Health inspection·January 15, 2026

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: 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. Title 42, Section 483.21(b) Comprehensive Care Plans (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 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. 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. On 12/8/25 at 10:05 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident regarding a fall with major injury. The department determined the facility failed to ensure resident safety for one out of six sampled residents (Resident 2) when Resident 2 had an avoidable fall (unintentional fall that happens because of identifiable and correctable factors) when she was not properly secured during transportation to an appointment. This failure caused Resident 2 to sustain a left femur (lower end of thigh bone) fracture (crack, break, or chip in bone) that caused pain and required surgery. During a review of Resident 2's Admission Record, it indicated Resident 2 was originally admitted to the facility in April 2024 with multiple diagnoses which included parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), hemiplegia (severe loss of strength on one side of the body), and hemiparesis (partial loss of strength on one side of the body). During a review of Resident 2's Minimum Data set (MDS - a federally mandated resident assessment tool) Section C, dated 11/4/25, it indicated, Resident 2 was cognitively intact (sufficient judgment, planning, organization, self-control, and memory). Resident 2's MDS Section GG, dated 11/4/25, the MDS indicated Resident 2 had impairment on both sides of her lower extremities (hip, knee, ankle, foot) and used a wheelchair as a mobility device. During an interview on 12/8/25 at 10:21 a.m., with the Administrator (ADM), the ADM stated Resident 2 had a fall on 11/24/25 inside the transportation van while on her way to an appointment. The ADM confirmed Resident 2 was sent to the hospital and returned to the facility on 12/2/25 with a confirmed injury of a broken femur that required surgery because of the fall in the van. The ADM stated the driver of the van was terminated from employment on 12/1/25 because of the result of Resident 2 not being properly secured in the van using the required seat belt and four anchors as trained. During an interview on 12/8/25 at 1:41 p.m. with Resident 2, Resident 2 stated during the van ride to her appointment her wheelchair was not fastened correctly in the van. Resident 2 stated she had notified the Driver (DRI) 1 twice that she was not secured properly and that he stopped once to make adjustments. Resident 2 further stated when she notified DRI 1 a second time that she was not secured properly, DRI 1 did not stop but continued to the appointment. Resident 2 stated when the van stopped at the final destination and was being unbuckled, she fell out of her wheelchair while in the van and injured herself. Resident 2 confirmed she had broken her femur and had to have surgery because of the fall. During an interview on 12/8/25 at 2:01 p.m., with DRI 2, DRI 2 stated he was trained with DRI 1 when first hired at the facility. DRI 2 confirmed both he and DRI 1 were trained extensively on safety and how to properly secure wheelchairs in the transportation van using the seatbelt and four anchors. DRI 2 confirmed residents would not be able to fall out of their wheelchairs if they were secured properly as trained. DRI 2 stated residents could potentially fall and seriously injure themselves if not properly fastened in the van. During a review of Resident 1's "Progress Note," effective date 11/24/25 13:01, it indicated, "Resident left for apt. [appointment] via WCVAN [wheelchair van] at approximately 1300. All skin intact upon leaving. No c/o [complaint of] pain or discomfort." During a review of Resident 1's "Progress Note," effective date 11/24/25 15:00 [3 p.m.], it indicated, "...received a call from [hospital name] stating that upon arrival to scheduled apt., WC [wheelchair] driver entered the building and stated the resident had fallen on the floor during transport. Per [hospital name], they recommended resident be immediately brought to ER [emergency room] for further evaluation." A review of the facility's document titled, "ED Physician Notes", dated 11/24/25 17:22:15 [5:22 p.m.], it indicated, "FELL OUT OF WHEELCHAOR [wheelchair] IN WHEELCHAOR VAN TWISTING LEG. PAIN...She reports that she was being transported in a wheelchair van to an appointment in Sacramento earlier today, there was a mishap in her wheelchair, and she fell forward and struck her left leg on the ground. She has had continued pain just proximal [closer to center of body] to her left knee...imaging interpretation left distal [away from center of body] femur fracture...Discussed with orthopedic surgeon [medical doctors who specialize in bone, muscle, and joint surgery] [staff name] who recommended CT [medical imaging] for preop [prior to surgery] planning and admission to hospital..." A review of the facility's document titled, "EMPLOYEE COUNSELING FORM", dated 12/1/25, it indicated, "Violation Date: 11/24/25...In Van...Failure to follow proper safety protocols while transporting patient ...Patient was injured while being transported by [DRI 1] ...Employee acknowledged on 11/26/25 that they were trained on proper safety protocols upon hiring and acknowledged on 11/26/25 that they did not follow all of them. Resulting consequence is termination." A review of the facility's document titled, "Job Description: VAN DRIVER", dated 2/24, it indicated, "Assists residents from loading and unloading from facility-approved vehicles...Ensure the safe transportation of residents to scheduled medical appointments...Properly securing WC [wheelchair] bound residents into bays in Vans." During a review of the facility's P&P titled, "Accident Prevention and Safety of Residents," revised 7/22, the P&P indicated, "Resident safety and supervision are facility-wide priorities...Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring,...Employees shall be trained in potential accident hazards and try to prevent avoidable accidents...facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and the adjust interventions accordingly." Therefore, the department determined the facility failed to ensure resident safety for one out of six sampled residents (Resident 2) when Resident 2 had an avoidable fall when she was not properly secured during transportation to an appointment. This failure led to Resident 2 sustaining a left femur (lower end of thigh bone) fracture (crack, break, or chip in bone) that caused pain and required surgery. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.