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 10/31/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident about a resident fall. The facility failed to ensure Resident 1, a two-year old male, with severely impaired cognition (mental action or process of acquiring knowledge and understanding) and dependent on staff for activities of daily living (ADL-activities such as bathing, dressing and toileting a person performs daily), remained free from accident. The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 1 did not turn her back on Resident 1, leaving Resident 1 unattended on a shower bed which had two gaps (open space) on each side of the side rails measuring eight inches (in -unit of measurement) in height and 22.5 in width, after CNA 1 transferred Resident 1 from his crib (a small bed for a baby or young child, with high bars to prevent the child from falling) to the shower bed. 2. Complete an assessment to determine the safety of using an adult-sized shower bed for Resident 1, who was a pediatric resident. 3. Use a pediatric-sized shower bed for Resident 1, instead of an adult-sized shower bed. 4. Ensure Resident 1’s Fall Risk Assessment was updated following Resident 1’s fall on 10/24/2025, to reflect changes needed in Resident 1’s care. 5. Include the use of size-appropriate shower beds for pediatric residents to ensure safety and prevent accidents in the facility-provided document titled, “Facility Assessment 2025”, reviewed on 4/17/2025, which only indicated the use of “Shower chairs.” 6. Follow its policy and procedure (P&P) titled, “Facility Assessment Patient Population,” which indicated, “A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations…. The facility assessment also includes a detailed review of the resources available to meet the needs of the residents’ population. This part of the assessment includes: … b. Equipment and supplies (medical and non-medical).” 7. Follow its P&P titled, “Accident Prevention,” which indicated, “Our facility strives to make the environment as free from accident hazards (a source of danger or an unsafe condition that has the potential to cause an accident, injury, or damage) as possible. Resident safety, supervision and assistance to prevent accidents are facility-wide priorities….” 8. Follow its P&P titled, “Resident Transfers,” which indicated, “Clinical staff may use additional clinical staff members for assistance as needed.” 9. Follow the facility-provided manual titled, “Healthcare Equipment Owner’s Manual,” which indicated, “Caregiver should be present and alert at all times while the equipment is in use…. Equipment may not be appropriate for all individuals. Assessment should be conducted by a skilled caregiver for proper suitability for the individual using the equipment.” As a result, on 10/24/2025 at 8:15 a.m., Resident 1 fell from the shower bed to the floor (28 inches high), on his right side and sustained a one-centimeter (cm-unit of measurement) discoloration (a change in the natural color of something) on his right cheek. Resident 1 was transferred to the General Acute Care Hospital (GACH) for further evaluation and care. A review of Resident 1’s Admission Record indicated the facility admitted Resident 1, a two-year old male, on 9/11/2025, with diagnoses that included unspecified (unconfirmed) chronic respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over an extended period, leading to low oxygen levels and/or high carbon dioxide levels in the blood) with tracheostomy and dependent on a ventilator (a machine or device used medically to support or replace the breathing of a person who is ill or injured), and liver transplant status (a life-saving surgery is performed when a person's liver fails) with gastrostomy. A review of Resident 1’s History and Physical (H&P), dated 9/11/2025, indicated Resident 1 was a medically complex (individuals who have chronic [persistent for a long time] health conditions that require significant and ongoing medical care) two-year-old with a history of extreme prematurity (born before 28 weeks, which is less than seven months of pregnancy) and who had a liver transplant on 1/2024. A review of Resident 1’s Order Summary Report, dated 9/11/2025, indicated the use of side rails (a bar attached to the side of a bed to prevent falls and assist with repositioning) for safety. A review of Resident 1’s Child Life Development Assessment, dated 9/12/2025, indicated Resident 1 could not communicate and was not able to verbalize his needs. A review of Resident 1’s Fall Risk Assessment, dated 9/12/2025, indicated Resident 1 had a score of eight. The Fall Risk Assessment indicated that residents who rate greater than eight should have a care plan for “Potential for Falls”. A review of Resident 1’s “Bed Rail” form dated 9/12/2025, indicated the Interdisciplinary Team (IDT – a coordinated group of experts from several different fields who work together to ensure all resident needs are met) recommended the bed rail for safety and prevention of falls and injuries due to balance deficit and impaired cognition