Health inspection·December 9, 2025

The following citation reflects the results of the California Department of Public Health investigation of one complaint, and one facility reported incident. Complaint number: 2609074 Incident number: 2605247 The inspection was limited to the specific complaint and incident investigated and does not represent the findings of a full inspection of the facility. The facility was found to be not in compliance with 42 CFR 483.1-483.75 - Subpart B - Requirements for Long Term Care Facilities. State Class AA citation 230022757 was issued for complaint number 2609074 at Title 42 CFR §483.25(d)(1), (2) 22 CCR §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. 22 CCR § 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 the 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 each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. §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. On 9/9/25 at 1:40 pm, the Department conducted an unannounced visit to the facility to investigate multiple falls of Resident 1 that resulted in a head injury. Resident 1 experienced four unwitnessed falls in seven days, three of which occurred after staff failed to replace an indwelling catheter (a soft tube that is inserted into the bladder and allows urine to drain into a collection bag) and contributed to Resident 1’s falls by her attempting to toilet herself. The facility failed to provide interventions to prevent further falls, did not complete neurological assessments of Resident 1 after the falls, and did not complete a bladder assessment related to the removal of the indwelling catheter. On 8/15/25 at 05:15 am, Staff found Resident 1 on the floor and reported that she "complained of hitting her head." On 8/19/25 at 12:55 a.m. and again at 9:10 p.m., staff found Resident 1 on the floor. On 8/20/25 at 1:30 p.m., Registered Nurse (RN) A observed that Resident 1 had "a bruise to her head, a change in condition related to abnormal vital signs, a blood pressure of 174/122 (normal is at or less than 120/80), an altered level of consciousness (a decrease in alertness, awareness and responsiveness), and increased confusion." Staff notified Resident 1’s primary physician, who "ordered Resident 1 to be sent to the acute care (local hospital) for further evaluation and treatment." The acute care hospital determined that Resident 1 had sustained "a subdural hematoma (bleeding between the brain and its lining)." These failures caused a major head injury, emergency hospitalization, a significant decline in quality of life, and ultimately, Resident 1’s death. Findings: A review of the facility’s policy and procedure (P&P) titled “Fall Management Program” revised 11/7/16, indicated it is the facility’s purpose to provide a safe environment that minimizes complications associated with falls. The P&P indicated that the Licensed nurse and/or IDT (Interdisciplinary Team, a group of professionals to address complex problems) will develop a Plan of Care according to the identified risk factors and root cause…. Following each resident fall, the Licensed Nurse will perform a Post-Fall Assessment and update, initiate or revise a Plan of Care. The Licensed Nurse will complete the Neurological Flow Sheet for an un-witnessed fall… for seventy-two hours following the fall incident. Within 15-20 minutes after a fall the Licensed Nurse will initiate a post fall huddle utilizing the Post fall Huddle form. Once the post fall huddle is completed the Licensed Nurse will update the care plan with immediate recommendations. A resident who sustains multiple falls as defined as more than one fall in a day, week… will be considered a high risk to fall and as a result may sustain a major injury. These residents may: require more frequent observation of activities and whereabouts, may require a structured environment or routine, and may require special equipment to promote independence…. These interventions will be documented on the Resident’s plan of care and in the resident’s clinical record. A review of the facility’s “Fall Incident Checklist” (undated), indicated that after a resident had a fall the staff was to place the resident on alert charting (structured process in healthcare for intensified monitoring and systematic documentation of a patient's condition) for 72 hours, initiate frequent safety checks and implement a new intervention in the long-term care plan. A review of the facility’s policy and procedure (P&P) titled “Bowel and Bladder Indwelling Catheter -Insertion, Maintenance and Discontinuation of” revised 7/22/25, indicated “Discontinuation of an Indwelling Catheter…. D. Bladder training (a therapy that aims to improve bladder control and uses scheduled urination timetable to help gain control of urination) will be provided as indicated per the Bowel and Bladder Training/Toileting Program. F. The residents’ care plan will be updated as necessary.” A review of the facility’s P&P titled “Bowel and Bladder “Training/toileting Program” revised 8/21/20, indicated, “The licensed nurse will assess a Resident’s bowel and bladder status…upon the removal of an indwelling catheter.” “Interventions identified by the licensed nurse and or the IDT will be care planned and communicated to the corresponding professional and to the facility staff for implementation. Following review and determination for the residents voiding (urinating)/bowel evacuation pattern, the licensed nurse will develop an individualized Bowel and Bladder Training Program to meet the Resident’s needs. The established pattern and individualized bowel and bladder training intervention (s) will be documented in the care plan. A review of Resident 1’s admission record dated 8/13/25, indicated Resident 1 was admitted to the facility from a local hospital on 8/13/25 with diagnoses that included Urinary Tract Infections (UTI, an infection in the bladder, causing pain and increased urination), Coronavirus (infectious respiratory disease caused by a virus), difficulty in walking, muscle weakness, cognitive (relating to the mental process involved in knowing, learning, and understanding things) communication deficit, dysphagia (difficulty with swallowing), need for assistance with personal care, chronic pain syndrome, atrial fibrillation (irregular heart beat that can cause dizziness, tiredness, lightheadedness, reduced ability to exercise, and weakness), overactive bladder (the sudden urge to urinate that may be hard to control), retention of urine (difficulty in urination), and osteoarthritis (bone inflammation) of the right and left knee. A review of Resident 1’s Admission Minimum Data Set (MDS, a data driven clinical assessment) with an Assessment Reference Date (ARD) (the last day of the observation period for a MDS assessment) of 8/20/25, Section C (review of mental status) indicated a Brief Interview for Mental Status (BIMS, a review of mental status with scoring from 0 to 15, where 0-7 represents severe mental impairment and 13-15 represents intact cognition ) was conducted and Resident 1 scored a 10 indicating moderate mental impairment. Section GG (functional abilities) indicated Resident 1 used a walker when walking, required moderate assistance from staff with standing, transferring to chair or bed, walking, and toilet transfers. Section H (Bowel and Bladder) indicated Resident 1 was admitted with an indwelling catheter and was continent (able to control) with her bowel movements. A review of Resident 1’s Hospital record titled “Physical Therapist (PT) Therapy Daily/Treatment” dated 8/12/25, PT documented “discharge recommendation: 24-hour supervision/assist….” A review of Resident 1’s August 2025’s Physician Orders indicated orders dated 8/13/25 included medications that increased her risk for falls, frequent toilet needs and increased bleeding as follows: Furosemide (a water pill that helps reduce fluid in the body through urination and caused Resident 1’s increased risk for falls due to her frequent toilet needs) 20 mg (milligrams a unit of measurement) daily. Rivaroxaban (a medication that prevents blood from clotting and increases the potential for bleeding and bruising) 15 mg daily. The Physician’s Orders also indicated that Resident 1 was incapable of making her own healthcare decisions. A review of Resident 1’s Fall Care Plan dated 8/14/25, indicated, “The Resident is at risk for falls related to deconditioning (the decline in physical and mental function), gait (the pattern how a person walks) balance problems, weakness” interventions included: -Call light is within reach and Resident needs prompt response to all requests. -Educate the Resident about safety reminders and what to do if a fall occurs. -Ensure that the resident is wearing appropriate footwear when ambulating or moving in wheelchair (w/c). -Follow facility fall protocol. -Physical Therapy to evaluate and treat as ordered or PRN (as needed). Fall 1: A review of Resident 1’s Progress Notes titled “Alert Note” dated 8/13/25 at 9:55 pm, Licensed Vocational Nurse (LVN) B indicated Resident 1 was found to be yelling out for help. Resident 1 was found sitting on the floor in front of her closet. A review of Resident 1’s Progress Notes titled “N Adv – Post Fall Evaluation” dated 8/13/25 at 10:30 pm, LVN B documented “fall was not witnessed. Fall occurred in the Resident’s room. Activity at the time of fall: Attempting to brush her teeth.” Resident 1’s post fall risk score was 7 (at risk for falls). A review of Resident 1’s Progress Notes titled “IDT Progress Notes – Falls” dated 8/14/25 at 7:23 am, the IDT clinical team reviewed and documented Resident 1’s unwitnessed non-injury fall that occurred on 8/13/25 at 9:45 p.m. Staff reported, “During rounds resident was heard yelling out for help. Upon staff investigation, resident was seen sitting on the floor in front of her closet, wearing non-skid socks. Per resident input, Resident stated, ‘I was