Health inspection·November 21, 2025

Code of Federal Regulations, Title 42, Section 483.25. Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: Code of Federal Regulations, Title 42, Section 483.25(d). Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 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: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (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. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 72313. Nursing Service - Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (1) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order. California Code of Regulations, Title 22, Section 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. California Code of Regulations, Title 22, Section 72613. Patient's Property Storage and Room Furnishings. (b) For each licensed bed there shall be provided: (1) A clean comfortable bed with an adequate mattress, sheets, pillow, pillow case and blankets, all of which shall be in good repair, and consistent with individual patient needs. On 10/30/25, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate one complaint regarding resident care. The Department determined that the facility failed to ensure two-persons assist and a low air loss mattress with appropriate setting was implemented when providing care to Resident 1, based on the resident's assessed needs. These failures resulted in Resident 1 falling from his bed and sustained a broken bone in his right big toe on 9/25/25. A review of Resident 1's "ADMISSION RECORD," indicated, Resident 1 was admitted to the facility with diagnoses of cerebral infarction (part of the brain does not get enough blood and oxygen causing brain tissue to die), left hemiplegia (little to no use of one side of the body), and severe obesity (significant excessive body weight that poses serious health risks). A review of Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool) revealed a score of 14 out of 15 total points which indicated Resident 1 had intact cognition. A review of Resident 1's "Weight Summary", dated 10/1/25, indicated Resident 1's weight was 359 pounds. A review of Resident 1's "Care Plan Report", revised 5/5/22, indicated, "...The resident [Resident 1] has an ADL [Activities of Daily Living, basic skills you need in regular daily life to care for yourself and/or others] self-care performance deficit r/t [related to] left sided weakness...BED MOBILITY...The resident requires extensive assistance with 2+ [two or more] persons physical assist to turn and reposition in bed as necessary...date initiated 01/02/2023..." Review of Resident 1's "Progress Notes", dated 9/25/25, indicated Licensed Nurse (LN) 1 documented, "...Called by the CNA [certified nursing assistant] in charge and he stated resident [Resident 1] slid from his bed now on the floor...found resident laying on his back on the floor...CNA [CNA 1] stated he turns on his left side then slid on the bed..." A review of Resident 1's "Radiology Results Report" dated 9/26/25 indicated, "...CONCLUSION: Acute fracture proximal phalanx right great toe [broken bone in the right big toe]..." During a phone interview on 10/21/25 at 2:18 PM, CNA 1 stated that Resident 1's fall occurred when he was preparing to change Resident 1 and the mattress "broke and he rolled out." At the time of the incident, CNA 1 stated he was positioned on the right side of Resident 1's bed and asked Resident 1 to roll over onto his left side. CNA 1 confirmed that the facility required two staff members to assist Resident 1 with ADLs; however, CNA 1 was alone at the time of the incident. CNA 1 reported that the air mattress, which had been installed the day prior, was unstable when Resident 1 turned. CNA 1 stated he was unsure who installed the air mattress for Resident 1 the day prior. During a concurrent observation and interview with Resident 1 on 10/21/25 at 1:41 PM, it was observed that Resident 1 was able to move the right side of his body but was unable to move his left side. Resident 1 stated on the day of the fall (9/25/25), CNA 1 assisted him with changing his brief (a disposable product used by people who cannot control their bladder and/or bowels). Resident 1 stated CNA 1 instructed him to turn to his left side but when he did so, the air mattress deflated on the left side, causing him to fall onto the floor. Resident 1 stated that only CNA 1 was present during the incident. Resident 1 further stated he can turn by himself, but since the fall, two staff members have now assisted him during care. However, he reported that CNA 1 "continues" to provide incontinence care (assistance provided to those who experience a loss of bowel and/or bladder function) alone in the mornings because "he does not want to wait for other staff." During an interview on 10/21/25 at 2:09 PM, the Director of Staff Development (DSD) stated that the facility's protocol for a newly installed air mattress included verifying that the mattress settings were appropriate for the resident's weight and checking the overall firmness of the bed. Additionally, nurses were trained to ensure that the mattress remains properly inflated and is not flat. The DSD further stated that both he and the Director of Rehabilitation (DOR) trained staff on proper air mattress repositioning. They emphasized that residents who were immobile or morbidly obese should be turned with the assistance of two CNAs at a time. Regarding Resident 1, CNA 1 was the only staff member assisting him during the incident and was subsequently written up for not following the protocol. A review of the facility's memo titled, "CORRECTIVE ACTION MEMO" dated 9/25/25 indicated, "...Type of Violation: Violation of Safety Rules...employee [CNA 1]...failure to follow company protocol regarding repositioning or doing ADL's care for morbid obesity patients have to be 2 people assist to prevent fall..." During a concurrent interview and record review with the Administrator (ADM) and the Assistant Director of Nursing (ADON) on 10/30/25 at 12:15 PM, the air mattress invoices were reviewed. The ADM stated that an air mattress was ordered from their vendor on 9/19/25 for another resident (Resident 3). When Resident 3 was discharged from the facility, facility staff switched Resident 3's bed, including the air mattress, with Resident 1's bed. The ADON confirmed the settings for Resident 1's air mattress were never added to Resident 1's treatment or medication administration record so the nurses could verify the mattress settings every shift. During a concurrent interview and record review with the ADON on 10/30/25 at 2:15 PM, the ADON stated she was unsure who decided to move Resident 3's bed to Resident 1's room, as there was no physician order for an air mattress for Resident 1. During a phone interview on 11/3/25 at 10:35 AM, the ADON stated that if an air mattress was applied to a resident's bed without a physician's order, there would be a risk of injury to the resident using the mattress. A review of the facility's Policy titled, "Sufficient Staffing" revised 10/2024 indicated, "...Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care..." A review of the facility's undated "Certified Nursing Assistant - Job Description" indicated, "...Major Duties and Responsibilities...Assist resident with or performs activities of daily living for resident in accordance with the care plans and established policies and procedures...Additional Assigned Tasks...Establish a culture of compliance by adhering to all facility policies and procedures..." A review of the facility's policy titled, "Assistive Devices and Equipment" revised 10/2024 indicated, "...Devices and equipment that assist with resident mobility safety and independence are provided for residents. These include...Specialty mattresses...The following factors will be addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment...Personal fit...equipment or device will be used according to its intended purpose and will be measured to...the resident's size and weight as much as possible...Requests or the need for special equipment should be referred to the appropriate Department..." Therefore, the department determined the facility failed to obtain a physician's order for the air mattress, ensure two persons assist and low air loss mattress with appropriate setting was implemented when providing care to Resident 1, based on the resident's assessed needs. These failures resulted in Resident 1 falling from his bed and sustained a broken bone in his right big toe on 9/25/25. These violations jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents and constitute a B citation.