Other·January 6, 2026

The following reflects the findings of the California Department of Public Health during an investigation of facility reported incident 2597957. Facility Reported Incident: 2597957 A deficiency was written for Facility Reported Incident 2597957 at F-tag 656-G. F656 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i)The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40. § 483.25 Quality of care. (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. Cal. Code Regs., tit. 22, §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. Cal. Code Regs., tit. 22, §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 9/5/25, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding a resident's fall with injury. Resident 1 is a 79-year-old male who was admitted to the facility on 6/2/25 with diagnoses of Muscle Weakness, Difficulty Walking, and Major Depressive Disorder (mood disorder). Based on interview and record review, the facility: 1) Failed to ensure that Resident 1 remained as free of accident hazards as is possible and to ensure that Resident 1 received adequate supervision and assistance devices to prevent accidents, when Resident 1, who had a history of confusion, poor safety awareness, gait disturbance and muscle weakness, attempted to use the toilet and fell on the following occasions: a. July 27, 2025: Unwitnessed fall while attempting to go to the bathroom unassisted. No injuries reported. b. July 28, 2025: Unwitnessed fall after using the bathroom, Resident 1 slipped and fell on his back. Sustained a scratch and swelling to the mid-back. c. August 6, 2025: Fall in the bathroom; Resident 1 missed the toilet and fell. No injuries reported. d. August 18, 2025: Possible fall while preparing for the day; Resident 1 hit his right rib on the corner of the sink. e. August 20, 2025: Witnessed fall while exiting the restroom. Resulted in an acute left femoral neck (thigh bone) fracture (break of the bone) requiring hospitalization and surgical repair. 2) Failed to implement Resident 1's bowel and bladder retraining program, when the bowel and bladder retraining program was listed on the Plan of Care Kardex (quick reference tool for staff containing a summary of the patient's care needs), but Certified Nursing Assistants (CNAs) were not prompted to document when Resident 1 was assisted to the bathroom. These failures resulted in multiple falls, with the August 20, 2025, fall resulting in a left femoral neck fracture requiring hospitalization and surgical repair. Findings: During a review of Resident 1's "Admission Record" (AR) undated, the AR indicated Resident 1 was admitted on 6/2/25, with diagnoses including difficulty in walking and muscle weakness. During a review of Resident 1's "Minimum Data Set" (MDS - a standardized assessment tool that measures the health status of the resident) dated 6/8/25, the MDS indicated, "Cognitive (mental processes of thinking, knowing, remembering, and understanding) Patterns. . .BIMS (Brief Interview for Mental Status to determine the cognitive status of a resident with scores ranging from 0 to 15 with the higher the score the more cognitively intact the resident is) Summary Score. . .03 (indicating severe cognitive impairment). . .Functional Abilities. . .toilet transfer (the ability to get on and off a toilet). . .01 (dependent-helper does all of the effort) Bladder and Bowel. . .Urinary Continence (ability to control movements of the bladder). . .3 (Always incontinent-no episodes of continent voiding). . .Bowel continence (ability to control movements of the bowel). . .2 (Frequently incontinent-2 or more episodes of bowel incontinence, but at least one continent bowel movement)." During a review of Resident 1's "Care Plan" (CP) dated 6/8/25, the CP indicated, "[Resident 1] is high risk for falls r/t (related to) confusion (lack of understanding). . .poor safety awareness. . .multiple falls. . .attempts to transfer and ambulate (walk) unassisted, takes self to bathroom. . .Interventions/Tasks. . .Offer toileting assistance after meals, at bedtime, q [every] 2hour and as needed per facility protocol. . .Date initiated. . .7/27/25." During a review of Resident 1's "Evaluation Scoring Report" (ESR-fall risk evaluation which determines the risk of the resident falling) dated 10/8/2025, the ESR indicated, "6/18/25. . .High Fall Risk. . .7/6/25. . .High Fall Risk. . .7/11/25. . .High Fall Risk. . .7/27/25. . .High Fall Risk. . .7/28/25. . .High Fall Risk. . .8/6/25. . .High Fall Risk. . .8/18/25. . .High Fall Risk. . .8/20/25. . .High Fall Risk." 1. During a review of Resident 1's "Progress Notes" (PN) dated 7/27/25 at 12 a.m., the PN indicated, "When entering resident's [1] room, resident was found on the floor at the end of his bed. Resident stated that he slipped when going to the restroom." During a review of Resident 1's CP dated 7/27//25, the CP indicated, "Resident had an unwitnessed fall; sustained no injury on 7/27/25. Attempted to go to bathroom unassisted; no injury. . .interventions/tasks. . .offer toileting (assist in using the toilet) Q (every) 2 hr (hours) and PRN (as needed) (toileting offered but not documented) . . ." 