Other·February 13, 2026

California Code of Regulations, Title 22, section 72311 Nursing Service (a)Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, 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. Code of Federal Regulations, Title 42, §483.25 (d) Accidents. The facility must ensure that- (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to maintain a safe environment and to ensure adequate supervision was provided to reduce Patient 1’s risk of injury from falls, self-harm, and impulsive behavior. These failures resulted in Patient 1 to experience eight unwitnessed falls between July 2024 and December 2025. On May 13, 2025, after the seventh fall, Patient 1 sustained a hematoma (severe bruising with swelling) and a skin tear to her forehead. During the eighth fall on December 21, 2025, Patient 1 was found on the floor under her roommate’s bed, with two red, swollen eyes, and was transferred to the General Acute Care Hospital (GACH) for evaluation and treatment. On December 24, 2025, at 9:49 a.m., Patient 1 was observed at the GACH, alert and in bed with noticeable injuries to both eyes and hands. Patient 1’s right eye was swollen and reddish black, while her left eye was swollen and bluish black. Additionally, there was purple discoloration on the outer side (lateral side) of her right hand and purple discoloration on her left hand between the index and middle finger. A review of Patient 1’s GACH emergency department (ED) note dated December 22, 2025, indicated,“...female presents to ED for fall...patient currently at (name of skilled nursing facility)...staff reported found patient on the floor yesterday around noon...unwitnessed fall...stated patient could not sit still for x-ray...and sent to ED...bilateral (both) black eyes...CT Brain (Computed Tomography-medical device used to scan the brain)...no acute intracranial hemorrhage (bleeding inside the skull)...admitted to tele unit (special-unit for remote vital sign monitoring) for observation...” A review of the GACH left-hand x-ray report dated December 23, 2025, indicated, “...no radiograph evidence of acute process (fracture)...” On December 24, 2025, at 10:37 a.m., during a concurrent interview and review of the GACH ED notes with the GACH medical doctor (MD), the GACH MD stated Patient 1 has dementia (loss of cognitive functioning- thinking, remembering, and reasoning- to such an extent that interferes with a person’s daily life and activities) and requires a sitter (a trained caregiver providing one-on-one observation and support to patients at high risk of harm) for direction and staying in bed while at the GACH. The GACH MD stated the family informed him of Patient 1’s history of falls at the skilled nursing facility; and the GACH MD stated that without a dedicated sitter Patient 1 was at risk for falling. On December 24 and 26, 2025, unannounced visits were made to the skilled nursing facility (SNF). On December 24, 2025, at 12:44 p.m., during an interview with Certified Nursing Assistant (CNA) 1, CNA 1 stated the following: a. On December 21, 2025, she was assigned to care for Patient 1 and at 11:30 a.m., she found Patient 1 under her roommate’s bed. Both of the patient’s eyes were red and swollen; b. Patient 1 had a history of being found underneath her roommate’s bed, which required two CNAs to return Patient 1 back to her bed; c. Patient 1 also had a history of hitting herself against objects when she was upset; d. She (CNA 1) did not report what she noticed on Patient 1’s eyes on December 21, 2025, at 11:30 a.m., to the LVN (Licensed Vocational Nurse), but she told CNA 2, who was assigned to care for Patient 1 during the 3-11 pm shift, to report Patient 1’s red swollen eyes since it was change of shift; e. She (CNA 1) should have reported Patient 1’s swollen eyes to the LVN prior to the shift change. During an interview on December 24, 2025, at 12:59 p.m., CNA 2 stated she was Patient 1’s assigned CNA during the evening shift (3-11 pm) on December 21, 2025, and was informed by CNA 1 that Patient 1’s eyes were swollen and purple. CNA 2 stated she informed the LVN. CNA 2 further stated Patient 1 was uncontrollable and the CNAs had reported it to the Assistant DSD (Director of Staff Development) who stated the patient could come out of bed and that she (Patient 1) could not be restrained. CNA 2 stated Patient 1 has never been assigned a one-on-one sitter even though they keep informing the DON (Director of Nursing) and the DSD that Patient 1 keeps getting hurt and getting out of bed. A review of Patient 1’s Admission Record indicated the patient was admitted to the facility on July 14, 2024, with diagnoses which included dementia, anxiety (excessive worry or fear), and history of falls. A review of Patient 1’s History and Physical completed on July 15, 2024, indicated Patient 1 does not have capacity to make decisions. A review of Patient 1’s BIMS (brief interview for mental status- tool to assess cognition status) score dated October 20, 2025, indicated, “...severely impaired...” The care plans were reviewed and indicated the following: -November 7, 2024, “...resident (patient) has an actual unwitnessed fall...intervention...CNA to check and change resident every 2 hours and as needed...”; - May 13, 2025, “...resident (patient) has an actual unwitnessed fall...goal...resident checked every 30 min and prn (as necessary)...resident will be free of falls...”; and There was no documented evidence found in Patient 1’s nursing progress notes for the months of March 2025 through December 2025 of Patient 1 being checked every 30 minutes as indicated in the care plan dated May 13, 2025. - March 14, 2025, “...expected behavior related to movement to floor mat...history of falls...per [family member] patients cultural (sic) is to sit on the floor every day and do activities and task...intervention...frequent visual monitoring..." There was no documented evidence found in Patient 1’s nursing progress notes for the months of March 2025 through December 2025 of frequent visual monitoring of Patient 1 as indicated in the care plan dated March 14, 2025. A review of Patient 1’s change of condition notes and nursing notes indicated Patient 1 had eight falls which occurred on the following dates: - October 4, 2024, at 4:30 p.m., “...resident [Patient 1] found sitting on the floor mat beside bed no injuries...md and [family member] notified...”; - October 10, 2024, at 9:30 a.m., “...resident [Patient 1] was wet and therefore climbed out of bed...instructed CNA to check resident often to be sure resident is clean and dry...MD and [family member] notified...”; - November 7, 2024, at 11:20 a.m., “...resident [Patient 1] was wet therefore climbed out of bed...instructed CNA to check resident often to be sure resident is clean and dry...MD and [family member] notified...” - December 4, 2024, at 9:31 a.m., “...resident [Patient 1] had an unwitnessed fall today at 8:00 a.m. bed was in lowest position floor mat in place...resident found sitting on her mat...MD and [family member] notified...” - February 19, 2025, at 10:46 a.m., “...resident [Patient 1] crawled out of bed onto floor mat...MD notified...