Health inspection·August 21, 2025

F656 Cal. Code Regs., Tit. 42, § 483.21 Comprehensive person-centered care planning. (a) Baseline care plans. (1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must— (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. (2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan— (i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). (3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. (b) Comprehensive care plans. (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: (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under § 483.24, § 483.25, or § 483.40; and (ii) Any services that would otherwise be required under § 483.24, § 483.25, or § 483.40 but are not provided due to the resident's exercise of rights under § 483.10, including the right to refuse treatment under § 483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv) In consultation with the resident and the resident's representative(s)— (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (2) A comprehensive care plan must be— (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to— (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must— (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident's written plan of care. (iii) Be culturally-competent and trauma-informed.

F689 Cal. Code Regs., Tit. 42 §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.

F725 Cal. Code Regs., Tit. 42 § 483.35 Nursing services. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required at § 483.71. (a) Sufficient staff. . . . (3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. (4) Providing care includes but is not limited to assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs. (d) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. On 7/3/2025 at 8 AM, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding the quality of care and safety of Resident 1. As a result of the investigation, CDPH determined that the facility failed to ensure Resident 1, who had a recent fall and who was identified at high risk for falls upon facility admission on 5/14/2025, received adequate staff assistance and supervision to prevent accidents and injury by failing to: 1. Ensure the facility communicated with and provided awareness to licensed nurses (Licensed Vocational Nurse [LVNs 1 and 2] and Registered Nurse [RN] 1) and certified nurse assistants (CNAs 1, 2, 3 and 4) that Resident 1 was identified as high risk for falls due to recent history of falls, history of falls, and of interventions to visually monitor every hour, in accordance with the care plan for falls and the physician order. 2. Ensure the Restorative Nursing Assistants (RNA - provides rehabilitative care to patients recovering from illnesses or injuries) check the fall risk visual identifiers (Red name band and/or red star on the room, bed, and wheelchair) for residents identified as high risk for falls during the RNAs daily resident rounds, in accordance with the facility’s policy and procedure (P&P) titled “Falling Star Program (a patient safety initiative specifically designed to identify patients at risk for falls and reduce patient falls and major injuries).” As a result of these deficient practices, Resident 1 sustained physical injuries from an unwitnessed fall (unknown date) as discovered by CNA 1, LVN 1, and RN 1 in the morning shift (7 AM to 3 PM) of 6/19/2025. Resident 1’s unwitnessed fall resulted in an acute (sudden onset) comminuted (fragments) right intertrochanteric (( a broken bone resulting in bone fragments in the upper part of the thigh) with moderate displacement (and angulation (the ends of the bone have moved out of position, and the bone is bent in a curved position). Furthermore, Resident 1 sustained bruising to the right knee and right inner thigh and complained of pain to the right hip and inability to move the right leg. The facility transferred Resident 1 to General Acute Care Hospital (GACH) 1 on 6/19/2025 for treatment and Resident 1 received surgical repair of the right hip and femur (bone of the thigh) fracture on 6/20/2025. Resident 1 was discharged from GACH 1 on 6/23/2025 and transferred to a different facility for rehabilitation. A review of Resident 1’s Admission Record (AR), indicated the Resident 1 was admitted to the facility on 5/14/2025 with diagnoses that included nondisplaced (the bone cracks or breaks but retains its proper alignment) fracture of the sacrum (the triangular bone at the base of the spine, below the lower back and between the hip bones), unspecified fall, left artificial hip joint, and idiopathic (cause unknown) peripheral autonomic neuropathy (nerve damage often causes weakness, numbness and pain, usually in the hands and feet). A review of Resident 1’s facility document titled “Fall Risk Data Collection” (FRDC), dated 5/14/2025, indicated Resident 1 had one to two falls over for the past three months. The FRDC indicated Resident 1 was not able to stand or balance on both feet. The FRDC indicated Resident 1 was identified as high risk for falls. The FRDC further