Health inspection·November 21, 2025

REGULATORY VIOLATION(S): Title 42 Code of Federal Regulations §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. Title 22 Code of California Regulations §72311. 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. Title 22 Code of California Regulations §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 10/6/2025, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility-reported incident (FRI) regarding a resident who sustained a fracture (broken bone). The facility failed to ensure Resident 1, was free from accidents, was provided with adequate supervision (refers to the ongoing monitoring and guidance provided by staff to ensure the safety and well-being of a resident) and assistive devices (tools that help residents perform daily tasks, maintain or improve their functional capabilities and enhance their independence) to prevent accidents. On 9/30/2025, the facility failed to supervise Resident 1 and did not provide a front-wheeled walker (FWW- a mobility aid with two wheels on the front legs and two non-wheeled legs at the back allowing residents to slide the walker forward which helps with stability and balance) when Resident 1 was ambulating to the bathroom. As a result, Resident 1, who was assessed as being at high risk for falls due to multiple risk factors including severe visual impairment characterized by age related macular degeneration in left eye and blindness in right eye, moderately impaired cognitive function (a decline in a resident’s mental abilities, impacting their ability to think, learn, remember, reason, and make decisions), history of severe hypertension requiring medications associated with increased fall risk, history of prior fall, and requiring moderate assistance from staff with toilet transfers and mobility (movement) had a fall on 9/30/2025 at 7:53 a.m. and sustained a left femoral intertrochanteric fracture (a break in the upper part of the left thigh bone). Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) for further evaluation and treatment. A review of Resident 1’s Admission Record, dated 10/7/2025, indicated Resident 1, a 93-year old female, was admitted to the facility on 1/8/2025 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), age-related macular degeneration of left eye (a medical condition that affects the macula [central part of retina {a light-sensitive layer at the back of the eye}] responsible for sharp, detailed vision), repeated falls and muscle spasms (a sudden, involuntary, and often painful contraction of one or more muscles usually in the legs). A review of Resident 1’s History and Physical Examination (H&P – a comprehensive assessment of a resident’s medical condition), dated 1/15/2025, indicated that Resident 1 does not have the capacity to understand and make decisions due to dementia. The H&P further indicated that Resident 1’s diagnosis included blindness in the right eye. A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 7/9/2025, indicated that Resident 1’s cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 1 needed maximum assistance from staff with toileting hygiene, showering, lower body dressing, and putting on or taking off footwear. The MDS further indicated that Resident 1 required moderate assistance with personal hygiene, toilet transfers and chair-to-bed or bed-to-chair transfers. A review of Resident 1’s Fall Risk Assessment, dated 1/8/2025, indicated that Resident 1 had a fall risk score of 24 (total score above 10 represents high risk for falls). The Fall Risk Assessment indicated that Resident 1 had intermittent confusion, had a fall prior to admission on 12/31/2024, was incontinent (having no or insufficient voluntary control over urination or defecation), and was legally blind in the right eye. The Fall Risk Assessment indicated Resident 1 had balance problem while standing and walking, decreased muscular coordination, change in gait (manner of walking) pattern when walking through doorway, jerking (sudden, involuntary movement) or unstable when making turns and requires use of assistive devices. The Fall Risk Assessment indicated Resident 1’s systolic blood pressure (the pressure in a person’s arteries when the heart contracts and pumps blood throughout the body) drops less than 20 millimeters of mercury (mmHg – unit of measurement for pressure) between lying and standing positions (when the blood pressure drops abnormally as a person changes from a lying to standing position, potentially resulting in dizziness [a sensation of spinning around and losing one’s balance]). The Fall Risk Assessment further indicated that Resident 1 takes three to four medications associated with increased fall risk and the presence of one to two predisposing medical conditions. A review of Resident 1’s Care Plan titled “Functional Abilities of Everyday Activities,” initiated on 1/20/2025, indicated that Resident 1 requires assistance with transfers and mobility. The goal is for Resident 1 to demonstrate the ability to transfer safely, as evidenced by no falls, with adherence to safe walking precautions. The interventions initiated on 4/10/2025 include