Health inspection·October 3, 2025

Title 42, § 483.25. Quality of Care (d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and Title 42, § 483.25. Quality of Care (d) Accidents. The facility must ensure that - (2) Each resident receives adequate supervision and assistance devices to prevent accidents. Title 22, § 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. Title 22, § 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: (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. Title 22, § 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: (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. Title 22, § 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. Findings: On 8/19/2025, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident regarding Patient 1's unwitnessed fall with significant injuries. Patient 1, who was identified as being at high risk for falls, had an unwitnessed fall in the restroom during toileting on 8/3/2025 at 8:30 PM. Based upon records, interviews, and observation, CDPH determined that the facility failed to: 1. Identify Patient 1's care needs through continuing assessment, evaluation, and updating of the Fall Prevention Care Plan when the interventions for SMART alarms (devices that use pressure sensors to detect when a patient gets out of bed or a chair, alerting a caregiver wirelessly to help prevent falls) were discontinued on 7/28/2025 and frequent rounding for one week expired on 8/1/2025. 2. Provide adequate supervision to ensure Patient 1 was free from falls particularly after the family refused the alarms. 3. Implement the facility's "Fall Risk Assessment and Prevention Program," policy and procedure (P&P) to develop and implement a care plan for falls based upon risks identified by a Registered Nurse (RN) through a complete fall risk assessment and communicate the plan of care to direct care staff via verbal or written instruction. As a result, Patient 1 was transferred to the acute care hospital for evaluation and treatment and then hospitalized due to several broken ribs and a broken right collarbone. During a review of the clinical record for Patient 1, Patient 1's Clinical History and Physical, dated 6/24/2025 documented that he was admitted to the facility on 6/24/2025, with diagnoses that included chronic obstructive pulmonary disease (a progressive respiratory disease, causing shortness of breath), heart failure, and progressive joint disease resulting in joint pain, and history of falls. Patient 1 used a four-wheel walker when ambulating. Patient 1 had intact cognition. During a review of the clinical record for Patient 1, Patient 1's Fall Prevention Care Plan initiated on 6/24/2025 was updated after each fall with the following interventions: a. Frequent rounding was initiated on 7/25/2025 for one week (end date 8/1/2025). b. Initiate SMART alarms on 7/26/2025 and were discontinued on 7/28/2025. c. Frequent rounding for two weeks was initiated on 8/3/2025, after Patient 1 fell. During a review of the clinical record for Patient 1, the Case Manager's Note, dated 7/3/2025, indicated his Brief Interview for Mental Status (BIMS) score was 13/15 (intact cognition). The note also indicated Patient 1 fell on 5/30/2025, prior to his admission to the facility, and he used a four-wheel walker to ambulate. During a review of the clinical record for Patient 1, the Interdisciplinary Resident Fall Investigation and Intervention indicated Patient 1 had unwitnessed falls on the following dates: a. 7/25/2025 at 3:28 PM - due to inability to gauge sleepiness and exhaustion and retire to bed. b. 7/26/2025 at 1:20 AM - due to impaired balance and overestimated ability. During a review of the clinical record for Patient 1, the Fall Risk Assessment Forms (total score of 10 or above represents HIGH RISK), indicated Patient 1 scores were as follows: a. 6/24/2025 (on admission), scored 16. b. 7/25/2025 (post-fall), scored 15. c. 7/26/2025 (post-fall), scored 18. During a review of the clinical record for Patient 1, the Interdisciplinary Progress Note - Nursing, dated 8/3/2025 at 10:30 PM, indicated Patient 1 had an unwitnessed fall while toileting and was found by the Certified Nurse Assistant on the floor in the restroom with his four-wheel walker behind him on 8/3/2025 at 8:30 PM. The note also indicated that Patient 1 was noted to have a bump on his right forehead, numerous suspected injuries to arms and legs. Patient 1 also complained of right rib and right clavicle pain when he was found. In addition, the note indicated Patient 1 was sent to the acute care at approximately 9:30 PM. During a review of the clinical record for Patient 1, the Interdisciplinary Progress Note - Nursing, dated 8/4/2025 at 4:10 AM, indicated Patient 1 was admitted to the acute care hospital with several broken ribs and broken right collarbone on 8/3/2025. During a review of the clinical record for Patient 1, the Interdisciplinary Progress Note - Nursing, dated 8/4/2025 at 8 AM, indicated Patient 1's responsible party refused the use of pressure alarms on 7/28/2025 because the alarms were keeping Patient 1 awake and exhausted. During a concurrent observation and interview on 8/20/2025 at 11:35 AM with Patient 1 in his room, Patient 1 was observed with multiple purplish black discolorations on the right side of his trunk, right side of his head/face, and some small, scattered purplish black discoloration on his right arm. Patient 1 was alert and oriented to person, place, and time. Patient 1 was notably short of breath and drowsy during the interview. Patient 1 stated he did not recall what happened on 8/3/2025 when he fell and sustained his injuries. During an interview on 8/19/2025 at 11:45 AM with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated Patient 1 was independent with his activities of daily living but was considered a high fall risk. CNA 1 stated Patient 1 was on frequent rounding checks for a little bit until it was discontinued. CNA 1 stated frequent rounding included checking on the residents [Patients] every 15 to 30 minutes, sometimes hourly depending on the patient's need and noting what was seen, addressing the four (4) Ps (pain, potty [bathroom needs], positioning, and possessions [or proximity of personal items]), and ensuring alarms were in place and working. During a concurrent interview and record review on 8/20/2025 at 2:08 PM with the Director of Nursing (DON), the DON stated Patient 1's frequent rounding was initiated on 7/25/2025 and concluded on 8/1/2025. The DON was unable to provide documented evidence to show there were fall prevention interventions implemented after the frequent rounding intervention was discontinued on 8/1/2025, two days prior to Patient 1's unwitnessed fall with significant injuries on 8/3/2025. The DON also stated the licensed nurses should have reassessed Patient 1's risk factors and updated Patient 1's Fall Risk Care Plan to continue frequent rounding indefinitely since Patient 1 and his responsible party refused the use of pressure alarms on 7/28/2025. During a review of the P&P titled, "Fall Risk Assessment and Prevention Program," dated 3/20/2023, the P&P indicated, "A Registered Nurse (RN), will complete the fall risk assessment on all Residents ... 3. After each fall ... II. Result/Scores ... B. Based upon the Fall Risk Assessment, if the Resident is assessed as a high risk, the Supervising Registered Nurse (SRN) or designee will: 1. Develop and implement a plan of care for falls based upon the identified risks... 2. Communicate the plan of care to direct care staff via verbal or written instruction." The facility failed to: 1. Identify Patient 1's care needs through continuing assessment, evaluation, and updating of the Fall Prevention Care Plan when the interventions for SMART alarms (devices that use pressure sensors to detect when a patient gets out of bed or a chair, alerting a caregiver wirelessly to help prevent falls) were discontinued on 7/28/2025 and frequent rounding for one week expired on 8/1/2025. 2. Provide adequate supervision to ensure Patient 1 was free from falls particularly after the family refused the alarms. 3. Implement the facility's "Fall Risk Assessment and Prevention Program," policy and procedure (P&P) to develop and implement a care plan for falls based upon risks identified by a Registered Nurse (RN) through a complete fall risk assessment and communicate the plan of care to direct care staff via verbal or written instruction. As a result, Patient 1 was transferred to the acute care hospital for evaluation and treatment and then hospitalized due to several broken ribs and a broken right collarbone. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.