Other·March 5, 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. On 12/30/2025 at 1:00 P.M., an unannounced onsite visit at the facility was conducted to investigate a facility reported incident of a resident fall with injury which occurred on 12/6/2025. The facility failed to: 1. Protect Resident 1 from bodily injury when a certified nursing assistant (CNA 1) left a bedside table positioned on the resident's left-side, not within a reachable distance of the resident's right side. Resident 1 fell off his bed while he attempted to reach over from his right side towards the bedside table positioned on his left side. 2.Provide care and services to prevent accidents for Resident 1 who had left sided hemiplegia (paralysis affecting one side of the body) and hemiparesis (one-sided weakness). 3. Ensure staff implemented appropriate care planned interventions for Resident 1's physical limitations. 4. Develop an individualized care plan that addressed Resident 1's physical limitations. These failures resulted or created a substantial probability of Resident 1 sustaining an unwitnessed fall from his bed on 12/6/2025. Resident 1 went to the hospital and was admitted for a forehead laceration and femoral neck fracture (fractured hip) based on the fall from the bed on 12/6/2025. On 12/30/25 at 1:30 P.M., a review of Resident 1's undated Admission Record was conducted. Resident 1 was admitted to the facility on 10/17/2025 with diagnoses that included hemiplegia (paralysis affecting one side of the body) affecting the movement of the left side of his body (hemiparesis). According to Resident 1's Care Plan Report, dated 12/8/2025, under Focus [Problem], Resident 1 was at risk for falls because of impaired mobility, history of CVA [Cerebrovascular Accident-blood flow to the brain was blocked], under Interventions, it was indicated that staff needed to ensure Resident 1 wore nonskid socks, keep environment clutter free, adequate lighting, maintain fall precautions such as low bed and call light within reach, and reorient Resident 1 as needed due to dementia (a loss in mental functioning). The care plan did not indicate putting Resident 1's belongings or items on the right side for easy access, safety, and fall prevention. The facilities Interdisciplinary Team note (IDT) Dated 2/23/2026, indicated, " Resident: Resident experienced an unwitnessed fall during the morning shift... During PM shift, resident reported pain rated 9/10 localized to right hip and right leg. On assessment, resident exhibited significant pain upon lifting right leg. According to Resident 1's Hospital Discharge Summary, dated 12/8/2025, the Emergency Department physician repaired the superficial forehead laceration with sutures, and Resident 1 was found to have a femoral neck fracture. Resident 1 returned to the facility on 12/8/2025. On 12/30/2025 at 2:00 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that Resident 1's roommate called for help, the staff answered the call light and found Resident 1 on the floor. Licensed Nurse (LN 1) assessed Resident 1 and found that Resident 1 had a bump on the forehead. LN 1 called the physician and ordered them to transfer Resident 1 to the hospital. Later, the hospital called the facility and said that Resident 1 had a left femoral neck fracture. The DON further stated that the facility did their investigation and found out that Resident 1's bedside table was on the affected side of Resident 1. The DON stated that the placement of the bedside table made it hard for Resident 1 to reach the items on the table which resulted in Resident 1 falling out of bed. The DON further stated that the fall could have been avoided, and corrective actions were implemented, such as in-service training for the staff and a 1:1 CNA education for CNA 1 (CNA assigned to Resident 1 on the day of the incident). On 12/30/2025 at 2:35 P.M., Resident 1 was observed sitting in a wheelchair in the activity room and was not available due to attending activities On 12/30/2025 at 3:35 P.M., an interview was conducted with LN 1. LN 1 stated she was giving medications to another resident when CNA 1 called her to check Resident 1. LN 1 entered the room and found that Resident 1 was on the floor between the B- bed and the C- bed. LN 1 explained that Resident 1's room had three beds, and Resident 1's bed was the C-bed away from the door. LN 1 further stated the bedside table was tilted and pushed against the B-bed. LN 1 saw Resident 1's right forehead with a bump and a superficial scrape, which had a moderate amount of blood. Resident 1's physician was made aware and asked the facility to transfer Resident 1 to the hospital. LN 1 further stated that Resident 1 told her that he was reaching for the remote control on the bedside table, felt weak, and then fell onto the floor. LN 1 stated the roommate pressed the call light because Resident 1's bedside table leaned against his right side. LN 1 further stated that CNA 1 arrived to answer the call light and saw Resident 1 laying on the floor, and she was called by CNA 1. On 1/8/2026 at 2:10 P.M., an interview was conducted with CNA 1. CNA 1 stated the last time she saw Resident 1 was before she took her 30-minute lunch break. CNA 1 stated she knew Resident 1 had left-sided weakness, and the bedside table should have been placed on Resident 1's right side of the bed. CNA 1 said she could not recall where the bedside table was located when she left Resident 1 to take a break. CNA 1 further stated that Resident 1's fall was unwitnessed, and Resident 1 was not a good historian. CNA 1 further stated that she came back from her 30-minute lunch break, saw the call light was on for Resident 1's roommate in B-bed, and she went to the room. She did not know how long the call light had been on before she responded. CNA 1 further stated she entered the room, the roommate on B-bed said he did not need help and CNA 1 then approached C-bed. CNA 1 saw Resident 1 on the floor, with blood on the face, and called LN 1. CNA 1 said that she did not know how long the call light had been on, but noticed it was on after she came back from her break. CNA 1 stated she told LN 1 she was going to lunch but not the CNA that is going to cover her section. CNA 1 said she only notified LN 1. According to the facility's policy, dated 8/28/25, titled Fall Management Program, "The facility will maintain an environment free of accident hazards, provide adequate supervision and assistive devices to prevent avoidable accidents..." The facility failed to: 1. Protect Resident 1 from bodily injury when a certified nursing assistant (CNA 1) left a bedside table positioned on the resident's left-side, not within a reachable distance of the resident's right side. Resident 1 fell off his bed while he attempted to reach over from his right side towards the bedside table positioned on his left side. 2.Provide care and services to prevent accidents for one of five sampled residents (Resident 1) who had left side hemiplegia (paralysis affecting one side of the body) and hemiparesis (one-sided weakness). 3. Ensure staff implemented appropriate care planned interventions for Resident 1's physical limitations. 4. Develop an individualized care plan that addressed Resident 1's physical limitations. 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.