supervising the resident (Resident 1) when standing up and getting in and out of bed, assisting with transfers to and from a chair or wheelchair daily and as needed, and encouraging the resident (Resident 1) to prevent dizziness or falls by rising slowly from a sitting to a standing position. A review of Resident 1’s Restorative Nursing Program Referral/Care Plan form dated 4/2/2025 indicated that Resident 1 is at risk for decreased Range of Motion (full movement potential of a joint), weakness in the bilateral lower extremities (BLE – both legs), as well as maintain current level of function (CLOF). The approaches included providing active range of motion exercises on BLE and ambulation (walking from place to place either independently, with the help of another person or with an assistive device like walker) for 160 to 200 feet (ft – unit of length) with touching assistance daily, as tolerated. The form included precautions for Resident 1 such as fall risk, hearing impairment, blindness in the right eye and hypertension (high blood pressure). A review of Resident 1’s Physical Therapy (PT – specialized rehabilitation to help residents regain, maintain, or improve physical function after an injury, surgery or illness) Discharge Summary dated 4/4/2025 indicated that services were provided from 1/16/2025 to 4/2/2025. The discharge recommendations included the use of an assistive device for safe functional mobility. A review of the Resident 1’s Progress Notes, Type: Situation, Background, Assessment, Recommendation (SBAR – a structured communication tool used to convey critical information about a resident) Summary dated 9/30, 2025, timed at 10:46 a.m. indicated that Resident 1 had a change in condition related to a fall. The SBAR indicated that on 9/30/2025 at 7:50 a.m. Resident 1 was observed in her (Resident 1) room on the floor, leaning against the wall in a sitting position. The SBAR indicated Resident 1’s vital signs (basic measurements of your body’s most important functions, including body temperature, pulse rate, breathing rate, and blood pressure) on 9/30/2025 at 8:00 a.m. were as follows: blood pressure of 195/114 mmHg (for elderly women [60 years old and above], a normal blood pressure reading is generally considered to be below 130/80 mmHg) taken on Resident 1’s left arm while on sitting position, pulse rate of 75 beats per minute (a normal resting pulse or heart rate for adult ranges from 60 to 100 beats per minute), respiratory rate of 19 breaths per minute (the normal respiratory rate for an adult at rest is 12 to 20 breaths per minute), and temperature of 98 degrees Fahrenheit (?F – unit of measurement with normal temperature for adults ranging from 97 ?F to 99 ?F). The SBAR further indicated that Resident 1 complained of pain rated five out of 10, with 10 representing the highest level of pain and zero (0) indicating no pain. Tylenol (a medication used to treat pain) was administered and Resident 1’s physician was notified on 9/30/2025 at 8:07 a.m., with orders to transfer Resident 1 via 911 (a phone number used to contact emergency services). A review of Resident 1’s Progress Notes, Type: Transfer to Hospital Summary, dated 9/30/2025, timed at 11:33 a.m., indicated that on 9/30/2025 at 7:53 a.m., Licensed Vocational Nurse (LVN) 1 called Registered Nurse 1 (RN 1) to Resident 1’s room and informed RN 1 that Resident 1 had an unwitnessed fall. Resident 1 was observed on the floor, leaning against the wall in a sitting position near her (Resident 1) bed. Resident 1 stated, “…. I just have pain in my left leg.” Resident 1 was unable to bend her (Resident 1) left leg, could slightly move the left leg and complained of pain in the left leg with swelling observed in the left knee. A review of Resident 1’s “Post-Fall Investigation Report” undated indicated that on 9/30/2025 at 8:25 a.m. Resident 1 was transferred to GACH 1 for further evaluation and X-radiation (X-ray – an imaging test that uses a small amount of radiation to create pictures of the inside of the body). The Post Fall Investigation Report indicated that the X-ray results from GACH 1 confirmed a left femoral intertrochanteric fracture. During an interview on 10/6/2025 at 10:24 p.m., with RN 1, RN 1 stated that she (RN 1) received a phone call (did not specify name of staff who called) early in the morning (unable to recall specific time) at the start of her (RN 1) shift on 9/30/2025, informing her (RN 1) that Resident 1 had an unwitnessed fall. RN 1 stated that upon entering Resident 1’s room, she (RN 1) observed Resident 1 sitting on the floor, leaning against the wall. RN 1 stated that LVN 1 was already present with Resident 1 and translated that Resident 1 stated she (Resident 1) was trying to go to the bathroom, but she (Resident 1) did not have comfortable shoes. RN 1 stated, “I saw her shoes. They looked uncomfortable. They had heels and were not closed-toe or closed-heel.” RN 1 further stated that Resident 1 initially denied pain; however, when RN 1 assessed Resident 1’s left leg, Resident 1 “moaned” in pain. She (RN 1) called 911, and Resident 1 was subsequently transferred to GACH 1. During an interview