Health inspection·December 24, 2025

F689 §483.25(d) Accidents. The facility must ensure that – §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR §72311. Nursing Service - General. (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. 22 CCR §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 11/5/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding a fall with injury. The facility failed to: a. Ensure Licensed Vocational Nurse (LVN) 3 responded to Resident 1’s family provided caregiver (Companion 1’s) report that Resident 1 repeatedly attempted to get out of bed unassisted on 8/26/2025. b. Ensure LVN 3 notified Registered Nurse (RN) 2 regarding Companion 1’s report that Resident 1 repeatedly attempted to get out of bed unassisted on 8/26/2025.    c. Ensure Resident 1’s bed’s pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) was plugged-in and functioning as ordered by Resident 1’s physician when Resident 1 was attempting to get out of bed unassisted on 8/26/2025.   d. Ensure LVN 3 and Certified Nursing Assistant (CNA) 3 did not move Resident 1 back to bed without a registered nurse (RN) assessing the resident for safe transfer to bed after Resident 1's fall on 8/26/2025. e. Ensure facility staff followed facility provided Policies and Procedures (P&P), including without limitation the P&P entries titled “Fall Management Program” and “Free of Accident Hazards / Supervision / Devices,” which establish protocols for mitigation of fall risk and accident risk that were not followed with regard to Resident 1. As a result, Resident 1 had an unwitnessed fall on 8/26/2025 at 9:21 p.m. and was transferred to the General Acute Care Hospital (GACH) for possible fracture (broken bone). At the GACH, Resident 1 was diagnosed with a right angulated (bent), displaced (the bone cracks or breaks and does not retain proper alignment) oblique (slanting or diagonal) fracture of the distal (away from the center of the body) humerus (a severe elbow fracture where the broken bone fragments have shifted out of alignment and are angled) requiring surgery with the placement of metallic hardware (device implanted into the body to provide support), blunt head trauma (injury caused by a sudden impact), and mild left frontal scalp (the skin covering the head) and periorbital (around the eye) soft tissue swelling / hematoma (a pool of blood in the affected area under the skin due to injury or trauma to larger blood vessels in the body). A review of Resident 1’s Admission Record indicated the facility admitted Resident 1, a 94-year-old female, on 8/19/2025, with diagnoses that included displaced intertrochanteric (a hip fracture that occurs between the greater [large bony prominence on the outer side of the femur {thighbone} and lesser trochanters {smaller projection on the inner side of the femur}, which are bony protrusions {sticks out} on the upper part of the femur) fracture of the left femur, pain, bacterial pneumonia (an infection/inflammation in the lungs), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life) of unspecified severity, age-related osteoporosis (weak and brittle bones), muscle weakness, and history of falling. A review of Resident 1’s Minimum Data Set (MDS - a resident assessment tool), dated 8/26/2025, indicated Resident 1 was able to understand others and able to make herself understood. The MDS further indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with personal hygiene and upper body dressing; and substantial/maximal assistance (helper does more than half the effort) with bathing, lower body dressing, toileting, rolling left to right, moving from sitting to lying, and moving lying to sitting on the side of the bed. A review of Resident 1’s Fall Risk Evaluation (FRE), dated 8/19/2025, indicated the resident had a history of one to two falls in the past three months, had balance problems while standing / walking, was regularly incontinent (having no or insufficient voluntary control over urination or defecation [the discharge of feces {waste matter discharged from the bowels after food has been digested} from the body]) of unspecified bladder (a hollow, muscular, balloon-like organ in the body that stores urine) or bowel, and was a high risk for falls.   A review of Resident 1’s care plan (CP) titled “Risk for fall: Resident is at risk for recurrent falls and spontaneous injuries related to history of falling, muscle weakness, left intertrochanteric fracture due to fall…,” initiated on 8/20/2025 indicated a goal for the resident to minimize risk of injury from falls. The CP interventions included anticipating and meeting the resident’s needs, promoting a safe environment, and that the resident needs activities that minimize the potential for falls while providing diversion and distraction.   A review of Resident 1’s CP titled “Bed Alarm: Resident is at risk for recurrent fall and spontaneous injury due to impaired safety awareness, cognitive impairment and getting out of bed unassisted, history of fall and poor follow through,” initiated on 8/19/2025, indicated a goal for Resident 1 to maintain optimal safety by ensuring the bed alarm is used consistently, and that staff respond appropriately to prevent falls. The CP indicated interventions included to place a functioning bed alarm on Resident 1’s bed, ensuring the bed alarm was securely attached, and training staff how to properly use the bed alarm.    