Health inspection·October 2, 2025

§ 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— (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. (2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan— (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. (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 (2) A comprehensive care plan must be— (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 §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. § 483.35 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. . . . (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. 22 CCR §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 oth (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. § 72557. Equipment and Supplies. (a) Equipment and supplies in each facility shall be of the quality and in the quantity necessary for care of patients as ordered or indicated. At least the following items shall be provided and properly maintained at all times: . . . (23) Shower and commode chairs, wheelchairs and walkers. On 8/18/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding a quality-of-care allegation. As a result of the investigation, CDPH determined the facility failed to: 1. Initiate the facility’s Falling Star Program (a resident safety initiative that uses a visual symbol, like a falling star, to identify residents at high risk for falls in healthcare settings) on 6/24/2025 when Resident 5 was identified as being at higher risk for falls following a fall incident on 6/24/2025. A fall risk assessment was completed for Resident 5 on 6/24/2025, however Resident 5 was not added to the facility’s Falling Star Program until 7/21/2025 (nearly a month later) in accordance with the facility’s policies and procedures (P&Ps) titled, “Falling Star Program” and “Falls and Fall Risk, Managing.” 2. Follow the facility’s Falling Star Program procedures after Resident 5’s falls on 6/24/2025 and 6/25/2025, which requires an Interdisciplinary Team (IDT – a group of professionals from different disciplines who work together to provide coordinated care for residents) Meeting to be held to determine whether Resident 5 should be placed on the facility’s Falling Star Program in accordance with the facility’s P&P titled, “Falling Star Program.” 3. Implement close supervision interventions in accordance with the facility’s P&P titled, “Falling Star Program,” indicating “to provide close supervision for resident on the falling star program by increasing frequency of rounds (scheduled checks by healthcare staff to assess resident status, manage needs, and collaborate on care plans, often at the resident’s bedside) to hourly. During hourly rounds, staff will ask or check … Potty – Evaluating … if they need to go to the bathroom.” 4. Ensure Resident 5’s wheelchair alarm (a safety device that alerts facility staff when a resident attempts to stand up or exit the wheelchair, used to prevent falls) was functioning, when on 8/13/2025 at 6 p.m. Resident 5 stood up from her wheelchair and entered Room A’s bathroom without triggering her (Resident 5’s) wheelchair alarm in accordance with the Physician’s Order, dated 7/23/2025, indicating that a chair (wheelchair) alarm was to be used while Resident 5 was in a wheelchair for safety purposes. 5. Provide supervision to Resident 5 on 8/13/2025 at 6 p.m., when Certified Nursing Assistant (CNA) 4 left Resident 5 alone in her wheelchair after being provided a dinner meal tray. As a result, Resident 5 had a fall on 8/13/2025 at 6 p.m. when CNA 4 left Resident 5 unsupervised in her wheelchair after being provided with a dinner meal tray. Resident 5 was then later found on the toilet in the bathroom of Room A with a posterior scalp (back portion of the scalp {hair-covered area of the head}) laceration (a deep cut or tear in the skin), posterior scalp hematoma (a collection of blood that has pooled outside of blood vessels {a tube through which the blood circulates in the body}, usually due to trauma or injury that damages a blood vessel) and bleeding. Resident 5’s laceration measured two centimeters (cm – unit of measurement) in length, one cm in width, and 0.2 cm in depth and the hematoma on the posterior side of the scalp measured three cm in length and 3 cm in width. Licensed Vocational Nurse 6 (LVN 6) applied a dressing (a pad or cover applied to an injury or wound to protect it, promote healing and prevent infection) on Resident 5’s laceration to control the bleeding. On 8/13/2025 at 6:30 p.m., Resident 5 was transferred to General Acute Care Hospital 1 (GACH 1) for further evaluation. A review of Resident 5’s Admission Record indicated the facility admitted Resident 5, a 103-year-old female, on 6/21/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), cerebral infarction (damage to the area of the brain caused by lack of blood flow), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and repeated falls. A review of Resident 5’s History and Physical (H&P - a comprehensive assessment of a resident’s medical condition), dated 6/23/2025, indicated that Resident 5 had fluctuating capacity to understand and make decisions. A review of Resident 5’s Fall Risk Observation/Assessment form, dated 6/24/2025, after Resident 5 had a fall on 6/24/2025, indicated that Resident 5 had a fall risk score of 24 (a score ranging from 16 to 42 signifies a high risk for falls). A review of Resident 5’s Care Plan for fall, initiated on 6/24/2025, indicated that on 6/24/2025 Resident 5 had an unwitnessed fall (an instance where a person falls but no one was present to see the event occur) and was identified as being at risk for recurrent falls and injury. A review of Resident 5’s Minimum Data Set (MDS – a resident assessment tool), dated 6/27/2025, indicated Resident 5 had moderately impaired cognitive functioning. The MDS indicated Resident 5 required moderate assistance from staff for toilet transfers and mobility. The MDS indicated Resident 5 required maximal assistance (helper does more than half of the effort) from staff with toileting hygiene, showers, and lower body dressing. The