Health inspection·March 6, 2026

Code of Federal Regulations, Title 42, Section 483.21(b) - Comprehensive care plans (b)(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 Code of Federal Regulations, Title 42, Section 483.25 - Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: Code of Federal Regulations, Title 42, Section 483.25(d) - 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. California Code of Regulations, Title 22, Section 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 the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 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 1/21/2026, the California Department of Public Health (CDPH) conducted an unannounced onsite visit at the facility to investigate the a Facility Reported Incident (FRI) regarding resident safety. The facility failed to: 1. Develop and implement an individualized fall prevention care plan, for Resident 1, with interventions including reminding Resident 1 to use a front wheeled walker ([FWW] a mobility aid with two wheels on the front legs and rubber-tipped or sliding legs on the back) and call for assistance before walking. 2. Implement the facility's Policy and Procedure (P&P) titled Care Planning- Interdisciplinary Team ([IDT]- Resident 1's health care team consisting of various specialties), which indicated the IDT was responsible for the development of an individualized comprehensive care plan for each resident. These failures resulted in Resident 1 walking without her FWW and falling, sustaining a left femur (thigh bone) fracture (broken bone) which required hospitalization in a general acute care hospital (GACH) for evaluation and treatment. Resident 1, a 68-year-old female, was readmitted to the facility on 1/12/2026, with diagnoses including bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (group of thinking and social symptoms that interferes with daily functioning), and abnormality of gait. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 10/24/2025, indicated Resident 1 had severely impaired cognitive (thought process) function for daily decision making. The MDS indicated Resident 1 required supervision (helper provides verbal cue as resident completes activity) for self-care activities such as eating, hygiene, getting dressed and mobility such as sitting, standing and walking. The MDS indicated Resident 1 used a mobility device walker (FWW). A review of Resident 1's Fall Risk Assessment, dated 10/8/2025, indicated Resident 1 scored a two. A score above 10 was considered a risk for falls. A review of Resident 1's Physical Therapy ([PT], a healthcare profession focused on improving movement, reducing pain, and restoring physical function through, exercise, manual therapy, and patient education) Evaluation and Plan of Treatment dated 10/2/2025, indicated Resident 1 was to be seen for follow up PT treatments to monitor Resident 1's mobility and educate Resident 1 on safe use of a FWW. A review of Resident 1's PT Treatment Encounter Notes dated 10/2/2025 to 10/28/2025, indicated Resident 1 used a FWW as an assistive device for gait training and was supervised for transfers, gait training and sitting. A review of Resident 1's Nursing Weekly Progress Notes dated 1/6/2026 at 9:50 p.m., indicated on 1/6/2026 at 9:40 p.m. facility staff (unnamed) observed Resident 1 in the hallway walking without her FWW, past room 54 then suddenly started running and fell on her left side. The notes indicated Registered Nurse Supervisor (RNS) 1 assessed Resident 1 and assisted resident to bed. Resident 1 stated she did not know what happened and reported a pain level of 3/10 (mild pain) on her left hip which Ibuprofen 100 mg was given to Resident 1. The notes indicated staff (unnamed) informed Resident 1's physician Resident 1 had a fall and complained of left hip pain. New physician orders were given for a stat (immediate) x-ray (a medical imaging test produces pictures of the body's internal structures, primarily bones and dense tissues) of the left hip. A review of Resident 1's Physician Order dated 1/2026, indicated a stat left hip x-ray and safety monitoring (resident supervision increased if there is a change in resident's condition) every 30 minutes for 72 hours. A review of Resident 1's Medication Administration Record (MAR) dated 1/2026, indicated Resident 1 received ibuprofen 100 mg as follows: 1/6/2026, at 10:00 p.m., for 3/10 left hip pain, and on 1/7/2026 at 9:00 a.m., for 10/10 left hip pain. A review of Resident 1's x-ray interpretation dated 1/7/2026, indicated there was an acute (sudden onset) fracture of the left thigh bone. A review of Resident 1's Physician Order dated 1/7/2026, indicated, to transfer Resident 1 to a GACH for further evaluation of left hip. A review of Resident 1's GACH Emergency Department (ED) records dated 1/7/2026, indicated Resident 1 had a fracture of left femur due to a mechanical fall (fall is caused by an external [to the resident] factor) on 1/6/2026. The GACH ED records indicated Resident 1 had a 7/10 pain (severe pain) to the left thigh and received ketorolac (a medication used for short-term management of moderate (4-6/10) to severe (7-10/10) pain) 60 mg injection (administered into a muscle with a needle) and a lidocaine patch (a topical, adhesive medicated patch used to relieve pain). A review of Resident 1's GACH Orthopedic (a medical specialty focused on the diagnosis, treatment, rehabilitation, and prevention of injuries and diseases of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles, and nerves) Consult records dated 1/8/2026, indicated Resident 1 had a left hip hemiarthroplasty (a surgical procedure to replace the ball of the left hip joint) surgery on 1/8/2026. A review of Resident 1's medical records, dated 1/24/2025 through 1/5/2026 indicated there was no care plan for Resident 1's risk for falls and the use of a FWW. There was no care plan that was developed and/or implemented prior to Resident 1's fall with injury on 1/6/2026. During a concurrent interview and record review on 1/21/2026 at 11:51 a.m., with RNS 1, Resident 1's Nursing Weekly Progress Note dated 1/6/2026 was reviewed. The progress note indicated Resident 1 was not ambulating (walking) with