Health inspection·July 29, 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. 483.21(b) Comprehensive Care Plans 483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - § 72311(a)(2) - Nursing Service - General (a)Nursing service shall include, but not be limited to, the following. (2) Implementing each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. §72523(a) 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 6/23/2025, the California Department of Public Health (CDPH) conducted a standard recertification survey and identified that the facility failed to ensure Resident 50, who were at high risk for falls and injuries, did not fall and sustain injuries. The facility failed to: 1. Ensure Resident 50's bed alarm (voice alarm with a personalized message that plays when an alarm is triggered) was turned on as one of the interventions of fall risk prevention program for Resident 50. 2. Ensure the licensed nurses evaluated the effectiveness of interventions of Resident 50's care plan titled, "At risk for falls, difficulty maintaining sitting/standing balance, history of falls/multiple falls" initiated on 12/25/2024, after the resident's fall on 4/19/2025, to develop new interventions to prevent the resident's fall on 5/22/2025 with injuries. 3. Ensure staff followed the facility's policy and procedure (P&P) titled, "Safety and Supervision of Residents," undated, which indicated, "the care team will target interventions that will reduce individual risks related to hazards in the environment including adequate supervision and assistive devices." These failures resulted in Resident 50 falling from a bed to the floor on 5/22/2025 around 7:25 a.m., sustaining a fracture (broken bone) to the right inferior (lower) pubis ramus (a bone in the pelvis, specifically a thin, flat part of the pubic bone), right superior (upper) pubic ramus fracture, right sacral (tail bone) fracture, and bilateral rib fractures which required hospitalization in a general acute care hospital (GACH) for evaluation and treatment. A review of Resident 50's Admission Record, indicated Resident 50, a 79 year old female, admitted to the facility on 10/11/2023 and readmitted on 5/27/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), osteoporosis (weak and brittle bones due to a lack of calcium and Vitamin D ), fractures of left and right humerus (the long bone of the upper arm), repeated falls, and lack of coordination. A review of Resident 50's Change in Condition (COC Form dated 12/22/2024 and timed at 2:16 p.m., indicated Resident 50 informed the charge nurse (unknown) that she fell in the bathroom the day before (12/21/2024) after getting up unassisted. The COC Form indicated Resident 50 stated she "lost her footing and fell on the ground," but was able to get up and went back to her bed on her own without calling for assistance. The COC Form indicated Resident 50 had hematoma to her right side of the head. The COC Form indicated Resident 50 was on "toileting every two hours and as needed, frequent visual checks and bed alarm in place and working." A review of Resident 50's Care Plan titled, "At risk for falls, difficulty maintaining sitting/standing balance, history of falls/multiple falls" initiated on 12/25/2024, the Care Plan goal for Resident 50 was to have decrease in significant injury as a result from falls and to minimize the risk for falls in the next three months. The Care Plan interventions included applying and check the bed alarm while in bed and or wheelchair, to remind and redirect Resident 50 to call for assistance and to have frequent visual checks. A review of Resident 50's Interdisciplinary Team (IDTNote dated 1/9/2025 timed at 11:14 a.m., indicated on 12/22/2024 around 7:15 a.m., Licensed Vocational Nurse (LVN) 12 observed Resident 50 with a hematoma to the right side of her head. IDT Note indicated Resident 50 stated she went to the bathroom unassisted and when she was returning to bed, she "lost her footing, bumped herself (location unknown) and ended up on the floor." Resident 50 stated she got up and went back to bed. The IDT Note indicated Resident 50 was on a fall management program which consisted of a bed alarm to remind and redirect Resident 50 to call for assistance, and a perimeter mattress (a mattress with raised edges to prevent falls) for extra support. The IDT note indicated Resident 50 was able to silence or turn off her bed alarm because she wanted to go to the bathroom by herself. A review of Resident 50's COC dated 4/19/2025 and timed at 6:30 a.m., indicated Resident 50 was found sitting on the bathroom floor after getting out of bed unassisted and suddenly feeling weak on 4/19/2025 around 6 a.m. A review of Resident 50's IDT Note dated 4/28/2025, and timed at 10:25 a.m., indicated Resident 50 had an incident on 4/19/2025 around 6:00 a.m., when Resident 50 was observed sitting on the floor outside the bathroom. The IDT note indicated Resident 50 was assessed with no injury. The IDT note indicated Resident 50 was currently on a toileting schedule and had a voice to remind and redirect Resident 50 to call for assistance. The IDT note indicated Resident 50 was observed by staff that she can manipulate the bed alarm. A review of Resident 50's Minimum Data Set (MD) dated 5/22/2025, indicated Resident 50 had moderately impaired cognitive skills for daily decision making and was dependent on staff with toileting hygiene, showering and bathing. A review of Resident 50's Physician's Order