Health inspection·February 19, 2026

§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. §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. (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. (C) Reviewing, evaluating and updating of 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. §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 12/22/2025 the California Department of Public Health (CDPH) received an anonymous complaint reporting unsafe nursing and administrative practices that placed a resident (Resident 88) at risk. On 1/5/2026 the CDPH conducted an unannounced visit at the facility to investigate the allegation. Upon investigating, it was determined on 10/13/2025 at 9:00 p.m., Resident 88 was found lying on the floor after attempting to go to the bathroom. On 10/14/2025 at a 1:00 a.m., Resident 88 had a second fall which resulted in a one-inch laceration (a deep cut in the skin) on the forehead The facility failed to: 1.Update Resident 88's care plan titled "Unwitnessed Fall" to include interventions such as a bed alarm (fall prevention device that alerts caregivers when a patient attempts to get out of bed), landing pads (foam pads placed on the floor alongside a bed to cushion the impact of a person falling), and maintaining the resident's bed in the lowest position after Resident 88's first fall on 10/13/2025 at 9:00 p.m. 2. Ensure Resident 88 was monitored every hour following a change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive [ability to think, understand, learn, and remember] behavioral, or functional status without which immediate intervention, may result in complications or death) on 10/13/2025. 3.Implement additional safety measures such as one-on-one supervision or move Resident 11 to a room closer to the nurses' station, despite multiple falls and high-fall risk status. 4. Follow its policy and procedure (P&P), titled "Accidents and Incidents-Investigating and Reporting," which indicated the facility will collect and evaluate information to determine the cause of a fall and identify pertinent interventions to prevent subsequent falls. As a result, Resident 88 experienced two falls, four hours apart on 10/13/2025, sustaining a laceration to the forehead, and skin tears on both hands and left arm. Resident 88 was transferred to a general acute care hospital (GACH) for evaluation and treatment, including closure of the forehead laceration with steri-strips (noninvasive adhesive strips used to close and support minor, shallow cuts and surgical incisions). Resident 88 was an 85-year-old male originally admitted to the facility on 12/3/2024 and readmitted to the facility on 9/21/2025. Resident 88's diagnoses included history of falling, cardiac pacemaker (medical device designed to regulate or maintain the heart's rhythm), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis), and difficulty walking. A review of Resident 88's Minimum Data Set (MDS-a resident assessment tool), dated 9/25/2025, indicated Resident 88 had the ability to understand others. Resident 88 was dependent (helper does all of the effort) on staff for help with toileting, showering, and lower body dressing. The MDS indicated Resident 88 needed substantial to maximal assistance (helper does more than half the effort) from nursing staff with walking, sitting, lying down, standing, and transferring. A review of Resident 88's Nursing Documentation Evaluation dated 12/3/24 at 11:49 p.m., indicated fall risk factors included history of falls, poor safety judgment, impaired balance and unsteady gait (walking). A review of Resident 88's care plan, titled "Resident is at risk for falls," dated 2/2/2025, indicated Resident 88 will be free from serious injury. The care plan interventions included maintaining a clutter-free environment in the resident's room, placing the call light in reach while the resident was in bed or close in proximity to the bed, reminding the resident to use the call light when attempting to ambulate or transfer and to place all necessary personal items within reach. A review of Resident 88's care plan, titled "Resident is at risk for falls: history of repeated falls" revised 1/7/2026, indicated to place the call light within reach, maintain a clutter free environment and close monitoring throughout the shift. A review of Resident 88's care plan titled "Resident was observed on the floor on the left side of the bed" revised on 1/7/2026, interventions included neuro checks ( assessments to evaluate the mental status) for 72 hours, to educate Resident 88 on the importance of not ambulating without assistance, using the call light for assistance, and toileting Resident 88 before and after meals, and at bedtime. A review of Resident 88's care plan titled "Unwitnessed fall" revised 1/7/2026, indicated to assess vital signs, level of consciousness, check for pain, and to perform a head-to-toe assessment for any signs of injury. A review of Resident 88's COC Evaluation dated 10/13/2025 at 9:48 p.m., the COC indicated Resident 88 had an unwitnessed fall. The COC indicated on 10/13/2025 at 3:00 p.m., Resident 88 was observed in bed, alert and verbally responsive. The COC indicated at 9 p.m., Certified Nursing Assistant (CNA) 7 notified Licensed Vocational Nurse (LVN) 4 that Resident 88 was found on the floor. The COC indicated Resident 88 had no apparent injuries and was unable to verbalize what happened when asked. A review of Resident 88's COC Evaluation dated 10/14/2025 at 12:55 a.m., indicated Resident 88 was found lying on the floor on his left side facing the door. The COC indicated resident sustained a one-inch laceration to the left side of the forehead. A review of Resident 88's "Emergency Department Hospital Admission" report dated 10/14/2025 indicated Resident 88 presented to the GACH with a left forehead laceration that required stitches (medical