Other·May 5, 2026

The following reflects the findings of the California Department of Public Health during the investigation of: Complaint and Facility Reported Incident (FRI): 2787689/2789740. Representing the Department, HFEN 38512. State Citation A was written. 42 C.F.R. § 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: (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 of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 3/10/26 at 9:30 A.M., an investigation was conducted regarding a complaint and facility-reported incidents involving two resident falls. The facility failed to prevent Resident 1 from falling when: - Fall preventative measures were not initiated after each fall to prevent further incidents of falls. - Resident-centered care plan interventions to include one on one supervision were not developed to address the needs of Resident 1 related to known falling risk. As a result, Resident 1 fell 13 times from 7/31/2025 to 2/1/2026. On her 13th and last fall, the resident sustained a broken rib, a left zygomaticomaxillary (cheekbone) complex fracture, and an orbital (eye socket) fracture. Resident 1 was admitted to the facility on 7/21/25 with diagnoses that included dementia (a loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life) and Parkinson's Disease (a movement disorder of the nervous system that worsens over time. A review of Resident 1's undated Face Sheet indicated Resident 1 was admitted to the facility on 7/21/25 with diagnoses that included dementia (a loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life) and Parkinson's Disease (a movement disorder of the nervous system that worsens over time). A review of Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool) dated 7/23/25, indicated a score of "0", or severely impaired cognition. A review of Resident 1's Nurse Practitioner/Physician's Assistant (NP/PA) progress note, dated 7/25/25, indicated Resident 1 had, "evidence of severe cognitive impairment...indicating severe dementia. She is completely disoriented, unable to recall or repeat words, perform basic calculations, follow commands, or recognize objects...". The NP/PA indicated Resident 1 did not speak, make eye contact or engage while being evaluated. A review of Resident 1's Physician's History and Physical Note, dated 8/17/25, indicated Resident 1 did not have the capacity to understand and make decisions. An observation of Resident 1 was conducted in her room on 3/10/26 at 10:15 A.M. Resident 1's name was outside of the room with a gold star next to her name. Resident 1 was seated in a wheelchair, in her room. Resident 1 did not respond to questions asked. Resident 1 was not wearing a colored wristband. A mattress with the edges built up was on the bed, and a fall mat was leaning against the wall. Resident 1's room was located approximately 10 feet from the nurse's station. A review of Resident 1's Nursing Progress Notes, Change in Condition Evaluations (COC, a form to evaluate a clinically significant change from the resident's normal levels of health) and care plan indicated the following incidents of fall and fall preventative measures initiated after each incident of a fall: Fall #1: The COC, dated 7/31/25, indicated the fall l occurred on 7/31/25 at 2:18 A.M. The COC summarized that Resident 1 was found sitting on the floor in her room. A review of Resident 1's care plan, dated 7/31/25 indicated new preventative measures implemented were to ensure the bed was lowered to the floor, and monitor Resident 1 for any new problems as a result of the fall. Fall #2: The COC, dated 8/3/25, indicated Resident 1 fell on 8/3/25 at approximately 1 P.M. in her room. The COC summarized that Resident 1 was found sitting on the floor near her bed. Resident 1's care plan, dated 8/3/25, indicated new fall preventative measures of moving Resident 1 closer to the nurses' station, and a physical therapy consult for strength and mobility. The care plan indicated unnamed facility staff would, "...determine and address causative factors of the fall...". Fall #3: The COC, dated 8/4/25, indicated Resident 1 fell on 8/4/25 at approximately 3:35 A.M. in the hallway outside of her room. Resident 1 was sent to the hospital for tests and returned to the facility. Resident 1's care plan, dated 8/4/25, indicated new fall preventative measures of adding floor mats next to the bed, and a consult from a pharmacist to evaluate Resident 1's medications. Fall #4: The COC, dated 8/11/25, indicated Resident 1 fell at approximately 7:30 A.M. in an unknown location. No new fall preventative measures were identified in Resident 1's 8/11/25 care plan. Fall #5: The COC, dated 9/18/25, indicated Resident 1 fell at approximately 6:40 A.M., in her room. Resident 1 was sent to the hospital for tests due to, "Small knot noted to right side of head...". Resident 