Health inspection·June 4, 2025

F 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report a resident's fall incident with fracture to the Department for one of two residents (Resident 1). Resident 1 experienced an unwitnessed fall, complained of pain on the left hip with an X-ray (process of imaging, using radiation) that indicated an acute fracture. This failure delayed the Department's investigation into the incident and had the potential for Resident 1 and other residents to experience a decline in safety, comfort, and overall well-being. Findings: On 5/16/25, an unannounced visit was made to the facility to investigate a complaint regarding a resident's unwitnessed fall. During a review of Resident 1's admission Record, this indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning) and fracture in the right femur (break in the right leg bone). A review of the Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 4/28/25, indicated Resident 1 had a BIMS (Brief Interview for Mental Status) score of 03 that indicated severe impairment. During a review of incident report (SBAR - a standardized communication tool) dated 5/6/25, this indicated an unwitnessed fall on 5/6/25 at 4:30 p.m. This document further indicated, Resident 1 was found on the floor supine position at the end of the bed; when asked what happened, Resident 1 stated, I fell off the bed and was also asked if he tried to walk, stated, I don't know. A review of the Order Summary Report dated 5/7/25, this indicated, May send to ER(Emergency Room) for evaluation and treatment r/t (related to) Left acute Intertrochanteric femoral fracture (a break in the thigh bone). A review of Resident 1's medical record titled First Choice Radiology Service .Radiology Interpretation with a date of exam on 5/7/25, this indicated: Significant Findings Left Hip .Impression: 1. Acute intertrochanteric femoral fracture . During the interview on 5/16/25 at 10:15 a.m., with the Licensed Nurse (LN 1) confirmed Resident 1 Page 1 of 2 555163 555163 06/04/2025 Shoreline Care Center 5225 South J Street Oxnard, CA 93033

F 0836 had an unwitnessed fall on 5/5/25 at around 4:30 p.m. and was reported to the charge nurse. Level of Harm - Minimal harm or potential for actual harm During the interview on 5/16/25 at 10:30 a.m., with the Director of Nursing (DON), DON stated the Resident 1 had an unwitnessed fall incident that resulted to left hip fracture. Residents Affected - Few During the interview on 5/29/25 at 3:15 p.m., Certified Nurse Assistant (CNA 1), CNA 1 stated that Resident 1 fell while she was showering another resident. A review of the California state law title 22, section 78427 (a)(1), indicated, Death, injury and unusual incidents shall be reported within 48 hours to the Department (Health Facilities Licensing). 555163 Page 2 of 2