A review of Resident 1’s Physician Orders indicated the following:   -Place a pad alarm in bed, monitor for placement and function every shift, dated 8/19/2025.   - Transfer Resident 1 out via 911 (phone number used to contact the emergency services) due to possible fracture status post fall, dated 8/26/2025.    A review of Resident 1’s Post Fall Evaluation / Interdisciplinary Team (IDT– a group of healthcare professionals with various areas of expertise who work together toward the goals of their residents), dated 8/27/2025, indicated Resident 1 had a previous fall on 8/12/2025, prior to admission to the facility. The Post Fall Evaluation /IDT document indicated on 8/26/2025 at 9:20 p.m. the family-provided companion (Companion 1) exited Resident 1’s room to make a phone call. The Post Fall Evaluation/IDT indicated at 9:21 p.m. on 8/26/2025, Resident 1 had an unwitnessed fall inside the resident’s room that resulted in swelling to the forehead, a skin tear to the left arm, swelling to the right upper arm, and a change in mobility status (did not specify the location).  A review of Family Member (FM) 1’s provided Incident Statement - Caregiver Report, dated 8/26/2025, indicated that on the evening of 8/26/2025 Companion 1 notified facility staff (name of staff not indicated) multiple times (did not specify the exact times) that Resident 1 was repeatedly attempting to get out of bed without assistance. The report indicated Companion 1 called the assigned nurse (name of nurse not indicated) who confirmed assistance would be sent, but no staff arrived. The report indicated Companion 1 exited the room to call Companion 1’s Home Health Care Agency (HHCA) Supervisor (on 8/26/2025 at 9:32 p.m.) then heard a loud noise from Resident 1’s room and discovered Resident 1 had fallen from the bed. A review of Resident 1’s GACH 1’s Records, dated 11/18/2025, indicated Resident 1 was admitted to the emergency department on 8/26/2025 at approximately 11 p.m. after a fall with blunt head trauma.  Resident 1’s diagnostic radiology (x-ray - a medical imaging test that produces images of the structures inside the body) indicated the resident sustained a right angulated, displaced oblique fracture of the distal humerus requiring surgery with the placement of metallic hardware. Resident 1’s Computed Tomography (CT - imaging procedure that uses x-rays and digital computer technology to create detailed pictures of the body) indicated the resident sustained a mild left frontal scalp and periorbital soft tissue swelling / hematoma. During an interview on 11/5/2025 at 3:15 p.m., with CNA 3, CNA 3 stated he (CNA 3) was assigned to care for Resident 1 on 8/26/2025 for the evening shift (3 to 11 p.m.) and Resident 1 had a family-provided caregiver at bedside.  CNA 3 stated the family-provided caregivers do not provide hands-on care in the facility because the caregivers say it is not their job. He (CNA 3) did not know Resident 1 was trying to get out of bed unassisted on 8/26/2025. CNA 3 stated sometime after his (CNA 3) break, the caregiver reported that Resident 1 had a fall and CNA 3 notified LVN 3 and the RN supervisor. Resident 1 was found lying face down near the window and there was no bed pad alarm sounding. He (CNA 3) assisted with placing Resident 1 back in bed after the fall. Resident 1 complained of arm pain when Resident 1 was moved to the bed.   During an interview on 11/6/2025 at 1:02 p.m., with LVN 3, LVN 3 stated he (LVN 3) was assigned to care for Resident 1 on 8/26/2025 during the evening shift. LVN 3 stated prior to admission, Resident 1 had a history of getting up unassisted resulting in a fall with injury. Resident 1’s family provided Companion 1 to sit with and verbally re-direct the resident and there was a physician’s order for a pad (bed) alarm to prevent the resident from getting up unassisted. Resident 1 was a little more confused and less redirectable on 8/26/2025. LVN 3 stated at approximately 9 p.m., during Resident 1’s medication pass (a structured process of administering medications to ensure residents receive medications safely, accurately, and timely), he (LVN 3) observed Resident 1 was trying to get out of bed. Companion 1 told him (LVN 3) that Resident 1 kept trying to get up unassisted. He (LVN 3) told Companion 1 to watch Resident 1 and keep the resident safe. He (LVN 3) also told Companion 1 that he (LVN 3) would provide help to redirect the resident so the resident would not fall. LVN 3 stated he (LVN 3) did not check whether Resident 1’s pad alarm was functional during the medication pass but should have because Resident 1 tried to get up unassisted. He (LVN 3) then exited Resident 1’s room and continued the medication pass for other residents because there was a time deadline to complete the medication pass. LVN 3 stated he (LVN 3) did not notify any staff to assist Companion 1 or that Resident 1 was repeatedly trying to get out of bed unassisted. LVN 3 stated he (LVN 3) should have immediately told the RN on duty that Resident 1 was more agitated and was trying to get up unassisted, but he (LVN 3) did not. Approximately ten minutes later, when he (LVN 3) was in the hallway, he (LVN 3) observed Companion 1 exited Resident 1’s room with a phone and stated Companion 1 was calling Companion 1’s HHCA Supervisor because Resident 1 was trying to get up. LVN 3 stated he (LVN 3) did not go to Resident 1’s room. He (LVN 3) then observed Companion 1 entered and exited Resident 1’s room and stated to him (LVN 3) that Resident 1 had fallen. LVN 3 stated he (LVN 3) entered Resident 1’s room and observed Resident 1 was on the floor and the bed pad alarm was disconnected (unplugged) and not alarming. LVN 3 stated if the bed pad alarm had been connected and functioning, it may have stopped Resident 1 from getting up and alerted staff to immediately respond to Resident 1’s attempt to get out of bed. Resident 1’s fall was preventable to a certain extent because he (LVN 3) should have checked the pad alarm during the medication pass, immediately notified the assigned CNA (CNA 3) to assist Companion 1, and notified the RN on duty to assess Resident 1. LVN 3 stated that preventing resident falls was the responsibility of facility staff, not family caregivers. During an interview on 11/6/2025 at 3:46 p.m., with HHCA Administrator (Adm), the HHCA Adm stated Resident 1’s family hired the HHCA to provide companions to Resident 1. The HHCA Adm stated companions provide conversation with the resident, oversee how the residents are doing and make sure they are getting therapy, and are not medically trained.   During an interview on 11/7/2025 at 11 a.m., with the HHCA Supervisor, the HHCA Supervisor stated she (HHCA Supervisor) was Companion 1’s Supervisor on 8/26/2025. The HHCA Supervisor stated Companion 1 called her (HHCA Supervisor) three times on 8/26/2025 to notify her that Resident 1 was agitated, restless, attempting to get out of bed, and that the facility staff were notified but they were not helping. During an interview on 11/7/2025 at 2 p.m., with RN 2, RN 2 stated when a nurse is made aware that a resident is confused and attempting to get out of bed, the nurse should act right away. On 8/26/2025 when LVN 3 observed, and was notified by Companion 1, that Resident 1 was repeatedly trying to get out of bed, LVN 3 should have checked the bed alarm and notified RN 2. RN 2 stated she (RN 2) was not notified that Resident 1 was attempting to get out of bed.   During a follow-up interview on 11/7/2025 at 3:11 p.m., with RN 2, RN 2 stated that when a resident has a family-provided companion while in the facility, it is still the facility’s responsibility to take care of the residents and provide fall interventions. RN 2 stated the pad alarm alerts staff when the resident moves and also reminds the confused resident to call for help. A pad alarm should be on when the resident is in bed and should be checked when staff enter the room. When LVN 3 was aware Resident 1 was attempting to get out of bed, LVN 3 should have checked the pad alarm, but the pad alarm was not sounding when RN 2 entered Resident 1’s room after the fall. RN 2 stated when LVN 3 did not check the bed pad alarm, he (LVN 3) did not notify her (RN 2) that Resident 1 was confused and attempted to get out of bed and did not provide further assistance to Companion 1. Resident 1 had a preventable fall that resulted in injury.  The facility’s procedure for a resident who has experienced a fall is to keep the resident in the same location and position until the registered nurse evaluates the situation and determines it is safe to move the resident.  On 8/26/2025, she (RN 2) entered Resident 1’s room and was upset that Resident 1 was placed in bed without a registered nurse assessment. She (RN 2) assessed Resident 1 in bed, Resident 1 could not move the right arm and had swelling on the left side of the head. RN 2 stated that she (RN 2) could not rule out the possibility that moving Resident 1 back to bed before a registered nurse assessment might have contributed to further injury to Resident 1. During an interview on 11/7/2025, at 4 p.m., LVN 3 stated that the facility's procedure following a resident fall is to refrain from moving the resident until a registered nurse conducts an assessment.  The RN assessment determines if there are other injuries, determines if it is safe to transfer a resident after a fall, and the RN assures safety of the resident during the transfer. LVN 3 stated on 8/26/2025, he (LVN 3) and Companion 1 entered Resident 1’s room and found Resident 1 on the floor, face down next to the window. He (LVN 3), CNA 3, and another CNA (unidentified) moved Resident 1 from the floor to the bed before RN 2 entered the room and assessed Resident 1. RN 2 was upset that LVN 3 moved Resident 1 before RN 2 assessed Resident 1. LVN 3 stated LVN 3 and the CNAs should not have placed Resident 1 in bed without an RN assessment, but they did. During an interview on 11/12/2025 at 8:52 a.m., with FM 1, FM 1 stated, on 8/26/2025, Resident 1 had a fall in the facility resulting in a broken right arm that required surgery. The phy