1 sustaining a fall. Resident one did indeed fall on 2/5/2026. Subsequently, Resident 1 was taken to the hospital on 2/5/2026 and was diagnosed with traumatic hematoma (severe of deep bruise) of the forehead and traumatic subarachnoid hemorrhage (bleeding into the space surrounding the brain, specifically between the brain surface and the thin membrane covering it, caused by a physical injury like a car accident or fall). Per the hospital's After visit summary, dated 2/5/26, Resident 1 may develop coma and death. Resident 1 was admitted to the facility on 1/9/26 with diagnoses which included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), per the facility's Admission Record. A review of Resident 1's History and Physical (H & P) dated 3/13/25, indicated Resident 1 had cognitive impairment, had hallucination (the experience of hearing, seeing or smelling things that are not there) and delusions (having false or unrealistic beliefs). A Nursing post fall evaluation note, dated 2/5/26, indicated Resident 1's fall occurred in the facility's activity room when Resident 1 attempted to ambulate without assistance. A review of Resident 1's CT head, dated 2/5/26, indicated "...acute subarachnoid hemorrhage in the left occipital lobe, Large forehead soft tissue hematoma, Acute right nasal bone fracture...There has been development of a large forehead scalp soft tissue hematoma..." A review of the hospital after visit summary, dated 2/5/2026, indicated Resident 1's reason for visit included "Fall...Traumatic hematoma of forehead...Traumatic subarachnoid hemorrhage with unknown loss of consciousness..." A review of Resident 1's skin assessment dated 2/5/26 indicated Resident 1 had hematoma in the forehead with the following measurement: - Length - 3.33 centimeters (cm, unit of measurement) - Width - 4.25 cm - Area (cm 2) - 10.55 cm On 2/10/26 at 9:50 A.M., an observation of Resident 1 in her room was conducted. Resident 1 lay in bed, with visible hematoma approximately 10 cm on the center of her forehead and was observed with hematomas around both her eyes. Resident 1 was unable to express self well and had difficulty answering simple questions. Resident 1 stated "Sure no, the pain." On 2/10/26 at 9:58 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated Resident 1 does not use the call light; she just gets up and the tab alarm (Audible device adhered to both wheelchair and resident's clothing which sounds when resident has moved from original seated position) goes off." On 2/10/26 at 10:17 A.M., a telephone interview was conducted with CNA 2. CNA 2 stated she provided care to Resident 1 since her admission on January 2026. CNA 2 stated Resident 1 was confused, was a fall risk, did not use her call light and would get up without calling for assistance. CNA 2 stated Resident 1's usual routine was, she tried to get up on her own. CNA 2 stated Resident 1 had that behavior (getting up on her own) upon admission. On 2/10/26 at 10:34 A.M., a telephone interview was conducted with LN 1. LN 1 stated Resident 1 was confused and had memory problems. LN 1 stated Resident 1 was at high risk for falls. LN 1 stated Resident 1 would get up frequently during the night shift which was her normal behavior. LN 1 stated before Resident 1 fell on 2/5/26, Resident 1 was more active between 3 A.M. to 5 A.M. LN 1 stated prior to Resident 1's fall on 2/5/26, she checked on Resident 1 two to three times and redirected Resident 1 to go back to sleep. LN 1 stated Resident 1 would lay back to bed, sleep and be awake again. LN 1 stated, on 2/5/26 at around 5 A.M., Resident 1 was hard to redirect. LN 1 stated staff placed Resident 1 in her wheelchair and put her in the activity room. LN 1 stated Resident 1 was calm and "seemed distracted" and so she left Resident 1 alone and went to care for another resident. LN 1 stated she then heard a scream and found Resident 1 on the floor. On 2/10/26 at 10:51 A.M., an interview and joint review of Resident 1's clinical record was conducted with LN 2. LN 2 stated Resident 1 was new to the facility and was confused. LN 2 stated she received a report from Resident 1's daughter that Resident 1 saw things which were not there. LN 2 stated the fall risk assessment for Resident 1 on admission was considered high. LN 2 stated Resident 1 had history of fall from her previous residence. On 2/10/26 at 11:21 A.M., a