indicated “IDT met with the resident’s family (Family 1 and 2) and discussed plan of care... Informed of risks upon fall risk assessment, red star fall program, and visual monitoring every hour and interventions to manage risks.” A review of Resident 1’s “History and Physical Examination (H&P),” dated 5/15/2025, indicated Resident 1 had the capacity to make healthcare decisions. The H&P indicated Resident 1’s diagnoses included a history of a previous fall with left hip fracture. A review of Resident 1’s physician order titled “General Order” dated 5/15/2025, indicated to provide Resident 1 with “Visual monitoring every hour for Falling Star Program.” A review of Resident 1’s care plan titled “High risk for falls that may result to physical harm” dated 5/15/2025, indicated a goal developed on 5/15/2025 to decrease the resident’s risk of falls and injury with intervention. The care plan interventions with an approach date of 5/15/2025, included placing Resident 1 in the facility’s Falling Star Program and providing awareness to staff that patient has history of falls and continued to be at risk for falls. The care plan interventions dated 7/3/2025 indicated “Visual monitoring every hour for falling star program” (two months after Resident 1 was identified as high risk for falls on 5/15/2025). A review of Minimum Data Set (MDS, a resident assessment tool), dated 5/20/2025 indicated Resident 1 is moderately impaired of cognition but able to recall when prompted with visual or verbal cues. The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, partial/moderate assistance (helper does less than half the effort) with personal hygiene and dressing; and substantial/maximal assistance (helper does more than half the effort) with bathing and toileting. The MDS further indicated under the section “Fall History on Admission/Readmission,” that Resident 1 had a previous fall in the last month and a fracture related to a fall in the past six months, prior to admission to the facility (5/14/2025). A review of Resident 1’s facility document titled “SBAR [Situation, Background, Assessment, Recommendations] - General” (document used for residents change of condition), dated 6/19/2025 timed at 7:37 AM, indicated at 7:30 AM, Resident 1 complained of right knee pain, and had discoloration (bruising) on the right knee and right inner thigh. The SBAR indicated [Resident 1] was unable to move her right leg due to pain. The SBAR indicated the resident was confused because she was trying to get out of bed...The SBAR indicated pain medication was given for pain management. The SBAR indicated the physician was made aware, and X-ray (used to create images of the inside of the body) was ordered. The document indicated on 6/19/2025 timed at 2 PM, the X-ray result indicated an acute comminuted right intertrochanteric fracture. The document indicated, at 3:40 PM, Primary Medical Doctor (PMD) ordered to transfer Resident 1 to [GACH] 1. A review of Resident 1’s physician order, dated 6/19/2025, indicated Resident 1 was transferred to [GACH 1] for further evaluation of acute comminuted right intertrochanteric fracture. A review of Resident 1’s GACH 1 Records titled “Emergency Department Reports” (EDR), dated 6/19/2025, indicated Resident 1 presented to the GACH 1 Emergency Department with right hip tenderness (sensitivity to pain) due to a right hip fracture. The EDR indicated under “Medical Decision Making” indicated “Patient [Resident 1] seen and evaluated and given the presentation, the diagnoses included but not limited to fracture, fall, UTI (urinary tract infection – infection of the urinary system), no dislocation, contusion [a bruise].” A review of Resident 1’s GACH 1 Records titled “History and Physicals” (H & P), dated 6/19/2025, indicated Resident 1 was recently admitted to GACH 1 after a fall leading to an insufficiency fracture (a crack in a bone that occurs without a definite injury). The GACH 1 record indicated Resident 1 was residing at a facility and had a fall a few days prior. The GACH 1 record indicated the X-ray report was consistent with a right intertrochanteric fracture. A review of Resident 1’s GACH 1 Records titled “Surgery and Procedure Reports” (SPR), dated 6/20/2025, indicated Resident 1 had a surgery of the right femur. A review of Resident 1’s GACH 1 Records titled “Discharge Summaries Notes” (DSN), dated 6/23/2025, indicated Resident 1 had a hip and femur fracture repair. The DSN indicated Resident 1 was transferred to another facility for rehabilitation on 6/23/2025. During a phone interview on 7/3/2025 at 10:20 AM with Resident 1’s family member (FAM 1), FAM 1 stated Resident 1 was alert and able to verbalize her needs. FAM 1 stated someone in the facility called him on 6/19/2025 and informed him that Resident 1 had a fall and sustained a fracture and would be transferred to GACH 1. FAM 1 stated Resident 1 was still at GACH 1 and had surgery because of the fracture. FAM 1 stated to call Resident 1 in GACH 1. During a phone interview on 7/3/2025 at 10:35 AM with Resident 1, Resident 1