going to go brush my teeth and sat on the floor when I lost my balance.’” Root cause of fall for Resident 1 was documented as “adjusting to new facility and most likely adjusting to required supervision/SBA (stand by assist) for ADL’s (activities of daily living, like brushing teeth, washing face, transferring to bed or wheelchair, walking and toileting) and probably not thinking she needed help. IDT rec (recommendation) is MRR (medication regimen review), continue with therapy evaluation for strengthening and safety transfers.” A review of Resident 1’s August 2025 Fall Care Plan indicated that on 8/14/25, the IDT updated one intervention related to the 8/13/25 fall to “continue with therapy evaluation for strengthening and safety transfers.” Fall 2: A review of Resident 1’s Progress Notes titled “Alert Note” dated 8/14/25 at 11:28 am, Registered Nurse (RN) A wrote that Resident 1’s indwelling catheter had fallen out and that staff did not replace it. A review of Resident 1’s August 2025 progress notes indicated there was no documentation in Resident 1’s progress notes to indicate why the indwelling catheter was not replaced. A review of Resident 1’s August 2025 Physician Orders indicated there was no order to discontinue the indwelling catheter. A review of Resident 1’s August 2025 Care Plans indicated there was no Bowel and Bladder Care Plan developed and no individualized Bowel and Bladder Training Program to meet Resident 1’s bladder needs, since she would then have to use the toilet instead of a urinary catheter to empty her bladder. A review of Resident 1’s Progress Notes titled “N Adv – Post Fall Evaluation” dated 8/15/25 at 5:10 am, LVN C noted “Fall was not witnessed. Fall occurred in the Resident’s room. Resident was attempting to self-toilet at time of the fall.” Resident 1’s post fall risk score was 14 (at high risk for falls).” A review of Resident 1’s Progress Notes titled “IDT Progress Notes- Falls” dated 8/15/25 at 7:23 am, IDT clinical team documented a review of Resident 1’s unwitnessed… fall on 8/15/25 at 5:10 am. “Per resident input, I fell and hit my head on the door’. ‘I don’t know what happened, I just fell.” The team identified that the root cause of the fall was Resident 1 adjusting to the new facility, which matched the root cause of Fall number one. The IDT noted that Resident 1’s indwelling catheter had been discontinued, and there was no documented discussion about a toileting program for Resident 1. A review of Resident 1’s Neurological Flow Sheet dated 8/15/25 starting at 5:10 am, indicated an incomplete flow sheet with no assessment of level of consciousness ("ability to think clearly"), movement ("balance and coordination"), hand grasps ("determines if there is a weakness for one side of the body"), pupil size ("a sudden change in pupil size can be a sign of a brain bleed"), or reaction documented for the first 24 hours. A review of Resident 1’s August 2025 Fall Care Plan indicated one updated intervention on 8/15/25 to include an orthostatic blood pressure (dropping of blood pressure that occurs when a person stands up from sitting or lying position) evaluation. There were no interventions for frequent observation of activities and whereabouts, and a structured environment or routine, or special equipment to promote independence as per their Fall Management Program policy when there were two or more falls in a week. A review of Resident 1’s Nursing Progress Notes/Alert Charting from 8/15/25 to 8/18/25 indicated that between 8/15/25 at 7:45 am, to 8/18/25 at 6:24 pm, for 82 hours, there was no shift (every eight hours) alert charting, for the required 72 hours after a fall, concerning Resident 1’s condition after the 8/15/25 fall at 5:10 am. A review of Speech Therapy Evaluation and Plan of Treatment dated 8/18/25 at 6:13 pm, by Speech Language Pathologist (SLP), SLP documented “However, due to the patient’s high level of pain (10/10) and multiple attempts to complete the assessment, ST discontinued the session and discussed with patient that it will be completed during the next treatment session.” ST continued to document “PT (patient) requires 24/7 supervision and is a high fall risk.” A review of Resident 1’s August 2025’s MAR indicated that on 8/18/25 at 6:35pm, Resident 1 reported a headache and rated the pain level as 6 ("on a scale of 0-10, where 0 is no pain and 10 is the worst pain one could experience"). Staff administered Tylenol 650 mg for moderate to severe pain. LVN B documented a follow-up charting on 8/18/25 at 8:24 p.m., indicating that the Tylenol was ineffective and Resident 1’s pain level was now a 5. Staff did not document any physician follow-up. Fall 3: A review of Resident 1’s Progress Note titled “Alert Note” by LVN B on 8/19/25 at 00:55 am, LVN B documented “This resident was heard asking for help, upon arrival the resident was found to be sitting on the floor with her back against the bed. When asked what happened the resident stat