2. During a review of Resident 1's PN dated 7/28/25 at 6 a.m., the PN indicated, "Resident was found lying on his back on the floor at the right side of bed, next to his side table and trash can. . .Resident stated he got up to use the bathroom, when he was done, he walked back to bed but he slipped and fell on his back." During a review of Resident 1's CP dated 7/28/25, the CP indicated, "Resident had an unwitnessed fall on 7/28/25 with scratch and bump to mid back attempting to go to bathroom unassisted. . .Interventions/tasks. . .remind resident to use call light and ask for assistance as needed. . ." 3. During a review of Resident 1's PN dated 8/6/25 at 6:45 p.m., the PN indicated, "At approx. (approximately) 6:45 p.m. CNA informed this CN (charge nurse) resident was found in resident restroom sitting on his buttocks on the floor. CNA asked resident what happened resident replied, "I miss the toilet and fell on my a**." During a review of Resident 1's CP dated 8/6/25, the CP indicated, "(Resident name) had an actual fall with no injury 8/6/25 in the bathroom. . .Interventions/Tasks. . .Bowel and Bladder retraining (resident physically assisted to the bathroom at specific times and interventions documented) . . ." There was no evidence that the facility implemented bowel and bladder retraining program. 4. During a review of Resident 1's PN dated 8/18/25 at 11:36 a.m., the PN indicated, "Resident stated he fell this morning when preparing for the day. Resident sated he was going to the restroom without his assistive device this morning to get himself ready, when he lost balance and grabbed into the restroom's handrail and hit his (R) (right) ribon [rib on] [sic] the corner of the sink." During a review of Resident 1's CP dated 8/18/25, the CP indicated, "(Resident 1) had an alleged fall on 8/18/25. . .Interventions. . .Continue interventions on the at-risk plan. . ." 5. During a review of Resident 1's PN dated 8/20/25 at 10 a.m., the PN indicated, "Resident was found laying [sic] on his back on the floor facing the entrance door of the room. According to staff who witnessed the fall, resident was coming out of the restroom when he lost his balance and hang his hand on the corner of the neighbor's bed, turned around before slipping on the ground. . .Resident stated he got out of the restroom and slipped. . ." During a review of Resident 1's CP dated 8/20/25, the CP indicated, "[Resident 1] had an actual witnessed fall on 8/20/25 attempting to ambulate without assistance from bathroom. . .Interventions/Tasks. . .Send to acute (hospital) for evaluation and treatment as indicated." During a review of Resident 1's PN dated 8/20/25 at 8:43 p.m., the PN indicated, "At approximately 1135 this writer assessed resident for pain and any delayed injuries due to fall. Resident reported experiencing pain in the (L) (left) leg and requested for pain pill. . .Notified (physician name) for breakthrough (medications that treats serious medical condition) RX (prescription) or possible send out to acute (hospital). MD (Doctor of Medicine) declined to give any more pain management and order received to send to [hospital name] for further eval, pain control and to rule out possible fracture. During a review of Resident 1's PN dated 8/20/25 at 8:49 p.m., the PN indicated, ". . .At 7:30pm, this writer called (the hospital) again and got an update on resident who obtained a fracture on (L) hip and will be admitted. . ." During a review of Resident 1's "Imaging Report" (IR-completed at the hospital) dated 8/20/25, the IR indicated "Acute left femoral neck fracture extending to the lesser trochanter. . ." During a review of Resident 1's "History and Physical" (H&P-completed at the hospital) dated 8/20/25, the H&P indicated, "(Resident 1) is coming from a skilled nursing facility and has been evaluated in the past for recurrent falls. . .While he was at the skilled nursing facility, he states he tried to use the restroom on his