Summary Report, indicated an order to apply and check the bed alarm while in bed and or wheelchair to remind and redirect the resident to call for assistance. A review of Resident 50's COC dated 5/22/2025 and timed at 7:25 a.m., indicated Resident 50 had an unwitnessed fall and was found lying on the floor on 5/22/2025 at about 7:25 a.m. A review of the facility's Investigation Report, (undated), indicated at the time of the incident on 5/22/2025, Resident 50's bed alarm was noted to be disconnected. A review of Resident 50's COC dated 5/22/2025 and timed at 2:58 p.m., indicated Resident 50 had laceration to her right eyebrow. Registered Nurse Supervisor (RNS) called 911 and Resident 50 was transferred to GACH on 5/22/2025 (unknown time). A review of Resident 50's GACH's Consultation Notes report dated 5/23/2025, indicated "Per the facility, Resident 50's bed alarm (talking device) did not alarm, and she got out of bed by herself and fell." The Consultation Note report indicated Resident 50 had a computed tomography scan (CT- scan) of the abdomen and pelvis on 5/22/2025. The CT scan indicated Resident 50 had a right inferior pubic ramus fracture, a right superior pubic ramus fracture, a right sacral fracture, and multiple bilateral rib fractures. During a concurrent observation and interview in Resident 50's room on 6/10/2025 at 8:22 a.m., Resident 50 was observed with a right eye bruise. Resident 50 stated she fell the "other day" (unable to state exact date). During an interview on 6/11/2025 at 1:46 p.m., Certified Nurse Assistant (CNA) 1, stated Resident 50 had a fall on 5/22/2025 and sustained a fracture. CNA 1 stated Resident 50 was confused and forgot to use her call light. During a concurrent interview and record review on 6/12/2025 at 8:55 a.m., LVN 9 stated Resident 50 was a high fall risk. LVN 9 stated Resident 50's room was close to the nurse's station. LVN 9 stated after each fall, the care plan should be revised to evaluate the effectiveness of interventions to prevent future falls from occurring. Reviewed Resident 50's Care Plan titled, "At Risk For Falls," LVN 9 stated Resident 50's care plan was not revised following her fall on 4/19/2025 and it should have been done because additional interventions could have prevented the resident's fall on 5/22/2025 which resulted in multiple fractures. LVN 9 stated Resident 50's fall was preventable if she had been monitored more closely and had a bedside commode (portable toilet) at her bedside as she gets up without assistance to use the bathroom. During a concurrent interview and record review of Resident 50's Care Plan titled, "At Risk for Falls," on 6/12/2025 at 10:10 a.m., RNS 2, stated Resident 50 was a high risk for fall and recently had a fall on 5/22/2025. RNS 2 stated that after a resident falls, the care plan should be revised to add new interventions. RNS 2 stated after Resident 50's fall on 4/19/2025, the care plan was not reviewed and revised. RNS 2 stated it was important to revise the care plan after a fall because the interventions in place were not effective, therefore, a new intervention could be added to prevent future falls. During an interview on 6/13/2025 at 9:24 a.m., the Director of Nursing (DON), stated a care plan was a guide that outlines the plan of care for the residents. The DON stated the care plan includes goals and interventions and should be revised when interventions were not effective. The DON stated Resident 50's care plan should have been revised after each fall so new interventions could be added to prevent future falls. During an interview on 6/13/2025 at 10:16 a.m., the Quality Assurance Licensed Vocational Nurse (QA LVN), stated Resident 50 tends to disconnect the bed alarm. A review of the facility's P&P titled, "Safety and Supervision of Residents" undated, the P&P indicated, "Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Implementing interventions to reduce accident risks and hazards shall include the following: ensuring that interventions are implemented and documenting interventions." A review of the facility's P&P titled, "Care Plans, Comprehensive Person-Centered" undated, the P&P indicated, "Assessments of residents are ongoing, and care plans are revised as information about the residents and residents' conditions change." The facility failed to: 1. Ensure Resident 50's bed alarm was turned on as one of the interventions of fall risk prevention program for Resident 50. 2. Ensure the licensed nurses evaluated the effectiveness of interventions of Resident 50's care plan titled, "At risk for falls, difficulty maintaining sitting/standing balance, history of falls/multiple falls" initiated on 12/25/2024, after the resident's fall on 4/19/2025, to develop new interventions to prevent the resident's fall on 5/22/2025 with injuries. 3. Ensure staff followed the facility's P&P titled, "Safety and Supervision of Residents," undated, which indicated, "The care team will target interventions that will reduce individual risks related to hazards in the environment including adequate supervision and assistive devices." These failures resulted in Resident 50 falling from a bed to the floor on 5/22/2025 around 7:25 a.m., and sustaining the right inferior pubis ramus fracture, right superior pubic ramus fracture, right sacral fracture, and bilateral rib fractures which required hospitalization in a GACH for evaluation and treatment. 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 to Resident 50.