[family member] notified...” - March 3, 2025, at 11:45 a.m., “...resident [Patient 1] was found in her room on her buttocks on floor around 10:40 a.m., md notified...[family member] notified...” - May 13, 2025, at 18:00 (6:00 p.m.),“...fall...skin contusion (bruise)...skin tear...top of scalp hematoma...top of scalp...skin tear...contusion...skin tear left side of forehead...neuro checks (assessment of nervous system)...resident [Patient 1] found on the floor bedside with lower part of body on floor mat...lower part of body on bare floor...head to toe assessment conducted noted with contusion/hematoma and skin tear on left side of forehead...assisted into bed and medicated for pain...MD notified...recommendations...neuro checks...skin care...clean skin tear with NS (normal saline)...apply TAB (triple antibiotic ointment)...medicate for pain...notified RP...” A review of Patient 1’s nursing notes dated May 19, 2025, at 7:10 p.m., indicated, “...family at bedside and requested resident (patient) be sent to (name of hospital) for evaluation of s/p (status post) fall (May 13, 2025), MD notified and order to send to hospital...resident present with contusion/hematoma s/p (status post - means "after") unwitnessed fall...resident transferred...” A review of the (named hospital) emergency room note dated May 19, 2025, indicated, “...fall on May 13 from the bed to the floor...CT head...small left frontal scalp hematoma...recommend follow up CT in 6 hours...family declines (follow up CT)...impression fall...closed head injury...acute nonintractable (treatable) headache...” A review of the change of condition note dated December 21, 2025, at 5 p.m., indicated, “...at 1620 (4:20 p.m.) CNA and nurse discussed discoloration (eye discoloration)...notified RN (Registered Nurse) of findings...PM (evening) CNA reports AM (morning) CNA reported around 8:30 a.m., discoloration...MD notified at 16:37 p.m. (4:37 p.m.)...stat (immediate) x-ray to orbital (eyes) bilaterally (both) neuro checks...” A review of the nurse notes dated December 22, 2025, at 8:27 a.m., indicated, “...resident (patient) assessed by RN supervisor...x-ray unable to be completed...Resident would not stay still for x-ray...resident sent to (named hospital)...” The physician order dated December 22, 2025, indicated, “...May send out to hospital for orbital head x-ray...” On December 26, 2025, at 3:10 p.m., a concurrent interview and record review was conducted with the DON and she stated the following: a. Whenever a patient is found on the floor it is considered a fall; b. Documentation of condition changes is completed for all fall incidents, and care plans are updated. c. Patient 1 is known for thrashing herself back and forth in the bed, banging on the wall and bed rails, and being found underneath her roommate’s bed; d. Patient 1 had six falls without injury, occurring on October 4 and October 10, 2024; November 7, 2024; December 4, 2024; February 19, 2025, and March 3, 2025; e. Patient 1 had two other documented falls that resulted in injury, on May 13 and December 21, 2025; f. During review of Patient 1’s care plans dated October 10, 2024, and November 7, 2024, both care plans indicated checking and changing Patient 1 every 2 hours; however, there was no documented evidence Patient 1 was being checked and changed every 2 hours. There should be documentation of nursing checking and changing the patient every 2 hours; g. During review of Patient 1’s care plan dated March 13, 2025, and May 14, 2025, the care plan dated March 14, 2025, indicated frequent monitoring and the care plan dated May 13, 2025, indicated monitoring every 30 minutes; however, there was no documented evidence in Patient 1’s medical record, including the CNA task report and the nursing progress notes, that Patient 1 was frequently monitored or monitored every 30 minutes; h. There should have been documentation of Patient 1’s monitoring; i. Patient 1’s falls and injuries were avoidable if nursing staff had been frequently monitoring Patient 1 as indicated in the care plan; and j. The facility did not follow its own policies and procedures for keeping Patient 1 safe. A review of the facility policy and procedure titled, “Safety and Supervision of Residents,” revised July 2017, indicated “...The care team shall target interventions to reduce individuals risk related to hazards in the environment including adequate supervision...Implementing interventions to reduce accident risk and hazards shall include the following...ensuring that interventions are implemented...” Based on interviews and record reviews, it was determined that the facility did not maintain a safe environment and provided adequate supervision to Patient 1 to reduce her risk of falls, self-harm, and impulsive behavior. These failures resulted in Patient 1 experiencing eight unwitnessed falls between July 2024 and December 2025. Two of which resulted in injury to Patient 1. On May 13, 2025, Patient 1 sustained hematoma and a skin tear to her forehead. On December 21, 2025, Patient 1 was found on the floor under her roommate’s bed, with two red, swollen eyes, which required Patient 1's transfer to the GACH. These violations, jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result, or a substantial probability of death or serious harm would result to the patient.