Health inspection·March 13, 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. (c) The licensee shall ensure that: (2) Each resident receives supervision and assistance as needed to ensure the resident’s safety. 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. On 1/14/26, at 10:20 A.M., an unannounced visit was conducted at the facility to investigate a complaint regarding the facility’s failure to provide adequate supervision and implement appropriate fall-prevention interventions for a resident (Resident 1) assessed as a high fall risk. Resident 1 was a cognitively impaired resident assessed as a high fall risk who required close supervision to prevent injury. Due to the facility’s failure to ensure continuous supervision and implement individualized fall-prevention interventions, Resident 1 was left unattended, sustained a fall, and suffered a serious physical harm, including a head injury and L4 spinal compression fracture, resulting in hospitalization, intubation, intensive care unit (ICU) admission, seizure activity, and placement of a feeding tube. The facility failed to: 1. Provide adequate supervision, for Resident 1 who had a severe cognitive deficit (decrease in mental processes) was assessed as a high fall risk and had a known medical diagnosis of dysphagia (difficulty swallowing) to keep Resident 1’s environment as accident as free as possible. This includes but is not limited to 1:1 (one staff closely supervising one resident ) to prevent falls and incorporating the 1:1 supervision) into Resident 1’s care plan. 2. Implement interventions outlined in Resident 1’s individualized fall-prevention and feeding care plan to ensure Resident 1’s safety. 3. Implement facility policies and procedures including but not limited to policy and procedure titled, “Care Plans, Comprehensive Person-Centered” dated March 2022 and “Falls and Fall Risk, Managing” dated March 2018. These failures resulted or created a substantial probability that led to Resident 1 sustaining a head injury, spinal compression fracture, onset of seizure activity, admission to the intensive care unit of a hospital, and placement of a breathing and feeding tube. Per the Skilled Nursing Facility Admission Record, Resident 1 was admitted to the skilled nursing facility on 12/21/25 with diagnosis including difficulty with walking, muscle weakness, history of falls, dysphagia (difficulty swallowing) and Intellectual Developmental Disability (IDD). Resident 1 had cognitive impairment poor safety awareness, confusion, and was unable to consistently recognize danger or appropriately use the call light. Resident 1 required assistance with transfers and ambulation and was assessed as a HIGH fall risk upon admission. Resident 1’s recent transfer documents from the hospital to the skilled nursing facility included a document titled “Inpatient Physical Therapy Evaluation” dated 12/19/25 at 1:30 P.M., which indicated, “…Safety Judgment: Decreased awareness of need for safety, Decreased awareness of need for assistance…”  Resident 1's Minimum Data Set (MDS-nursing facility assessment tool) dated 12/25/25 indicated that Resident 1 was rarely or never understood with severe cognitive deficits (a decrease in the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) to understand and make decisions. According to the MDS section J: Resident 1 was assessed as a fall risk and had experienced falls prior to admission to the skilled nursing facility.    Record review of Resident 1’s nutritional care plan with date initiated as 12/22/25 interventions indicated, “…1:1 (one staff to one Resident) Feeding Assistance…”  Resident 1’s Speech evaluation dated 12/22/25 indicated, “…Previous treatment 1:1 feeder…Swallowing Abilities=Severe…Risk Factors: Aspiration [choking]…”  The facility's document labeled "Feeding list" undated included Resident 1’s name. Resident 1’s skilled nursing facility record was reviewed.   Resident 1’s History and Physical (H&P) examination by the facility Medical Doctor (MD) dated 12/22/25, indicated, “…This resident…does NOT have the capacity to understand and make decisions…”  Resident 1’s admission fall risk assessment titled, “…FALL RISK OBSERVATION/ASSESSMENT…” dated 12/21/25 at 20:37 (8:37 P.M.) indicated,  Resident 1’s fall risk score was a 20 that identified Resident 1 was a “…HIGH RISK…” Resident 1’s fall risk care plan initiated 12/22/25, indicated, “…Educate/remind resident to call for assistance...Keep call light within reach…Keep within supervised view as much as possible…” Resident 1’s skilled nursing facility Electronic Health Record (EHR) progress noted by Licensed Nurse (LN) 1 titled “Nurse’s Note” dated,12/25/25 at 20:00 (8:00 P.M.), indicated,  “…Resident spotted one time trying to get out of his wheelchair…Medication nurse for 100 hall instructed all of the CNAs [Certified Nursing Assistant] in the hallway to do visual inspections every 30 minutes and switch with other CNA as needed to keep resident under continuous supervision. Nurse on duty had also instructed CNAs that if resident was to be alone inside of room, to be in the same room with the resident…” A record review of Resident 1’s progress noted by LN 1 was reviewed.  