Health inspection·August 15, 2025

The following reflects the finding of the California department of Public Health during Investigation of a facility reported incident number CA00964124 A Class A citation was issued. Code of Federal Regulations, Title 42, Section 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Code of Federal Regulations, Title 42, Section 483.25(d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and 2) Each resident receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 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. California Code of Regulations, Title 22, Section 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 7/1/2025 California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident regarding a resident falling with injury. The facility failed to ensure Resident 1 was closely supervised, monitored, and within staff reach to prevent a fall, in accordance with the facility's policies and procedures (P&P). The facility was aware that Resident 1 was confused (the inability to think as clearly or quickly as you normally do) and had a history of falls and impulsive behavior (refers to actions that are taken without sufficient thought or consideration of the consequences) of getting up from the wheelchair (WC) without assistance. As a result, Resident 1 had a fall onto the left side of the face on 6/24/2025 at around 8:15 PM. On 6/24/2025 at 8:30 PM, Resident 1 was transferred to a General Acute Care Hospital (GACH) Emergency Room (ER-the department of a hospital that provides immediate treatment for acute [sudden onset] illnesses and trauma[injury]) for further evaluation via 911 (emergency response telephone number). At the GACH, Resident 1 was diagnosed with closed fracture (a break in a bone that does not extend through the skin or surrounding tissues) of the left orbital floor (the bony socket around the eye) and swelling and abrasion (a superficial wound caused by the scraping or rubbing away of skin or other surface tissue) of the left eyebrow. A review of Resident 1's Admission Record indicated, Resident 1 was admitted on 5/28/2025 with diagnoses including dementia (a decline in mental ability severe enough to interfere with daily life), muscle wasting/atrophy (when muscles start to shrink and weaken), difficulty in walking, and mixed incontinence (involuntary leakage of urine). A review of Resident 1's Admission Fall Risk Evaluation record dated 5/28/2025 indicated that Resident 1's fall risk score was 10 (a score of 10 or greater is an indicator that the resident is at a high risk for falls). The fall risk evaluation record indicated that fall prevention protocol (nonspecific) should be initiated immediately and documented on the care plan. A review of Resident 1's High Risk for Fall care plan (CP) initiated on 5/29/2025, indicated that Resident 1 was a high risk for falls related to Resident 1's history of fall, confusion, incontinence (the involuntary loss of urine and stool), poor communication/comprehension, psychoactive drug (a drug or substance that causes changes in mood, awareness, thoughts, feelings, or behavior) use and recent hip surgery (not specified). The High Risk for Fall CP indicated Resident 1 had a balance problem while standing and while walking, had decreased muscular coordination, and required use of an assisting device (such as cane, wheelchair, walker, and furniture) for mobility. The High Risk for Fall CP goals included to assist Resident 1 "with ambulation (walking) and transfers, ... and evaluate for fall risk on admission and PRN (as necessary)." A review of Resident 1's Care Plan Report on Status Post Fall (S/P) initiated 5/29/2025 and revised on 6/25/2025, indicated Resident 1 fell on 11/24/2025. The Care Plan Report goals indicated that Resident 1 would be free of falls, would be free of minor injury, and would not sustain serious injury through target date of 9/9/2025. The Care Plan Report interventions included that the facility would follow the fall protocol (unspecified), frequent visual monitoring, and place the resident in front of the nursing for visual monitoring (the act of observing and maintaining awareness) ... and staff to be available promptly (initiated on 6/2/2025). The Care Plan Report interventions also included to review information on past falls and attempting to determine cause of falls. A review of Resident 1's Multidisciplinary Care Conference (MCC-is a mechanism by which information is shared between various professionals involved in the patient's care) dated 5/30/2025, at 11 A.M., indicated Resident 1 was a high risk for falls. The MCC interventions included to have the resident's bed in a low position, placing bilateral (both side) floor mats (primarily refers to a bedside mat designed to reduce injury from falls), and supervising Resident 1 closely. The MCC indicated that Resident 1's family member (FM) stated Resident 1 had been having anxiety, had poor impulse control, was at high risk for falls, and did not call for assistance. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 6/4/2025, indicated Resident 1 was cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 was dependent on staff assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 1's Situation Background Appearance Review and notify (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents) dated 6/24/2025, documented by Licensed Vocational Nurse (LVN) 1, indicated that on 6/24/2025 at 8:30 P.M. Resident 1 had a witnessed fall and hit her head (Fall witnessed by LVN 1). The SBAR indicated, "[Resident 1] stood up from the [WC] attempting to ambulate without assistance. Upon assessment, [Resident 1] alert and responsive. Observed [Resident 1] with left eye swelling and applied ice pack. [Resident 1] able to move all extremities (hands and legs) without difficulty." The SBAR indicated that a Medical Doctor (MD) was paged (to call a person using a loudspeaker/electric device) who gave an order to transfer Resident 1 to the Emergency Room for further evaluation. "Orders (MD) taken and carried out." The SBAR indicated Resident 1 was transferred to GACH via 911. A review of Resident 1's Emergency Department After Visit Summary GACH record dated 6/24/2025, indicated, "the reason for visit (Resident 1), fall. Diagnoses abrasion of the left eyebrow, ground level fall, closed fracture of the left orbital floor, and injury of the head." During an interview on 7/1/2025, at 12:58 P.M., LVN 1 stated Resident 1 was dependent on WC for mobility, required frequent use of the bathroom to urinate and tried to get up from the WC, and attempted to walk. LVN 1 stated Resident 1 had a diagnosis of dementia, which caused Resident 1 to forget that she (Resident 1) was not steady on her feet and that is reason