joint interview and record review was conducted with the Director of Nursing (DON). The DON stated she was not aware Resident 1 was active around three to five in the morning. The DON stated it was challenging for Resident 1 to use the call light because of Resident 1's cognitive impairment. The DON stated Resident 1 had a fall risk assessment performed on 1/9/26 with a score of 13, which was a high risk. In addition, the DON stated Resident 1 had previously lived at the facilities assisted living location and had history of falls and episodes of falling downstairs. Furthermore, during the interview, the DON stated the facility was aware Resident 1 needed assistance due to her fall history. The DON stated Resident 1 had a caregiver when she lived at the assisted living location. The DON stated that the facility could not provide 1:1 (one staff to one resident) monitoring for Resident 1 because it would be an extra cost for the family. The DON stated Resident 1's care plan was not individualized to recognize Resident 1's previous falls and fall risk behaviors to prevent further falls. The DON stated1:1 monitoring needs of Resident 1 and the resident's behavior of getting up during the early morning hours were not care planned prior to Resident 1's 2/5/2026 fall. On 2/11/26 at 10:23 A.M., a telephone interview was conducted with CNA 3. CNA 3 stated she was familiar with Resident 1 since January 2026. CNA 3 stated Resident 1 was confused, would not use the call lights and would get up on her own. CNA 3 stated Resident 1 could stand very slowly but was unsteady. CNA 3 stated at times at night, Resident 1 would be restless and would try to get up on her own. CNA 3 stated on 2/5/26 at around 12 midnight, Resident 1 was restless, was talking to someone who was not there, and was hard to redirect. CNA 3 stated on 2/5/26 at 4 A.M. Resident 1 was restless, agitated, and insisted on getting up. CNA 3 stated she had Resident 1 sit in her wheelchair and then took her to the activity room around 4:20 A.M. CNA 3 stated at 4:20 A.M. while Resident 1 was in the activity room alone, she made her second rounds. CNA 3 stated her colleague was in the other hallway and the Licensed Nurse (LN) was passing medications to other residents. During that time, CNA 3 stated she attended to another resident and stayed with the other resident for about 15 minutes. CNA 3 stated no one watched over Resident 1 in the activity room while she was with the other resident. CNA 3 stated when she was exiting the other resident's room, she heard the alarm go off and saw Resident 1 on the floor, face down. A review of the facility's policy, Falls and Fall Risk, Managing, revised 3/2018, 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...Risk Factors ... Resident conditions that may contribute to the risk of falls include ...c. delirium and other cognitive impairment ..." A review of the facility's policy, Falls - Clinical Protocol, revised 3/2018, indicated, "Assessment and Recognition ...a. Staff will ask the resident and the caregiver or family about a history of falling ...3. The staff and practitioner will review each resident's risk factors for falling and document in the medical record, a. Examples of risk factors for falling include ...gait and balance disorders, cognitive Impairment ...confusion ...Treatment and Management ... 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) ..." The facility failed to: 1. Ensure Resident 1 received adequate supervision and assistance when she was positioned in her wheelchair and left alone in the facility's activities room. (Resident 1 was assessed by the facility as a high risk for falls when she scored 13. A score of 10 or higher is high risk ).While unattended, Resident 1 stood up and fell from her wheelchair which resulted in a head injury. 2.Develop an individualized written care plan for Resident 1, who had a known history of falls, in accordance with the facility's own fall policy and procedures. Resident 1 sustained a fall on 2/5/2026 which resulted in a head injury. 3. Implement an individualized written care plan for Resident 1, who had a known history of falls, in accordance with the facility's own fall policy and procedures. Resident 1 sustained a fall on 2/5/2026 which resulted in a head injury. These violations, jointly or separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.