The note titled “Nurse’s Note” dated 12/25/25 at 20:55 (8:55 P.M.) late entry, indicated, “…Heard medication nurse shouting across the hallway to the front nurse’s station. Medication nurse requested crash cart (a set of trays/drawers/shelves on wheels used in hospitals for transportation and dispensing of emergency medication/equipment at site of medical/surgical emergency for life support protocols); crash cart taken to her. Walked into the room to find resident lying face down and having agonal (a critical, abnormal reflex characterized by gasping, snorting, or labored, infrequent breaths that occur when the brain is severely deprived of oxygen) respirations. Resident also had a bleeding laceration (a ragged, jagged tear in the skin), on top left of the forehead. Oxygen tank and non-rebreather (a, high-concentration oxygen therapy device featuring a reservoir bag, one-way valves, and a face mask)… used C-spine[Cervical-spine refers to neck] to stabilize cervical neck [sic], used a 3 person assist to turn resident to the supine [lying flat on your back with your face, chest, and stomach facing upward] position. Resident breathing had slowed down to the point where he was fully unconscious [a person is not reacting to sound, touch, or pain] by this time. Writer ran out, grabbed treatment cart to control bleeding to the forehead using gauze and bandages." A record review of Resident 1’s EHR progress note was conducted.  “Nurse’s Note” dated 12/25/25 at 21:00 (9 P.M.) late entry by LN 2, indicated,  “…Found the resident lying on the floor …Some abrasion to bilateral UE [upper extremity-arms and hands]. The resident was[sic] unresponsive [unconscious] at this time. The chest compression (manual technique, life-saving used during CPR to pump blood to a person's heart and brain) initiated [sic] and oxygen with a non re-breather [sic] mask was given. 9-11 was called. arrived at 21:10. Resident is transportation to [Hospital Name] for further eval…” Resident 1’s hospital record was reviewed.  Resident 1’s hospital emergency notes titled, “ H&P”(History and Physical) dated 12/25/25 9:38 P.M, indicated, “…General Appearance: Awake and non-responsive, uncomfortable appearing, hematoma (clotted blood that pools outside of blood vessels, usually after an injury), to forehead…” Review of Resident 1’s Trauma notes titled, “ Trauma Tertiary [third in order] Note” dated, 12/26/25 12:32 P.M., indicated “…presented to [Hospital Name] after being found down. Patient was found to have the following injuries: L4 compression fracture with 30% height loss…Patient is intubated someone who has had a hollow breathing tube (inserted through their mouth or nose into their windpipe (trachea) to maintain an open airway, deliver oxygen, provide anesthesia, or assist breathing with a ventilator, used when patient cannot breathe adequately on their own).. (.Seizure activity noted overnight…Neurology consulted given seizure activity… Resident 1’s hospital discharge notes were reviewed.  The document titled, “Discharge Summary” dated 1/9/26 3:05 P.M., indicated, “…Diagnosis on discharge Seizure disorder Dysphagia [difficulty swallowing]…It was presumed that the patient suffered arrest from acute respiratory failure, in the setting of recurrent aspiration [choking]. Apparently, patient was witnessed to have two generalized TC [tonic clonic- sudden loss of consciousness, body stiffening which is a tonic phase, and rhythmic jerking-clonic phase] seizures after admission. MRI [a magnetic resonance image of the brain] 12/26, which revealed findings concordant [consistent or align with one another] with recent seizure activity…Patient’s brother has elected to maintain FC [feeding connection]/FT [feeding tube]…” Record review of Resident 1’s skilled nursing facility and hospital records indicated Resident 1 had no documented history of seizure activity or dependence on a feeding tube prior to the facility-to-hospital transfer on 12/25/25. A review of the facility's policy and procedure titled, “Care Plans, Comprehensive Person-Centered” dated March 2022, indicated “…describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being…” A record review of the facility's policy and procedure titled, “Falls and Fall Risk, Managing” dated March 2018, indicated “…If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable...” On 1/14/26 at 1:40 P.M., an interview was conducted with CNA 1. CNA 1 stated that upon starting her evening shift approximately 7 P.M., on 12/25/25, she observed Resident 1 independently wheeling himself (using a wheelchair for ambulation -the act of walking or moving place to place) in the hallway. CNA 1 stated she provided Resident 1 with a meal tray, and watched Resident 1 eat independently. CNA 1 reported that Resident 1 remained seated in his wheelchair unsupervised in the hallway from approximately 7 P.M to 8 P.M., on /12/25/25.  