the facility staff instructed Resident 1 to stop getting up when the resident tried to get up from the WC without staff assistance. LVN 1 stated that sometimes Resident 1 listened to the instructions and other times Resident 1 did not. LVN 1 stated the facility staff would quickly get to the resident to prevent her from getting up without assistance and did not fall. LVN 1 stated facility staff would have Resident 1 sit at the nursing station, and sometimes behind the nursing station with a staff member to ensure that the staff can easily catch the resident to prevent falls when the resident tried to get up from the WC. LVN 1 stated that on 6/24/2025 around 8:15 P.M., Resident 1 was sitting approximately 8 feet (ft-unit of measurement) in the hallway and across the nursing station between resident room numbers 18 and 20 and LVN 1 did not have direct access to Resident 1. LVN 1 stated Resident 1 was wearing eyeglasses. LVN 1 stated she was seated behind the desk at the nurses' station and was the only staff at the nursing station. LVN 1 stated she observed Resident 1 stand up from the WC and LVN 1 verbalized to Resident 1 to stop getting up from the WC and to sit back down but Resident 1 did not sit down. LVN 1 stated that by the time LVN 1 moved from behind the nursing station desk, Resident 1 was up already and turned to the left, attempted to ambulate by taking maybe one step and then fell to the floor and hit the left side of the face with the eyeglasses still on. LVN 1 stated Resident 1 suffered redness to the corner of the left eye and that the redness progressively increased with swelling. LVN 1 stated she applied ice on the resident's left eye. LVN 1 stated she called 911 to transfer Resident 1 to GACH because the resident was on a blood thinner (not specified). LVN 1 stated Resident 1 left for GACH on 6/24/2025 at around 8:30 P.M. LVN 1 stated Resident 1 is at risk for falls because the resident, "is ... very fragile, has dementia, and is on Ativan (a medication primarily used to help people feel calmer and less anxious)." LVN 1 stated if she had been close enough "(arm's length" - very near or close by, easily reachable) to Resident 1, then LVN 1 would have been able to quickly get to and brace Resident 1's fall because Resident 1 is small enough. LVN 1 further stated she should also have placed Resident 1 behind the nursing station next to LVN 1 as she has previously done. LVN 1 stated, "close supervision means that the resident needs to be watched at all times, at least an arm's length away." During a concurrent interview and record review on 7/1/2025, at 3:05 P.M., with the Director of Nursing (DON), Resident 1's Admission Falls risk Evaluation record dated 5/28/2025, high risk for fall care plan dated 5/29/2025, and MCC notes dated 5/30/2025 were reviewed. The DON stated the Resident 1's Admission Falls risk Evaluation record, high risk for fall care plan, and MCC notes indicated that Resident 1 was high risk for fall and that the resident required close supervision by staff. The DON stated Resident 1's high risk for fall care plan was not revised after the Interdisciplinary Team (IDT [MCC] - refers to a group of healthcare professionals from different fields who collaborate to provide comprehensive patient care) meeting on 5/30/2025 at 11 AM and should have included to supervise Resident 1 closely. The DON stated that close resident supervision means that the staff needs to be within the reach of a resident. The DON stated that within reach means at arm's length of the staff. The DON stated that Resident 1's care plan should have been revised based on IDT recommendation which is resident specific which includes resident centered interventions. A review of the facility P&P, titled, "Fall Management Program," revised 3/13/2021, indicated, "Purpose -To provide residents a safe environment that minimizes complications associated with falls. C. The interdisciplinary Team (IDT) and/or the licensed nurse will develop a care plan according to the identified risk factors and root cause(s). D. The IDT will initiate, review, and update the resident's fall risk status and care plan at the following intervals: on admission, quarterly, annually, upon identification of a significant change of condition, post fall and as needed." Post-Fall Response: A. Following every resident fall, the licensed nurse will perform a post-fall evaluation and update, initiate or revise the resident's care plan. Fall Investigation, Reporting, and Documentation: C. IDT will investigate the fall including a review of the resident's medical record ... D. IDT will review circumstances surrounding the fall ...will review and revise the care plan as necessary. Recurrent Falls: A. A resident who endures more than one fall ... will be considered at high risk for falls. B. Monthly, for those (residents) identified as high risk for falls, the IDT will meet to review the fall risk interventions for appropriateness and effectiveness until the frequency of their (residents) falls diminishes. C. The residents' care plans will be updated with the IDT recommendations." A review of the facility P&P, titled "Resident Safety" revised on 4/15/2021, indicated, "To provide a safe and hazard free environment. Policy: Residents will be evaluated on admission quarterly and whenever there is a change in condition to identify circumstances that pose a risk for the safety and wellbeing of the resident. Procedure: I. During the comprehensive assessment period the interdisciplinary team (IDT) members will assess the resident's safety (e.g. [example], fall... behavior issues) as well as any other resident specific safety risks. III. After a risk evaluation is completed, a resident centered care plan will be developed to mitigate safety risk factors. IV. The IDT will establish a person-centered observation or monitoring systems for the resident to address the identified risk factors identified. V. To observe the safety and wellbeing of the residents, ... The person-centered care plan may require more frequent safety checks." The facility failed to ensure Resident 1 was closely supervised, monitored, and within staff reach to prevent a fall, in accordance with the facility's P&Ps. The facility was aware that Resident 1 was confused and had a history of falls and impulsive behavior of getting up from the WC without assistance. As a result, Resident 1 had a fall onto the left side of their face on 6/24/2025 at around 8:15 PM. On 6/24/2025 at 8:30 PM, Resident 1 was transferred to a GACH ER for further evaluation via 911. At the GACH, Resident 1 was diagnosed with closed fracture of the left orbital floor and swelling and abrasion of the left eyebrow. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result for Resident 1.