MDS also indicated Resident 5 had a fall prior to admission to the facility. A review of Resident 5’s Physician’s Order dated 7/21/2025, indicated to increase staff supervision for safety. A review of Resident 5’s Physician’s Order dated 7/23/2025, indicated that a chair (wheelchair) alarm was to be used while Resident 5 was in a wheelchair for safety purposes. The Physician’s Order further indicated for staff to monitor the functionality of the chair alarm every shift and at each opportunity the resident is observed to ensure continued safety. A review of Resident 5’s Care Plan for fall, initiated on 8/13/2025, indicated that on 8/13/2025 Resident 5 had an unwitnessed fall. The Care Plan interventions included anticipating and addressing the resident’s needs, and the use of a chair alarm to ensure resident safety. A review of Resident 5’s Situational Background Assessment and Recommendation (SBAR – a communication tool used to provide concise, clear, and effective information regarding a resident’s condition) Communication Form, dated 8/13/2025, timed at 6:32 p.m., indicated that on 8/13/2025 (time not indicated), CNA 4 reported that Resident 5 attempted to go to the bathroom unassisted and had an unwitnessed fall. The SBAR further indicated to transfer Resident 5 via 911 (a universally recognized and designated emergency telephone number in the United States used to request immediate assistance in an emergency) for further evaluation. A review of Resident 5’s Progress Note (written summary by a healthcare professional detailing a resident’s condition, care, treatments, and response to interventions during a specific encounter), dated 8/13/2025, timed at 6:05 p.m., indicated that on 8/13/2025, at approximately 6:05 p.m., Registered Nurse (RN 2) was informed of an unwitnessed fall involving Resident 5. The Progress Note indicated that Resident 5 reported hitting her (Resident 5) head and had a visible laceration on the back of her (Resident 5) head. The Progress Note indicated a dressing was applied to Resident 5’s head and the bleeding was controlled. The Progress Note further indicated that on 8/13/2025 at 6:30 p.m., Resident 5 was transferred to GACH 1 for further evaluation. A review of Resident 5’s Physician’s Order dated 8/15/2025, indicated to cleanse Resident 5’s posterior scalp laceration with normal saline (NS – a salt and water solution), pat dry, apply xeroform (a moist yellow dressing that covers the wound and promote wound healing), cover with gauze (a thin, light, and loosely woven fabric used for wound dressings) and wrap with stretch gauze (a flexible, absorbent bandage used to secure dressings, provide compression, and offer support for wounds) every day or as needed for 21 days. During an interview on 8/19/2025 at 12:09 p.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated that on 8/13/2025, at approximately 6 p.m., she (LVN 4) entered the bathroom in Room A and found Resident 5 sitting on the toilet without any assistance from facility staff. LVN 4 stated that there was no audible sound from Resident 5’s wheelchair alarm at the time. LVN 4 further stated that Resident 5 had sustained a head injury and was subsequently transferred to GACH 1 on 8/13/2024 at 6:30 p.m. for further evaluation and treatment. During a concurrent interview and record review on 8/19/2025 at 1:18 p.m., with LVN 6, Resident 5’s Comprehensive Skin Evaluation/Assessment form dated 8/13/2025 was reviewed. The form indicated that on 8/13/2025 (time not indicated) Resident 5 was observed with moderate sanguineous drainage (leakage of fresh blood from an open wound, characterized by a bright red color and a syrup like consistency) from a laceration located on the posterior scalp, measuring two cm in length, one cm in width, and 0.2 cm in depth. The form indicated Resident 5 had a purple-colored hematoma, on the posterior scalp measuring three cm in length and three cm in width. The form indicated that Resident 5’s posterior scalp injury was cleansed, and treatment was provided in accordance with the Physician’s Order. LVN 6 stated that on 8/13/2025, at approximately 6:30 p.m., she (LVN 6) was asked to assist with Resident 5’s treatment. LVN 6 stated that upon entering Room A, LVN 6 observed Resident 5 sitting on the toilet. LVN 6 further stated that Resident 5 was repeatedly grabbing her head and had visible blood on her (Resident 5) hand. During a concurrent interview and record review on 8/19/2025 at 1:58 p.m. with the Assistant Director of Nursing (ADON), Resident 5’s Care Plan for fall, initiated on 7/20/2025 was reviewed. The Care Plan indicated that Resident 5 was at risk for falls related to altered balance (difficulty keeping a stable and upright position) while standing and walking, decreased muscular coordination (ability of multiple muscle to work together accurately to produce a desired movement or action), history of multiple falls, and an unsteady gait (pattern of walking that lacks stability and coordination resulting in increased risk of falls). The Care Plan indicated that Resident 5 sustained falls on 7/19/2025, 7/20/2025, 8/3/2025, and 8/10/2025. The care plan interventions included Resident 5 was added to the facility’s Falling Star Fall Prevention Program as of 7/21/2025 and to keep Resident 5 within supervised view as much as possible. The ADON stated that the purpose of the Falling Star Program was to alert and inform facility staff of residents identified as high risk for falls. The ADON further stated that the Falling Star Fall Prevention Program should have been initiated for Resident 5 on 6/24/2025, when Resident 5 was assessed and identified as being at high risk for falls. During an interview on 8/19/2025 at 3:58 p.m., with RN 2, RN 2 stated that on 8/13/2025, at approximately 6 p.m., she (RN 2) was informed by facility staff (unable to recall who) that Resident 5 had sustained a fall. RN 2 stated that upon entering Room A, she (RN 2) observed Resident 5 sitting on the toilet in the bathroom with a visible head injury. RN 2 stated that Resident 5 stated she (Residen