and possibility of rolling out of bed. A review of Resident 1’s Care Plan titled “Potential for Injury,” dated 9/15/2025, indicated that intervention include staff will perform frequent visuals checks and will not leave Resident 1 unattended with side rails down or seat belts unstrapped. A review of Resident 1’s Minimum Data Set (MDS- a resident assessment tool), dated 9/22/2025 indicated Resident 1’s cognitive skills (thought process) for daily decisions were severely impaired. The MDS indicated Resident 1 was dependent on staff for ADLs. The MDS indicated Resident 1 had a bed rail and used an invasive mechanical ventilator (a life support machine that helps a resident breathe). The MDS indicated Resident 1 was 33 inches in height and 26 pounds (lbs. – unit of measurement) in weight. A review of Resident 1’s Situation Background Assessment Recommendation (SBAR- technique that provides a framework for communication between members of the health care team about a resident's condition) Communication Form, dated 10/24/2025, indicated Resident 1 fell and sustained a right buccal (side of cheek) 1 cm purple discoloration. The SBAR indicated Registered Nurse (RN) 2 did a full body and neurological assessment (a series of questions and physical tests used by doctors to check how well a person's nervous system is working) and noted Resident 1 had no changes in level of consciousness (describes their degree of awareness and responsiveness) and behaviors. The SBAR indicated an ice pack was applied to Resident 1’s right cheek for five minutes. The SBAR indicated Resident 1’s physician was notified on 10/24/2025, at 8:30 a.m., and the physician gave an order for Resident 1 to be transferred to GACH for further evaluation and care. A review of Resident 1’s Progress Notes, dated 10/24/2025, timed at 8:15 a.m., indicated that on 10/24/2025, at 8:15 a.m., CNA 1 bathed Resident 1 and turned to put a sheet on the bed when Resident 1 fell. Resident 1 cried and RN 2 noticed a pea-sized right cheek discoloration. During an interview on 10/31/2025, at 9:10 a.m., with RN 3, RN 3 stated on 10/24/2025, at 8:15 a.m., she was in Resident 1’s room in front of a medication cart calculating a medication dose beside Resident 1’s crib and facing a window. RN 3 stated Resident 1 was off the ventilator, and she (RN 3) had disconnected him from the oxygen saturation sensor (a device that estimates the amount of oxygen in blood) so CNA 1 could shower Resident 1. CNA 1 brought the shower bed inside Resident 1’s room and transferred Resident 1 from the crib to the shower bed. RN 3 stated when she turned her head to the left, she (RN 3) observed Resident 1 on the floor on his right side and CNA 1 was standing in between the crib and the shower bed. Although the shower bed had both side rails up, there was a huge gap in between. Resident 1 fitted in the side rail gap and fell on the floor. RN 3 stated when she (RN 3) picked Resident 1 up from the floor, she noticed Resident 1 had a discoloration on the right cheek. RN 3 stated CNA 1 did not inform her (RN 3) that she (CNA 1) was to turn around to put a sheet on Resident 1’s crib. If she (RN 3) knew, she could have supervised Resident 1 to prevent the resident from falling. During an interview on 10/31/2025, at 9:32 a.m., with CNA 1, CNA 1 stated Resident 1 was an active resident, who could sit and crawl on his (Resident 1) own. CNA 1 stated the facility had only adult-sized shower beds. On 10/24/2025, at 8:15 a.m., she (CNA 1) placed the shower bed between Resident 1 and Resident 2’s cribs and then she stood in the middle of Resident 1’s crib and the shower bed. CNA 1 stated she carried Resident 1 from the crib and placed him (Resident 1) on the shower bed. She (CNA 1) raised both side rails up and turned to get a bed sheet from the crib to cover Resident 1 before transferring Resident 1 from Resident 1’s room to the shower room. CNA 1 stated as she (CNA 1) turned around, Resident 1 slipped in between the shower bed rails and fell to the floor. She (CNA 1) could not catch Resident 1. She (CNA 1) did not ask for assistance from RN 3 who was present beside Resident 1’s crib. As she (CNA 1) picked up Resident 1 from the floor, Resident 1 was crying, and CNA 1 noticed a small discoloration in Resident 1’s right cheek. CNA 1 stated if she had asked RN 3’s assistance, to watch Resident 1 while she (CNA 1) turned to get the bed sheet from the crib, Resident 1 would not have fallen. During an interview on 10/31/2025, at 9:45 a.m., with RN 2, RN 2 stated that on 10/24/2025, she (RN 2) was the assigned charge nurse in the pediatric subacute unit (a specialized care unit for children who are medically complex and require a higher level of skilled nursing care). RN 3 informed her (RN 2) that Resident 1 fell. RN 2 stated when she (RN 2) went to Resident 1’s room, Resident 1 was already back in the crib, crying. She (RN 2) did a full body and neurological assessment on Resident 1 to check for physical injury. Resident 1 had a right cheek discoloration. RN 2 stated after consoling (to comfort) Resident 