CNA 1 stated that after returning from a bathroom break, she observed nursing staff (LN 2) with Resident 1 who was “lying face down on the floor with a bleeding head wound.” CNA 1 stated oxygen was applied to Resident 1 who was minimally responsive, moving only his hand, at the time he was found on the floor. CNA 1 stated she was not informed that Resident 1 was a fall risk.  On 1/14/26 at 1:51 P.M., an interview and record review were conducted with LN 1. LN 1 stated he was the nursing supervisor on duty when Resident 1 fell (12/25/25).  LN 1 stated he had directed the CNA’s (assigned to hallway 100 where Resident 1’s room was) to closely monitor Resident 1 because Resident 1 had repeatedly attempted to get out of his wheelchair and was seen wheeling himself throughout the hallway. LN 1 stated Resident 1 was a high fall-risk and required close supervision “at all times” and “should be on a one to one [1:1] supervision” (one staff supervising one resident) for safety. LN 1 further stated Resident 1 did not have orders for a 1:1 supervision and Resident 1 was not care-planned (plan created by nursing based on an assessment) for 1:1 supervision “but should have been because he was a safety risk.”  LN 1 stated Resident 1’s assigned CNA (CNA 1) used the restroom and that CNA 1 had told a “registry” (temporary or contracted staff) CNA, (CNA 3) “to watch [Resident Name].” CNA 3 ignored CNA 1’s instructions to supervise Resident 1.  LN 1 stated Resident 1 had not been supervised and fell. LN 1 stated Resident 1’s baseline was “alert but not oriented (confused) x [times]3 [person, place, time]” and was non-verbal (did not speak).  LN 1 further stated after the fall Resident 1 was having “agonal” breathing (an abnormal, reflex-driven pattern of slow, gasping, or snoring-like breaths that occurs in severe emergencies),  but had a pulse. LN 1 further stated the only intervention that we did was oxygenation (the process of supplying, treating, or enriching blood with oxygen), he [Resident 1] still had a pulse we just gave oxygen via non re-breather mask (non-invasive medical device that delivers high concentration of oxygen) used for acute respiratory distress (life-threatening, a very serious condition and may cause rapid, severe shortness of breath, low oxygen levels, and stiff lungs, often occurring in critically ill patients due to sepsis, pneumonia, or injury).  On 1/14/26 at 2:03 P.M., an interview was conducted with CNA 1. CNA 1 stated she did not ask another nursing staff to supervise Resident 1 because she was unaware Resident 1 was a fall risk. CNA 1 stated LN 1 did not endorse or communicate to her that Resident 1 required close monitoring or supervision. CNA 1 stated Resident 1 had confusion and was unable to fully verbalize his needs, communicating primarily through gestures. CNA 1 further stated if she had been informed Resident 1 was a fall risk, she would have immediately notified another nursing staff member to supervise Resident 1 to prevent the fall. On 1/14/26 at 2:11 P.M., an interview was conducted with CNA 2. CNA 2 stated  Resident 1 was not assigned to her on 12/25/25; however, Resident 1 was located on the same unit throughout her shift. CNA 2 stated she observed Resident 1 sitting alone in his wheelchair and noted Resident 1 appeared confused and not fully oriented, which she believed to be Resident 1’s baseline. CNA 2 stated she was not informed that Resident 1 was a fall risk and therefore did not recognize the need for close supervision. CNA 2 stated she later observed nursing staff next to Resident 1 who was found on the floor. CNA 2 stated she observed Resident 1 to have had irregular breathing, which prompted LN 2 to administer oxygen via a “non-rebreather” mask.  CNA 2 further stated Resident 1 had been observed earlier seated in his wheelchair with a walker positioned in front of him and that no staff member instructed her to monitor or supervise Resident 1 at any time during her shift, including when the assigned CNA 1 left the area to use the restroom. On 1/14/26 at 3:40 P.M., an interview was conducted with CNA 4. CNA 4 stated Resident 1 required maximum assistance (the staff performs approximately 75% or more of the physical work, while the patient contributes 25% or less) for sit-to-stand movements and transfers due to being “wobbly and unstable.” CNA 4 stated Resident 1 used a walker and had ambulated with a walker during therapy sessions. CNA 4 stated Resident 1 was confused and appeared unable to consistently understand how to use the call light for safety, despite staff encouragement. CNA 4 further stated that due to Resident 1’s confusion, and inability to fully verbalize his needs, staff would need to respond promptly to prevent unsafe attempts to stand if Resident 1 needed assistance. On 1/14/26 at 3:47 P.M., an interview was conducte