Health inspection·February 4, 2026

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 residents' choices. Code of Federal Regulations, Title 42, Section 483.25(d), Accidents (d)(1) The resident environment remains as free of accident hazards as is possible; and (d)(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. (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 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. The following citation was written as a result of an unannounced visit to the facility on 12/16/2025 for the investigation of complaint #2685810. As a result of the investigation, the Department determined the facility failed to: 1. Ensure Resident 1's care plan and interventions were updated to provide sufficient supervision based on his identified needs as high risk for falls and facility policy to prevent accidents. As a result of these failures, Resident 1 had a fall on 11/8/25 and was subsequently transferred to a general acute care hospital (GACH) for further evaluation. This evaluation indicated that Resident 1 had diffuse intracranial hemorrhage (widespread bleeding inside the skull increasing the pressure in the brain, cutting off oxygen flow and causing cells to die) and later died in the hospital on 11/10/25. A review of the Admission Record indicated Resident 1 was admitted August of 2016 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness) following nontraumatic subarachnoid hemorrhage (bleeding into the spaces around the brain) affecting left dominant side and aphasia (a disorder that makes it difficult to speak) following cerebrovascular disease (loss of blood flow to a part of the brain). The Minimum Data Set (MDS- a standardized resident assessment tool) dated 8/8/25 indicated, Resident 1 had impairment (functional limitation that interfered with daily function) on both sides of upper extremities and required setup assistance (resident completes activity, helper assists only prior to or following the activity) once in a wheelchair to wheel at least 50 feet and make two turns and to wheel at least 150 feet in a corridor or similar space. Further review of Resident 1's clinical records indicated the following: -Care Plan, initiated 12/28/23 indicated, Resident 1 had confusion at times and impaired decision making per physician, diagnosis of anoxic brain injury (no oxygen in the brain causing brain cells to die) with cognitive dysfunction (impaired memory). The interventions included "Provide cues and supervision as needed."; -Care Plan, initiated 12/28/23 indicated, Resident 1 had impaired vision and the intervention included "Fall prevention/precaution per policy"; -Care Plan, initiated 11/11/24 indicated, Resident 1 was at risk for falls, repeat falls with possible injuries due to impaired mobility, cognition (ability to think, learn, and understand) poor vision related to history of stroke (loss of blood flow to a part of the brain) , hypertension, and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) with neuropathy (numbness or weakness in the hands and feet) with contributing risk factors of cardiac (heart condition) and history of falls; -Care Plan, initiated 8/16/24 indicated, Resident 1 had impaired cognitive function/dementia (a progressive state of decline in mental abilities) or impaired thought processes. The interventions included to "Cue, reorient and supervise as needed."; and, -Fall Risk Evaluation, dated 8/8/25 indicated, Resident 1 was high risk for falls with a score of 14. During a review of Resident 1's Weekly Nursing Summary (WNS) dated 11/2/25, the WNS indicated, Resident 1 required supervision or touching assistance for "LOCOMOTION ON [ability to move within the unit]/OFF Unit [ability to move to and from locations outside the unit such as outside the facility]- Wheel 50 feet with two turns; Wheel 150 feet". The WNS further indicated Resident 1 was alert/oriented with forgetfulness at baseline (usual or expected) and was able to self-propel around facility with little to no assistance and to continue with current plan of care. During a review of Resident 1's Social Services Note (SSN) dated 11/7/25, the SSN indicated, Resident 1 was alert and oriented x 3 (awareness to person, place, and time) and the Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 12/15 which indicated Resident 1 had moderate cognitive impairment (noticeable memory problem). The SS Note further indicated Resident 1 will remain in the facility due to Resident 1 requiring 24-hour supervision. During a review of Resident 1's Progress Note dated 11/8/25 indicated, "[Resident1] had unwitnessed fall on 11/8 around 1120 AM in garden area between A wing & D wing...was found on floor on side walk [sic] on wheelchair with feet in air and back on sidewalk and head on the side walk [sic] and hit head on concrete sidewalk. [Resident 1] verbalized hitting head...Unable to assess any injuries due to resident stating pain and not medically safe to turn resident or get resident off ground...noted resident on floor when sitting out in patio during lunch...had BP [blood pressure] elevated 219/87 [normal BP is below 120/80]. 