Other·March 24, 2026

42 CFR §483.25(d)(1)(2) 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. 22CCR §72523(a) 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 2/10/2026, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI), indicating a resident (Resident 1) sustained a rib fracture (broken bone). On 2/25/2026, the CDPH conducted an unannounced visit to the facility to investigate the FRI. Upon investigation the CDPH determined Resident 1 lost her balance and fell while attempting to sit on a rolling stool that was left in the facility's dining/activity room. The facility failed to: 1. Ensure the residents' environment was free of accident hazards when a rolling stool was left in the facility's dining/activity room where it posed a safety hazard to residents due to the rolling mechanism of the chair. 2. Follow its Policy and Procedure (P/P), titled, "Hazardous Areas, Devices and Equipment" dated 7/2017 that indicated "hazardous areas and objects in the resident environment, such as furniture that is unstable, will be identified and addressed." These deficient practices resulted in Resident 1 losing her balance and falling while attempting to sit on the rolling stool. Resident 1 complained of pain to her right hip and left rib area and was transferred to a General Acute Care Hospital (GACH) where she was assessed with multiple right rib fractures. These deficient practices also had the potential to cause harm to other residents in the area where the rolling stool was left unattended. Resident 1, an 80-year-old female, was initially admitted to the facility on 10/19/2019 and readmitted on 6/2/2025. Resident 1's diagnoses included multiple fractures of the ribs on the right side and paranoid schizophrenia (a chronic mental health condition characterized by intense, irrational, and persistent distrust, suspicion, and fear of others, along with auditory hallucinations [the perception of sounds, such as voices, music, or noises, in the absence of any external stimulus] and delusions [fixed, false beliefs firmly held despite clear, contradictory evidence]). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 12/3/2025, indicated Resident 1's cognition (the ability to think and reason) was moderately impaired. The MDS indicated Resident 1 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard as resident completes activity, provided throughout the activity or intermittently) with walking more than 10 feet and when sitting to standing. A review of Resident 1's Situation, Background, Assessment, Recommendation ([SBAR] a communication tool used by healthcare workers when there is a change of condition among the residents) dated 2/8/2026 and timed at 4:30 p.m., indicated Resident 1 sustained an unwitnessed fall in the activity room, and was lying on her left side. The SBAR indicated Resident 1 verbalized she had pain to both her right hip and left rib area. A review of Resident 1's Physician's Orders, dated 2/8/2026, indicated to transfer Resident 1 to the GACH for a suspected fall and injury. A review of the facility's Five-Day Summary, dated 2/10/2026, indicated on 2/8/2026, at approximately 4:30 p.m., Resident 1 independently ambulated into the activity room, where Certified Nursing Assistant (CNA) 1 was present. CNA 1 was assisting another resident and briefly turned away when Resident 1 attempted to sit on a rolling stool, which rolled from underneath her (Resident 1) causing her to fall on to her left side. A review of the GACH's Information Sheet dated 2/8/2026, indicated Resident 1 arrived to the GACH on 2/8/2026, at 8:50 p.m. A review of Resident 1's GACH Computed Tomography Scan ([CT Scan] a procedure that produces detailed images of bones, organs, and soft tissues), dated 2/9/2026 and timed at 10:34 p.m., indicated Resident 1 had right-sided rib fractures. A review of Resident 1's GACH History of Present Illness (HPI), dated 2/9/2026, indicated Resident 1 presented to the emergency department (ED) after a mechanical fall (a fall caused by an external environmental factor) from losing her balance. The HPI indicated the CT scan of Resident 1's chest showed right side rib fractures, and the plan was to observe Resident 1, control her pain, provide prophylaxis (action taken to prevent disease, especially by specified means or against a specified disease) to prevent a deep vein thrombosis ([DVT], a serious condition where a blood clot forms in a deep vein, usually in the legs, causing symptoms like swelling, pain, warmth, and redness, and the clot can break loose and travel to the lungs, being potentially fatal), and be evaluated by physical therapy (PT). During an interview on 2/25/2026 at 11:55 a.m., the Director of Nursing (DON) stated there was a care plan created for Resident 1 related to a fall she sustained in 6/2025, but it had been resolved due to Resident 1 meeting her goals. The DON stated Resident 1 was steady on her feet and there had been no other care plan created prior to her current fall on 2/9/2026. The DON stated Resident 1 was still at risk for falls due to her use of psychotropic medications (a class of prescription drugs designed to affect the mind, emotions, and behavior by altering the chemical balance of neurotransmitters in the brain). During an interview on 2/25/2026 at 3:24 p.m., the Administrator (ADM) stated the rolling stool was from the rehabilitation/therapy room and should not have been in the activity/dining room because it was not safe and posed a safety risk to residents. The ADM stated she was not able to identify who left the rolling stool in the dining/activity room. During an interview on 2/25/2026, at 3:30 p.m., CNA 1 stated on 2/8/2026 sometime before dinner (5 p.m.), she was in the dining room/activity room supervising residents while the residents watched television. CNA 1 stated she witnessed Resident 1 walk into the dining room and get water from the water station. CNA 1 stated she was assisting another resident, and when she turned around, she witnessed Resident 1 fall and land on her left side as a rolling stool rolled away from her (Resident 1). CNA 1 stated she did not see the rolling stool in the dining/activity room prior to it rolling away from Resident 1 and thought it must have been pushed under a table and Resident 1 pulled it out to sit on it. A review of the facility's P/P, titled, "Hazardous Areas, Devices and Equipment" dated 7/2017, indicated "hazardous areas and objects in the resident environment, such as furniture that is unstable, will be identified and addressed." The facility failed to: 1. Ensure that the residents' environment was free of accident hazards when a rolling stool was left in the facility's dining/activity room where it posed a safety hazard to residents due to the rolling mechanism of the chair. 2. Follow its P/P, titled, "Hazardous Areas, Devices and Equipment" dated 7/2017 that indicated "hazardous areas and objects in the resident environment, such as furniture that is unstable, will be identified and addressed." These deficient practices resulted in Resident 1 losing her balance and falling while attempting to sit on a rolling stool. Resident 1 complained of pain to her right hip and left rib area and was transferred to a GACH where she was assessed with multiple right rib fractures. These deficient practices had the potential to cause harm to other residents who were in the area where a rolling stool was left unattended. These 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 to Resident1 and Resident 2.