Health inspection·September 29, 2025

The following reflects the findings of the California Department of Public Health during the investigation of: Complaint: 2591418 Event ID: 1D4407-H1 Representing the Department, HFEN 44262 State Citation B was written. Regulations: Title 42 of the Federal Code of Regulations §483.25(d) Accidents The facility must ensure that – §483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. Title 22, CCR §72311(a) (1) (A)(2) 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. (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 CCR §72523(a). 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 August 27, 2025, at 12:48 PM, an unannounced visit was conducted at the facility to investigate a complaint about a patient fall involving a Certified Nursing Assistant (CNA). The facility failed to provide adequate supervision for Patient 1, who required two-person assistance in subacute unit (a specialized care area that provides patients with intensive medical and rehabilitative care). Patient 1 fell out of bed as only one CNA was present during care. The facility failed to: 1. Ensure adequate supervision was provided. 2. Follow the care plan for a two-person assist during brief changes and repositioning. 3. Follow its policy and procedure to prevent accidents These failures resulted in Patient 1 sustaining a left intertrochanteric (thigh bone) fracture from the fall. Findings: During review of Patient 1’s Admission Record (general demographics information), the Admission Record indicated Patient 1 was admitted to the facility on June 3, 2024, with diagnoses which included type 2 diabetes (body has trouble controlling blood sugar), hypertension (high blood pressure), dependance on respirator (difficult to breathe on own, machine dependent). During a review of Patient 1’s “History and Physical (H&P),” dated January 27, 2025, the “H&P” indicated, Patient 1 did not have the capacity to understand and make decisions. During a review of Patient 1’s “Minimum Data Seta (MDS - clinical assessment tool used in nursing homes that serves as a comprehensive summary of a patient’s functional capabilities, health conditions, and care needs.) Section GG Functional Abilities,” dated June 7, 2025, the “MDS Section GG Functional Abilities” indicated, “…Toileting hygiene, Shower/bath self, Roll Left and Right=Dependent= Helper does All of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the Patient to complete the activity…”. During a review of Patient 1’s “Situation Background Assessment Recommendation (SBAR)” notes dated July 29, 2025, at 5:22 AM, the SBAR indicated “During rounds, patient noted to slide from bed and struck head on oxygen concentrator and was lowered on to the ground by staff. Noted with open area to top of Left eye with scant bleeding. Noted with bruising to cheekbone and cheek. Transfer to acute to rule out fracture.” During a review of Patient 1’s X-ray (generate images of tissue and structure of body) report, dated July 29, 2025, the X-ray of the left hip shows displaced intertrochanteric fracture. The X-ray report also indicated “PLAN: At this time, family is choosing to pursue nonsurgical management for left hip fracture, and they are listing his high propensity (natural tendency) to infections as a deterrent to surgery at this time”. During a review of Patient 1’s care plan dated June 25, 2024, the care plan indicated “Patient 1 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Activity Intolerance, Confusion, Limited Mobility, Limited ROM. INTERVENTIONS: BATHING/SHOWERING: The patient is totally dependent on (2) staff to provide(bath/shower)…and as necessary. BED MOBILITY: The Patient is substantial assistance on (2) staff for repositioning and turning in bed (Q2hrs) and as necessary”. During an interview on August 27, 2025, at 1:20 PM, with CNA 1, CNA 1 stated, “It’s always a two (2) person assist to change the patients here in subacute. The CNAs help each other. If it is busy I have to wait, I cannot take the risk of doing the care alone. The nurse also helps if needed.” During an interview on August 27, 2025, at 1:38 PM, with CNA 2, CNA 2 stated, “In subacute, we always have 2 persons assist with ADLs, we have a buddy with another CNA, but we can always ask the nurses or Respiratory Therapist”. During an interview on September 2, 2025, at 10:08 AM, with CNA 3, CNA 3 stated, “It was about 1:30 AM. I wanted to see if Patient 1 was wet. He was, so I placed him on his side, he rolled and I tried to catch him, I ran to the other side, he slid down to the floor…I called for the nurses and we got him back to bed. He was not able to help in the repositioning, he is contracted (a shortening or tightening of muscles, tendons, or other tissues). He is a two-person assist after the fall. Now everyone in subacute is two-person assist. I would always provide care for him on my own. I was made aware he had a fracture”. During an interview on August 27, 2025, at 2:10 PM, with the Director of Nursing (DON), the DON stated Patient 1 had a fall on July 29, 2025, with femur (thigh bone) fracture. The DON stated that upon their investigation, CNA 3 did not wait for help. The LVN (Licensed Vocational Nurse) stated she was in the middle of medication pass, and said “to give a couple minutes”. CNA 3 was doing patient care, there was no siderails and the patient fell. The DON further stated, Patient 1 requires a two-person assist, CNA 3 should have waited for help as they have a ‘buddy system”. During a review of the facility’s policy and procedure (P&P) titled, “Fall and Fall Risk, Managing,” undated, the P&P indicated, “Based on previous evaluation and current data, the staff will identify interventions related to the patient specific risk and causes to try to prevent the patient from falling and to try to minimize complications from failing.” Conclusion: In violation of the above cited standards, the facility failed to: 1. Ensure adequate supervision was provided. 2. Follow the care plan for a two-person assist during brief changes and repositioning. 3. Follow its policy and procedure to prevent accidents, resulting in Patient 1 sustaining an intertrochanteric fracture of the left hip. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health and safety of patients.