911 [emergency services] was called d/t [due to] medically not safe to transfer resident off sidewalk onto wheelchair..." A review of Resident 1's Discharge Summary on 11/10/25 from the acute care hospital indicated the discharge diagnosis was "Fall, initial encounter". The reason for admission indicated Resident 1 was status post (after or following) ground level fall (person's feet are on the same level as the ground before a fall) with diffuse intracranial hemorrhage (widespread bleeding inside the skull increasing the pressure in the brain, cutting off oxygen flow and causing cells to die) and was admitted for comfort care. Resident 1 passed away on 11/10/25 at 6:55 a.m. During a concurrent interview and record review with the Director of Nursing (DON) on 12/16/25 at 10:22 a.m., the DON showed the list of residents with incidences of falls for the past 2 months. The DON stated Resident 1 had a fall on 11/8/25, resident was sent out, and he died in the hospital. A follow up interview was conducted on 12/16/25 at 11:50 a.m. with the DON, the DON stated Resident 1 was able to exit the building by himself. The DON further stated Resident 1 was found with wheelchair tipped backwards, a nurse was there taking a break, when the nurse saw Resident 1, he was already on the ground. During an interview with the Licensed Nurse (LN 1) on 12/16/25 starting at 1:03 p.m., LN 1 stated she was the desk nurse when Resident 1 fell, and it was a weekend. LN 1 described Resident 1 as alert and oriented to self, place and situation with slow slurred speech, and wheelchair bound. LN 1 stated Resident 1 would be up in his wheelchair, he would sit in the hallway a little bit then he goes to breezeway, and he makes his way to the garden. In a subsequent observation and interview on 12/16/25 at 1:10 p.m., LN 1 with the state surveyor went out in the garden area located between A and D wing. LN 1 showed the actual spot where Resident 1 was found with his back and head on the concrete floor. LN 1 stated Resident 1's front two wheels were up in the air, the back wheels on the ground and Resident 1's legs were up with the two front wheels. LN 1 confirmed the A wing nurses' station had glass windows with vertical blinds and the garden area was not visible from the said nurses' station. During a concurrent observation and interview on 12/16/25 at 1:14 p.m., LN 1 showed the state surveyor where she was sitting in the dining room/activity room when she was informed Resident 1 had a fall. LN 1 stated she saw Resident 1 on the ground from the dining room glass window. LN 1 further stated when she went to check on Resident 1 outside, there were licensed staff on the scene, and she was the one who called 911. LN 1 stated Resident 1 was by himself in the patio area when he had a fall. LN 1 further stated Resident 1 required supervision to some extent, at least twice a day during the day when resident was outside (patio). LN 1 confirmed there was no supervision provided to Resident 1 when the fall incident occurred in the patio. During a telephone interview with the Certified Nursing Assistant 1 (CNA 1) on 12/16/25 at 2:20 p.m., CNA 1 stated Resident 1 was active, and he would go out in the patio by himself every day. CNA 1 further stated Resident 1 goes out around 9 a.m., CNA 1 was unable to recall the last time she saw Resident 1 before the fall on 11/8/25. During an interview with the DON on 12/16/25 at 3:10 p.m., the DON stated she could not find documented evidence indicating Resident 1 was safe by himself in the patio. During a telephone interview with CNA 2 on 12/17/25 at 12:34 p.m., CNA 2 stated sometimes Resident 1 would allow staff to push his wheelchair sometimes he would say "no". CNA 2 further stated when Resident 1 was outside (patio) she was monitoring him often, "because anything can happen". CNA 2 added falls can be prevented when CNAs checked on residents more frequently and Resident 1 would be safe in the patio by himself if a CNA was watching him. During a telephone interview with LN 2 on 12/17/25 at 1:23 p.m., LN 2 stated Resident 1 was up in his wheelchair inside his room between 10-11 a.m. on 11/8/25. LN 2 further stated she was on break between 11:30 to 12 noon and she informed her CNAs she was going for a break. When LN 2 came back from her break she was informed Resident 1 had a fall in the patio. LN 2 was asked if Resident 1 was a fall risk, LN 2 responded, "not that I know", and LN 2 stated Resident 1 was alert, he can press the call light and he can verbalize his needs. During a telephone interview with the DON on 12/18/25 at 4:29 p.m., the DON stated Resident 1's Fall Risk Evaluation dated 8/8/25 indicated Resident 1 was at high risk for falls with a score of 14. The DON further stated whenever a resident was at high risk for falls an individualized plan of care would be initiated. The DON added since Resident 1 was a high risk for falls, he needed close supervision from direct care staff which included the LNs and CNAs. The DON further added if Resident 1 was provided with close supervision or frequent checks Resident 1's fall was avoidable. There was no documented evidence Resident 1's care plan was updated when Resident 1 was identified as high risk for falls on 8/8/15. A review of the facility's policy and Procedure ( P & P) revised July 2017 and titled, "Safety and Supervision of Residents" indicated, "...Resident safety and supervision and assistance to prevent accidents are facility-wide priorities...Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents...The care team shall target interventions to reduce individual risks...including adequate supervision...Implementing interventions ...Ensuring that interventions are implemented...Resident supervision is a core component of the system approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs...certain resident risk factors...are addressed...These risk factors...include...Falls..." A review of the facility's P & P revised March 2018 and titled, "Falls and Fall Risk, Managing" 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." The Department determined the facility failed to ensure Resident 1's care plan and interventions were updated to provide sufficient supervision based on his identified needs as high risk for falls and facility policy to prevent accidents. This failure resulted in Resident 1's fall and subsequent transfer to the acute care hospital for further evaluation. This evaluation indicated that Resident 1 had diffuse intracranial hemorrhage and later died in the hospital. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result.