on 10/6/2025 at 1:22 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated that he (CNA 1) was assigned to Resident 1 on 9/30/2025 and learned of the unwitnessed fall after it had occurred, when nursing staff (did not specify) were already assessing Resident 1 in her (Resident 1) room. When asked about Resident 1’s toileting routine, CNA 1 stated that Resident 1 was “ambulatory” (means a resident is physically able to get out of bed and walk without assistance) and that “she (Resident 1) goes to the restroom by herself.” During a concurrent interview and record review on 10/7/2025 at 9:39 p.m., with the Director of Rehabilitation (DOR), Resident 1’s PT Discharge Summary dated 4/4/2025 was reviewed. The DOR stated that from 1/16/2025 to 4/2/2025, Resident 1 was in the PT program and was discharged on 4/2/2025 with recommendations to ambulate (walk) with contact guard assistance (CGA - when a helper has one or two hands on a resident to steady him/her as a precaution and to ensure safety). When asked if Resident 1 should have been ambulating by herself (Resident 1) to the bathroom, the DOR stated, “Not at all. Somebody has to be by her (Resident 1) side for safety. When we discharged her (Resident 1) on 4/2/2025 [from PT], she (Resident 1) was CGA.” The DOR further stated that, “The shoe [Resident 1] was wearing had a little heel and she (Resident 1) said that she (Resident 1) twisted her (Resident 1) ankle.” Resident 1 “needs to use a walker for ambulation but she (Resident 1) also needs someone to be with her (Resident 1).” The DOR stated that “If she (Resident 1) needs to use the restroom, they (facility staff) are supposed to bring the front wheeled walker to her (Resident 1) and go with her (Resident 1) to the restroom. We don’t keep a walker by the bedside otherwise (the) resident will try to use it by themselves.” During an interview on 10/7/2025 at 12:38 p.m., with Restorative Nursing Assistant (RNA) 1, RNA 1 stated that when a resident is discharged from rehabilitation, the physical therapists (a healthcare professional who creates and implements treatment plans to help residents restore mobility, function, and independence after an injury, surgery, or illness) will show the Restorative Nursing Assistants (RNAs) on how to perform exercises with the resident to maintain mobility. RNA 1 stated that if she (RNA 1) is unfamiliar with a particular resident, the “first thing” RNA 1 will “look at [is] the care plan” to see PT’s recommendations. RNA 1 stated that she (RNA 1) had previously walked with Resident 1 (specific date not mentioned) using a walker and would stand “next to” Resident 1 as they walked together in the hallway. When asked if RNA 1 had seen Resident 1 ambulating independently (by herself), RNA 1 stated, “Yeah, I was doing exercises with another resident and I saw her (Resident 1) walking by herself in the hallway (specific date not mentioned).” During a concurrent observation and interview on 10/9/2025 at 11:09 p.m., with Certified Nursing Assistant (CNA) 2, inside Resident 1’s room, observed a pair of black sandals inside a plastic bag on top of Resident 1’s wheelchair approximately four to five ft from Resident 1’s bed. CNA 2 stated that Resident 1 wore black sandals when ambulating to the restroom. The sandals were open-toed and open-heeled (the toe and heel portion of the sandals were not covered), with approximately a one-inch (in – unit of length) wedge heel. During a concurrent interview and record review on 10/9/2025 at 5:07 p.m., with the Director of Nursing (DON), Resident 1’s Care Plan titled “Functional Abilities of Everyday Activities,” initiated on 1/20/2025, was reviewed. When asked if Resident 1 should have been ambulating by herself (Resident 1) to the bathroom, the DON stated, “No, because the care plan designated [Resident 1] needs assistance when ambulating.” When asked if Resident 1 should have been ambulating by herself (Resident 1) in the hallway, the DON stated, “Absolutely not.” The PT Department communicates their recommendations to the nursing staff through the care plan. The DON stated that a resident’s care plan “keeps everyone updated on any changes,” and “it’s supposed to be looked at and reviewed.” The DON stated, “closer observations of our residents is needed”. The DON stated the nursing staff “should be able to get resident[s] up, make sure they are stable, [and] make sure there is a walker or wheelchair” available. A review of the facility’s policy and procedure (P&P) titled, “Ambulation,” dated 3/1/2015 and reviewed on 7/28/2025, indicated the initial steps in preparing to ambulate a resident is to “check the care plan” and “prepare any equipment”. The P&P indicated that a front wheeled walker “allows for a more fluid gait pattern while still giving support”. The P&P indicated that as part of “safety during ambulation,” the nursing staff should “make sure the resident wears good, supporting shoes.” A review of the facility’s P&P titled, “Ambulation of a Resident,” dated 4/1/2016 and reviewed on 7/28/2025, indicated the following: “Prior to standing the resident, ensure that the resident is wearing non-skid slippers or sh