threads used to hold skin and tissue together while the body heals) with steri-strips. The report indicated Resident 88 had skin tears to the left elbow, left forearm, and hands covered with gauze (wound dressing). The report indicated Resident 88 had generalized bruising and scabs (protective crust over a wound) to his body (sites not indicated). During an interview on 1/07/2026 at 9:19 a.m. with CNA 6, CNA 6 stated Resident 88 was confused and required constant assistance with toileting. CNA 6 stated on 10/14/2025, Resident 88 fell while attempting to walk to the bathroom. CNA 6 stated Resident 88 was assessed as high risk for falls and should have been monitored or supervised every two hours. During a concurrent interview and record review on 1/07/2026 at 9:36 a.m. with LVN 2, Resident 88's COCs dated 10/13/2025 and 10/14/2025, and care plan titled "Resident is at High Risk for Falls" dated 6/12/2025 were reviewed. LVN 2 stated the COC indicated Resident 88 fell on 10/13/2025 at 9:00 p.m.,and had a second fall on 10/14/2025 at 1:00 a.m. (4 hours apart). LVN 2 stated on 10/13/2025 at 9:00 p.m., Resident 88 was found lying on the floor after attempting to go to the bathroom. LVN 2 stated Resident 88 required assistance with ambulation, had a second fall on 10/14/2025 which resulted in a one-inch laceration on the forehead after the second fall. LVN 2 stated Resident 88 was assessed at high risk for falls, had a history of falls but did not have interventions in place such as a bed alarm and frequent rounding to prevent further falls. During an interview on 1/07/2026 at 10:19 a.m. with CNA 7, CNA 7 stated she was assigned to Resident 88 on 10/13/2025. CNA 7 stated, at 6:30 p.m., while collecting trays, she observed Resident 88 in the room. CNA 7 stated the next time she saw Resident 88 was after the fall on 10/13/25 at 9:00 p.m. CNA 7 stated Resident 88 frequently attempted to get up without assistance. During a concurrent interview and record review on 1/07/2026 at 3:30 p.m., with LVN 4, Resident 88's care plan titled "Unwitnessed Fall" dated 10/13/2025 was reviewed. LVN 4 stated the care plan did not include interventions such as bed alarms or landing pads after Resident 88's fall on 10/13/2025 at 9:00 p.m. LVN 4 stated Resident 88 experienced two falls: the first on 10/13/2025 at 9:00 p.m., when the resident was found sitting next to the closet, and the second fall on 10/14/2025 at 1 a.m. He stated fall prevention measures such as landing pads and bed alarms should have been included in Resident 88's care plan but they were not. During an interview on 1/08/2026 at 1:15 p.m. with Registered Nurse Supervisor (RNS) 3, RNS 3 stated Resident 88 fell on 10/13/2025 at 9:00 p.m. and Resident 88's fall care plan updated on 10/13/2025 did not include new safety measures such as bed alarm or any new fall precaution measures to prevent further falls. RNS 3 stated Resident 88 fell again on 10/14/2025 at 1 a.m. RNS 3 stated the falls could have been prevented with more frequent rounding (at least every one to two hours), moving Resident 88 to a room closer to the nurses' station, and implementing a bed alarm. During a concurrent interview and record review on 1/08/2026 at 6:54 p.m. with the Director of Nursing (DON), Resident 88's care plan titled "Unwitnessed Fall" dated 10/13/2025 was reviewed. The DON stated the care plan did not include interventions such as landing pads or a bed alarm following the fall on 10/13/2025 at 9:00 p.m. The DON stated Resident 88 fell again on 10/14/2025 and sustained a laceration on the forehead. The DON stated Resident 88 was at high risk for falls and required supervision and assistance. She stated interventions such as a bed alarm, one-on-one supervision, and landing pads should have been implemented but were not. The DON stated the interventions in Resident 88's care plan was insufficient to prevent additional falls. The DON stated Resident 88 sustained an injury after the second fall on 10/14/2025 which required evaluation and treatment at a GACH. A review of the facility's Policy and Procedure (P&P), titled "Accidents and Incidents-Investigating and Reporting," revised 3/2018, indicated "The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The P&P indicated the following data, as applicable, shall be included on the Report of Incident/Accident form ... any corrective action taken... If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance). A review of the facility's P&P, titled "Accidents and Incidents-Investigating and Reporting," date revised 3/2018, indicated "The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. The P&P indicated based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling..." The facility failed to: 1.Update Resident 88's care plan titled "Unwitnessed Fall "to include interventions such as a bed alarm, landing pads, and maintaining the resident's bed in the lowest position after Resident 88's first fall on 10/13/2025 at 9:00 p.m. 2. Ensure Resident 88 was monitored every hour following a COC on 10/13/2025. 3.Implement additional safety measures such as one-on-one supervision or move Resident 11 to a room closer to the nurses' station, despite multiple falls and high-fall risk status. 4. Follow its P&P, titled "Accidents and Incidents-Investigating and Reporting," which indicated the facility will collect and evaluate information to determine the cause of a fall and identify pertinent interventions to prevent subsequent falls. As a result, Resident 88 experienced two falls, four hours apart on 10/13/2025, sustaining a laceration to the forehead, and skin tears on both hands and left arm. Resident 88 was transferred to a GACH for evaluation and treatment, including closure of the forehead laceration with steri-strips. These violations had a direct or immediate relationship to the health, safety, or security of Resident 88.