Health inspection·April 16, 2026

The following reflects the findings of the California Department of Public Health during the annual recertification survey. Survey Event ID: 1DFD0E-H1 State Citation B was written. §72311. Nursing Service - General. (a) Nursing service to 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 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. On 1/5/26 at 10 a.m., an unannounced visit was conducted at the facility for their annual recertification survey. Patient 6 was an elderly female who was admitted to the facility in November 2025 with diagnoses that included hemiplegia (paralysis that affects only one side of the body) affecting right dominant side, and morbid obesity (severe obesity, excessive fat stores and a body mass index of 40 or higher (BMI, a measure of body fat based on height and weight, normal BMI is 18.5-24.9). On 12/2/25 at 5:20 a.m., while Certified Nursing Assistant (CNA) 1 provided incontinent care (providing support for individuals who cannot control their bladder or bowels), without assistance from another staff, CNA 1 turned Patient 6 to the side, close to the edge of the mattress, with no bed rail to hold onto. Patient 6 fell out of bed and sustained left shoulder fracture (partial or complete break in a bone). The facility failed to ensure Patient 6's individualized care plan was implemented when CNA 1 turned Patient 6, who was half-awake, to the right side without having two staff present and a bed rail to hold onto. This failure resulted in Patient 6's fall that led to a left shoulder fracture. During a review of Patient 6's Minimum Data Set (MDS, an assessment tool used to direct resident care) assessment dated 11/17/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive [mental processes involved in gaining knowledge and comprehension] status regarding attention, orientation, and ability to register and recall information) score of 15. A BIMS score of 13-15 is an indication of intact cognitive response. During a concurrent observation and interview on 1/5/26 at 10:38 a.m. with Patient 6, in the hallway close to Patient 6's room, Patient 6 wore a sling on the left arm. Patient 6 stated she had to wear it after falling two weeks after admission to the facility. Patient 6 stated falling out of bed when CNA 1 placed her in a right-side lying position but did not instruct her to hold onto anything. Patient 6 was unsure if there was a bed rail. Patient 6 stated she rolled out of bed, landing on her left side, and experienced immediate significant pain in the left shoulder after the fall. Resident 6 stated she was then sent to the hospital for treatment. During a review of Patient 6's "Progress Notes" dated 12/2/25, the "Progress Notes" indicated, on 12/2/25, at 5:20 a.m. CNA 1 "Noticed that the resident had fallen". The "Progress Notes" further indicated, Patient 6 was turned on her side near the edge of the bed and slid off, resulting in the fall. Patient 6 was transferred to the hospital for further evaluation due to concern of possible injury or fracture. During a review of Patient 6's "Emergency Department (ED) Provider Notes" dated 12/2/25, the "ED Notes" indicated Patient 6 sustained an impacted (bone pieces are jammed together) fracture of the surgical neck with extension to the greater tuberosity (fracture of the left shoulder) and had been placed in a sling. During a telephone interview on 1/6/26 at 11:21 a.m. with CNA 1, CNA 1 stated, on 12/2/25, around 5-5:30 a.m., CNA 1 went to Patient 6's bedside to provide incontinent care. CNA 1 stated he informed Patient 6 of his intention to change her, to which Patient 6 responded with a faint mumble. CNA 1 stated he proceeded to change Patient 6 and her bed linen, which were soaked with urine. CNA 1 described himself as tall and stated he raised the bed waist height and positioned himself on Resident 6's left side. CNA 1 then requested Patient 6 to turn to her right side (CNA 1 faced Patient 6's back) while he applied the fitted sheet at the foot of the bed. During this process, CNA 1 stated he observed Patient 6's legs began to slide towards the edge of the bed before she turned completely to her right and rolled out of bed. CNA 1 stated he reached over the bed to prevent Patient 6 from falling but found it difficult due to Patient 6's weight and her deep sleep state, "Like she was in a deep coma." CNA 1 stated that he worked under a registry and was unfamiliar with Patient 6's care requirements, as this was his first assignment with Patient 6. CNA 1 stated he did not receive any report or instructions from the charge nurse at the start of the shift. CNA 1 also stated he tried to ask for assistance from other staff members, but none were available as they were all occupied. CNA 1 stated there were no rails attached to Patient 6's bed. During a review of Patient 6's bed mobility care plan, undated, the care plan indicated interventions that included providing quarter rails on both sides of the bed to enable positioning and increase mobility. During a telephone interview on 1/7/26 at 9:18 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated CNA 1 did not ask for help and only informed her after Patient 6 had fallen out of bed. During a review of Patient 6's "IDT (Interdisciplinary Team, a group of individuals representing different departments of the facility): Post Accident/Fall (IDTPA, a review of the incident including identifying contributing factors to prevent recurrence)", undated, the "IDTPA" indicated, improper positioning during care, specifically placing the resident too close to the mattress edge while turning, likely contributed to the fall. To prevent re-occurrence, the follow-up measures included reinforcing proper bedside positioning techniques and re-educating CNAs on continuous physical support during turns. During a review of the facility's policy and procedure (P&P), titled "Repositioning", undated, the P&P indicated, to reposition a resident in bed, check the care plan for resident's specific positioning needs and the resident's level of participation, lower the side rails (if applicable) on the side where you are standing, use two people and a draw sheet to avoid shearing (when layers of skin tissue slide in opposite directions, damaging blood vessels and deep tissue, like sliding down in a chair or bed) while turning resident in bed, encourage the resident to participate if able, and encourage the resident to hold the side rail with the top arm in the direction of the turn. During an interview on 1/8/26 at 11:10 a.m. with Director of Staff Development (DSD), DSD stated CNA 1 should have called for help, communicated with the charge nurse of his inability to get help from another staff, and ensured Patient 6 was fully awake before providing care. DSD stated, following the fall incident, CNA 1 was removed from the schedule and not allowed to return to work. In violation of the above cited standards, the facility failed to ensure Patient 6's individualized care plan was implemented when CNA 1 provided incontinent care without two staff present and with no bed rails to hold onto. This failure resulted in Patient 6's fall that led to left shoulder fracture. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.