1 later returned to the facility. Resident 1's care plan, dated 9/18/25, indicated new fall preventative measures identified were a physical therapy consult for strength and mobility, and moving Resident 1 closer to the nurse's station. Fall #6: The COC, dated 10/9/25, indicated Resident 1 fell at approximately 2:20 P.M. in the facility dining room. Resident 1's care plan, dated 10/9/25, indicated new fall preventative measures identified were increased monitoring of the resident during the evening shift, and offering toileting prior to bedtime. Fall #7: The COC, dated 10/17/25, indicated Resident 1 fell at approximately 7:37 A.M. in the hallway near the resident's room and the nurse's station. Resident 1's care plan, dated 10/17/25, indicated new fall preventative measures identified were to assist Resident 1 when walking, and when transferring from one place to another. Fall #8: The COC, dated 11/14/25, indicated Resident 1 fell at approximately 6:40 A.M., in her room. No new care plan fall preventative measures were identified. Fall #9: The COC, dated 11/18/25, indicated Resident 1 fell at approximately 3:50 A.M. in her room. Resident 1's care plan, dated 11/18/25, indicated new fall preventative measures of offering toileting assistance before bedtime, and increased visual checks during the evening shift. Fall #10: The COC, dated 12/12/25, indicated Resident 1 fell at approximately 4:57 P.M. in her room. X-rays were ordered by the physician. Resident 1's care plan, dated 12/12/25, indicated new fall preventative measures identified was to increase Restorative Nursing Assistant (RNA, a type of rehabilitative care to help restore independence) frequency, and to maintain needed items, such as water and the call light within reach. Fall #11: The COC, dated 1/2/26, indicated Resident 1 fell at approximately 7 P.M. outside of her room. Resident 1's care plan, dated 1/2/26, indicated new fall preventative measures of scheduled toileting and a physical therapy evaluation. Fall #12: The COC, dated 1/11/26, indicated Resident 1 fell at approximately 6:55 A.M. inside of her room. Resident 1's care plan, dated 1/11/26, indicated new fall preventative measures of obtaining a urine test for possible infection. Fall #13: The COC, dated 2/1/26, indicated Resident 1 at approximately 11 A.M. inside of her room. Per the COC, "...Resident's bed noted elevated above the floor level". Resident 1 was sent to the hospital due to discoloration on the left side of her face. Resident 1's care plan, dated 2/1/26, indicated new fall preventative measures of a scoop mattress (a special mattress with raised edges around the perimeter to prevent the user from rolling off the bed). A review of Resident 1's hospital imaging results, dated 2/1/26, indicated that Resident 1 had sustained a broken rib, a left zygomaticomaxillary complex fracture (the cheekbone) and an orbital fracture (one or more bones surrounding the eye, or the eye socket). An interview was conducted with LN 1 on 3/10/26 at 3:03 P.M. Per LN 1, he was aware of Resident 1 falling several times. LN 1 stated he was familiar with Resident 1, and dementia was probably the reason Resident 1 tried to get out of bed or up from her wheelchair without assistance. LN 1 stated staff tried to keep eyes on Resident 1 to prevent injuries. Per LN 1, Resident 1's FM was very attentive, but staff were not always patient. LN 1 stated he had heard staff giving directions to Resident 1 even though she had dementia and would not understand the directions given. LN 1 stated, "a one to one (1:1, a staff member assigned to monitor the resident at all times) may have worked to prevent more falls. Obviously with 11 falls, our staff did not prevent further falls." An interview was conducted with LN 2 on 3/10/26 at 3:15 P.M. LN 2 stated she had started her shift 2/1/26 at 3 P.M. and heard from another nurse Resident 1 had fallen and gone to the hospital. LN 2 stated she had called the hospital to get a report and to find out if Resident 1 was returning to the facility. LN 2 stated the hospital informed her Resident 1 had two facial fractures and would return to the facility. LN 2 stated she was aware Resident 1 had fallen from LN 3, who was the assigned nurse on 2/1/26. LN 2 stated Resident 1 had had previous falls, the most recent fall approximately two weeks earlier. LN 2 stated staff tried to keep Resident 1 from falling by keeping her engaged in activities. Per LN 2, "We're trying everything for her, but it's not effective..." An interview was conducted with Director of Staff Development (DSD, staff responsible for education and training of facility CNAs) on 3/10/26 at 4:07 P.M. Per the DSD, she was not aware how many falls Resident 1 had experienced. Per the DSD, Resident 1 had, "...fallen quite a bit, maybe five to six times..." The DSD stated