own and had a fall. CT (computed tomography scan-imaging procedure that uses x-ray to create detailed images of internal organs, bones, and blood vessels) hip shows acute left femoral neck fracture extending to the lesser trochanter. . .Plan for surgical evaluation tomorrow." During a review Resident 1's "Consultation Report" (CR-completed at the hospital) dated 8/20/25, CR indicated, "Reason for consultation narrative: left hip pain. . .patient is a. . .male who had a ground-level fall yesterday. . .He denies any pain except for the left side of his lower extremity. . .Plan. . .Patient is a. . .male with a rather vertical pattern of the femoral neck fracture. He has a subcapital (head of the bone) fracture that extends to the top of the lesser trochanter. Given that this is intracapsular (occurring within a capsule) and displaced (moved from its proper place), we recommend a hip hemiarthroplasty (surgical procedure to replace half of a joint). During a review of Resident 1's "Discharge Summary" (DS) dated 8/24/25 (four days after being admitted from the skilled nursing facility to the hospital), the DS indicated, "Date of Admission: 8/20/25. . .for left hip fracture status post (Resident 1's current condition) mechanical fall (fall caused by external, environmental factors) status post left hip hemiarthroplasty. Hip CT showed acute left femoral neck fracture extending to the lesser trochanter. . .patient had left hemiarthroplasty. . ." During an interview on 9/5/25 at 2:50 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 had prior falls, would not call for assistance, and would take himself to the bathroom independently. During an interview on 10/6/25 at 1:13 p.m. with CNA 2, CNA 2 stated she was assigned to Resident 1 at the time of the fall (8/20/25). CNA 2 stated she was unaware Resident 1 was a fall risk or that Resident 1 was on bowel and bladder retraining program. CNA 2 stated Resident 1 would attempt to get up by himself and go to the bathroom. CNA 2 was unaware Resident 1 had prior falls. During an interview on 10/6/25 at 2:33 p.m. with CNA 3, CNA 3 stated Resident 1 was a fall risk, and would go to the bathroom independently. CNA 3 stated she was not aware Resident 1 was on a bowel and bladder retraining program. CNA 3 stated when a resident is on bowel and bladder retraining program, it should show on the POC (point of care computer system used by CNAs to document and includes the Kardex [quick reference tool for staff containing a summary of the patient's care needs]) for the CNAs to document each time the resident was assisted to the bathroom. During an interview on 10/6/25 at 2:39 p.m. with CNA 4, CNA 4 stated Resident 1 was a fall risk, and he was not on a bowel and bladder retraining at the time of the fall (8/20/25). During an interview on 10/6/25 at 10:20 a.m. with Director of Nursing (DON), DON stated Resident 1 was placed on bowel and bladder retraining program on 8/7/25 (13 days prior to the fall) due to Resident 1 falling on 7/27/25, 7/28/25, 8/6/25, while taking himself to the bathroom. DON stated that when a resident is on a bowel and bladder retraining program the CNAs were required to physically assist the resident to the bathroom and document the resident was assisted to the bathroom. DON stated the CNAs were made aware of the bowel and bladder retraining program through the POC Kardex. DON stated the bowel and bladder retraining did appear on the POC Kardex, but the task was not triggering for the CNAs to document each time Resident 1 was assisted to the bathroom. During an interview on 10/14/25 at 3:38 p.m. with DON, DON stated at the time of the 8/20/25 fall, the bowel and bladder retraining program should have been ongoing. DON stated that after 14 days, the data collected was used to evaluate the effectiveness of the retraining program and determine how Resident 1 was doing on the bowel and bladder retraining. DON stated the bowel and bladder retraining was not implemented correctly for Resident 1 on the POC prior to the 8/20/25 fall. During a review of the facility's policy and procedure (P&P) tilted, "Care Plans, Comprehensive Person-Centered" dated 3/22, the P&P indicated, "A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. . .the comprehensive, person-centered care plan. . .includes measurable objectives and timeframes. . .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. . .care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. . .when possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. . .the interdisciplinary team (group of professional