1, Resident 1 stopped crying. CNA 1 should not have turned her (CNA 1) back if Resident 1 was on the shower bed. CNA 1 should have notified RN 3 or the Respiratory Therapist to monitor Resident 1, while she gathered needed supplies for the resident’s care. During an interview on 10/31/2025, at 10:01 a.m., with RN 2, RN 2 stated the shower bed used by the pediatric subacute unit for shower was the adult-sized shower bed that was too big for the pediatric residents. During a concurrent interview and record review on 10/31/2025, at 10:07 a.m., with the Pediatric Nurse Manager (PNM), Resident 1’s Fall Risk Assessment, dated 9/12/2025, was reviewed. The PNM stated Resident 1 was active and moved a lot. Resident 1 was at risk for falls. The PNM stated on 10/24/2025, at 8:15 a.m., LVN 3 informed him (PNM) that Resident 1 slipped through the bottom gap of the shower bed rail and fell on the floor. The facility needed to provide a safe equipment for Resident 1’s use. CNA 1 should have never turned her (CNA 1) back from Resident 1. CNA 1 was new at the facility and had no prior experience with pediatric residents. Resident 1’s fall was avoidable and unacceptable. The PNM stated CNA 1 should have focused on Resident 1 and not the task. If CNA 1 did not turn her (CNA 1) back from Resident 1, Resident 1 would not have fallen. The PNM stated CNA 1 should have always kept a hand at Resident 1 when turning her (CNA 1) back. Resident 1 had a 1 cm round bruising (when small blood vessels under the skin tear or rupture, most often from a bump or fall) on his (Resident 1) right cheek from the fall. During a concurrent observation and interview on 10/31/2025, at 10:43 a.m., with the Maintenance Supervisor (MS), observed the MS measured the shower bed. The MS stated the shower bed had two gaps measuring eight inches in height and 22.5 inches in width on both sides. The height of the shower bed from the floor was 28 inches. The gap between the top of the shower bed to the top of the shower rail was 14 inches high and from the bottom of the shower bed to the bottom of the shower rail was 11 inches high. The MS stated the facility had four total standard (adult size) shower beds and two shower beds were used for each unit (adult and pediatric subacute). During an interview on 10/31/2025, at 10:56 a.m., with the Staff Development Coordinator (SDC), the SDC stated the shower bed used by the adult and the pediatric sub-acute residents were all adult-sized shower beds. The SDC stated the facility had modified the shower bed (date not indicated) and applied a green net in the shower bed gaps to prevent pediatric residents from slipping through. The application of the net was still not safe to prevent a fall. The SDC stated Resident 1’s fall was avoidable and preventable. Resident 1 could have broken bones and sustained a concussion from the fall. During an interview on 10/31/2025, at 11:04 a.m., with the Director of Nursing (DON), the DON stated Resident 1’s Fall Risk Assessment should have been updated after the fall on 10/24/2025. The DON stated the facility had to assess Resident 1 for safety. Since Resident 1’s Fall Risk Assessment was not done on 10/24/2025, Resident 1 could have a recurrent (repeated) fall. CNA 1 should have either called for assistance or ensured one of her hands was on Resident 1 while she grabbed the sheet from the crib. The DON stated because of Resident 1’s fall, Resident 1 had a discoloration on his (Resident 1) right cheek. During an interview on 11/4/2025, at 9:28 a.m., with CNA 1, CNA 1 stated she (CNA 1) did not hear any sounds that Resident 1 was moving on the shower bed when she (CNA 1) turned her (CNA 1) back. When she (CNA 1) turned back around Resident 1 had already slipped in between the shower bed rail and was already falling. She (CNA 1) could not catch Resident 1’s fall. CNA 1 stated RN 3 was inside the room but was busy and RN 3’s back was against the shower bed. CNA 1 stated her (CNA 1) mistake was not asking for assistance. During an interview on 11/4/2025, at 10:39 a.m., with the PNM, the PNM stated the combination of size-appropriate shower bed and CNA 1 not being attentive while providing care to Resident 1, caused Resident 1’s fall. During an interview on 11/4/2025, at 11:15 a.m., with the DON, the DON stated the facility failed to use size-appropriate shower bed for pediatric resident. The adult size shower bed used for Resident 1 was too big for a 2-year-old. The facility failed to prevent Resident 1’s fall when CNA 1 turned her back on Resident 1. CNA 1 should always have her (CNA 1) hands on Resident 1, during care to prevent falls and in juries. The facility could have provided a smaller shower bed free from gaps or have two staff provide showers to Resident 1 to prevent Resident 1’s fall. Resident 1 could have had fracture (break in bone) and developed a brain injury or skin breakdown from the fall. During an interview on 11/4/2025, at 1:41 p.m., with the PNM, the PNM stated Resident 1 was not assessed for safety for the use of adult-sized shower bed. All pediatric residents were not as