Resident 1 needed something to do with her hands to keep her occupied. Per the DSD, the intervention to keep Resident 1 busy would not work during nighttime hours as Resident 1 needed to sleep. The DSD stated she was not aware of whether a 1:1 observation of Resident 1 had been attempted to keep her safe. The DSD stated staff should be familiar with Resident 1's diagnosis of dementia and how to provide care specific to the diagnosis. An observation of Resident 1 was conducted on 3/16/26 at 12:21 P.M. Resident 1 was seated in a wheelchair in the dining room, with the FM assisting her with the meal. An interview was conducted with CNA 2 on 3/16/26 at 12:21 P.M. CNA 2 stated he knew Resident 1 well. CNA 2 stated Resident 1 did not listen to staff, and "...she does what she wants to...she falls often...she doesn't understand us. I'm not sure what her diagnosis is, or why she acts that way...". Per CNA 2, Resident 1 usually fell at night. CNA 2 stated, "When her [FM] is with her she doesn't seem to fall. If her [FM] would stay maybe she wouldn't fall..." A telephone interview was conducted with CNA 1 on 3/17/26 at 11:15 A.M. CNA 1 stated he was assigned to provide care to Resident 1 on 2/1/26, the day of her fall with an injury. CNA 1 stated he often worked with Resident 1 and was familiar with her care. CNA 1 stated when he returned from break, he saw many staff in Resident 1's room and saw her sitting on the floor with her cheek appearing red. CNA 1 stated he noticed the bed was as high as it could go. CNA 1 stated he assisted getting Resident 1 back into bed, then prepared her to go to the hospital. CNA 1 stated it was difficult to work with Resident 1, even though he spoke the same language she did. CNA 1 stated, "It's hard to get her to do things. She doesn't like to listen..." CNA 1 stated he did not know what medical condition made Resident 1 act that way. CNA 1 stated he had received education on dementia in the past but did not know if Resident 1 had dementia. CNA 1 stated Resident 1 had fallen before but he did not know how many times, only that it was more than other residents, "...maybe three falls..." CNA 1 stated residents who were at risk for falls had a gold star by their name outside of the room, and staff knew to check on them more often. CNA 1 stated the facility should have implemented other things to prevent falls, like possibly having a CNA always sit with her. CNA 1 stated he was aware of the care plans but did not routinely review them. A telephone interview was conducted with LN 3 on 3/17/26 at 11:45 A.M. LN 3 stated she was assigned to Resident 1 on 2/1/26. LN 3 stated the FM for Resident 1 came to her and asked for help in the room. LN 3 stated she went to the room and saw Resident 1 sitting on the floor by her bed, hugging her legs. Per LN 3, Resident 1's bed was raised up to its highest level. LN 3 stated she saw a reddened area and swelling on Resident 1's face. A review of Resident 2's Physician's History and Physical exam, dated 10/29/25, indicated Resident 2 had no memory of recent events, and had significant memory difficulty. The physician indicated Resident 2 had a past medical history of dementia and brain injury. An interview and observation of Resident 2 was conducted on 3/16/26. Outside of the room, Resident 2's name was posted, with a gold star next to it. Resident 2 was in bed, and the bed was low to the floor. Gray landing mats were next to the bed on the floor. Resident 2 was not wearing a yellow wristband. Resident 2 stated he was admitted for seizures. Resident 2 stated he fell at home about a week ago. Resident 2 stated he believed he was at a hospital due to the fall. A concurrent interview and record review with the DON was conducted on 4/2/26 at 3:10 P.M. The DON acknowledged that fall preventative measures were not initiated after each fall incident. The DON also acknowledged adding care plan interventions related to Resident 1's falls did not stop the resident from falling. The DON stated resident-centered intervention should be developed to address the specific needs of the resident. Per an undated facility document, titled Fall System, "In the Event of a Fall...Individualized interventions initiated..." A policy on updating care plans was requested but not provided by the facility. The facility failed to prevent Resident 1 from falling when: - Fall preventative measures were not initiated after each fall to prevent further incidents of falls. - Resident-centered care plan interventions were not developed to address the needs of Resident 1 related to fall. As a result, Resident 1 fell 13 times and on her last fall, the resident sustained a broken rib, a left zygomaticomaxillary (cheekbone) complex fracture, and an orbital (eye socket) fracture. These violations, jointly, 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.