her FWW on the day of the fall but should have ambulated with her FWW. RNS 1 stated there was no care plan for fall risk in place prior to the fall that occurred on 1/6/2026. RNS 1 stated a fall prevention care plan should have been created and implemented before Resident 1's fall on 1/6/2026. During an interview on 1/21/2026 at 1:50 p.m., Licensed Vocational Nurse (LVN) 1 stated Resident 1 was alert and oriented to person and place but had periods of confusion. LVN 1 stated Resident 1 walked with an FWW. Resident 1 should have been ambulating with a FWW on the day she fell, which may have prevented the fall. Resident 1 had periods of confusion and may have forgotten to use her walker when she came out of her room and walked down the hallway. LVN 1 stated staff that observed Resident 1 ambulating without her FWW should have stopped her from ambulating without her FWW. During a concurrent observation and interview on 1/21/2026 at 2:34 p.m., with Resident 1 in her room, Resident 1 stated on the day of the fall (1/06/2026), she exited her room and was walking down the corridor without her FWW and she fell on her left hip. Resident 1 stated she knew she needed her FWW but forgot to take it with her. During a concurrent interview and record review on 1/22/2026 at 9:41 a.m., with RNS 2, Resident 1's PT Evaluation and Plan of Treatment dated 10/2/2025, Physician Orders List dated 10/29/2025 and the resident's care plan titled "Potential risk for fall" dated 1/12/2026 were reviewed. RNS 2 stated Resident 1 learned to use a FWW when ambulating during PT sessions in the hallway with the Registered Physical Therapist (RPT-a licensed healthcare professional who diagnoses and treats individuals with movement limitations, injuries, or chronic pain to improve quality of life and restore function). RNS 2 stated when Resident 1 transitioned to the Restorative Nursing Assistant (RNA - a specialized program focused on rehabilitation techniques that help individuals regain and maintain their highest level of physical functioning, mobility, and independence) Program on 10/29/2025, the RNA orders indicated Resident 1 was to ambulate with an FWW. RNS 2 stated a care plan was a comprehensive document outlining the interventions, risks, and objectives for the residents' care. RNS 2 stated Resident 1 was a fall risk and used a FWW to ambulate. RNS 2 stated licensed staff should have initiated and implemented a care plan for risk-for-falls with interventions to ensure Resident 1 always used her FWW for ambulating, and the fall could have been prevented. During a concurrent observation and interview on 1/22/2026 at 1:42 p.m., with the Director of Nursing (DON), the video surveillance of the night of the fall (1/6/2026) was reviewed. At 9:43:37 p.m., Resident 1 was observed exiting the room. At 9:43:42 p.m., Resident 1 walked by Certified Nursing Assistant (CNA) 1 and increased her speed. At 9:43:47 p.m., Resident 1 lost her balance and fell to the ground. The DON stated if Resident 1 had her FWW, the FWW could have prevented the fall from happening. The DON stated the IDT did not meet and a care plan was not developed to address Resident 1's risk for falls or use of an FWW. The DON stated a fall risk care plan should have included interventions such as keeping the resident's call light within reach, remove clutter from the room, good lighting, non-skid socks, and reminding Resident 1 to use her FWW. The DON stated Resident 1 was a high fall risk and the care plan should have been implemented before she fell. During a concurrent interview and record review on 1/22/2026 at 4:32 p.m., with the DON, the Fall Risk Assessments dated 10/8/2025 and 1/7/2026 were reviewed. The DON stated on 10/8/2025, Resident 1's fall risk score was two and a score above 10 indicated the resident was high risk for falls. The DON stated on 1/7/2026, another Fall Risk Assessment was done, and Resident 1 scored a 5 which indicated Resident 1 was still not a high risk for fall even though Resident 1 fell on 1/6/2026. The DON stated the Fall Risk Assessment was not an accurate assessment of Resident 1's risk for falls because prior to the fall, Resident 1 was not considered a high risk for falls and after the fall, Resident 1 was still not considered a high risk for fall. The DON stated the Fall Risk Assessment did not assess Resident 1 appropriately for the risk of falls. During a review of the facility's P&P, titled Care Planning-Interdisciplinary Team, revised September 2013, the P&P indicated the facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.... "The care plan is based on the residents' comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel such as the resident's Attending Physician; the Registered Nurse who has responsibility for the resident, the Therapists (speech, occupational, recreational, etc.), as applicable; the Director of Nursing (as applicable); the Charge Nurse responsible for resident care; the Nursing Assistants responsible for the resident's care; and others as appropriate or necessary to meet the needs of the residents." During a review of the facility's P&P titled, Safety and Supervision of Residents, revised July 2017, indicated resident safety and supervision and assistance to prevent accidents are facility-wide priorities.... The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any speci?c accident hazards or risks for individual residents... The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices... Implementing interventions to reduce accident risks and hazards shall include the following such as communicating speci?c interventions to all relevant staff; assigning responsibility for carrying out interventions; providing training, as necessary; ensuring that interventions are implemented; and documenting interventions...... The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition. During a review of the facility's P&P, titled Resident Mobility and Range of Motion, revised July 2017, the P&P indicated, "residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable...... As part of the resident's comprehensive assessment, the nurse will identify the resident's current mobility status including his or her ability to walk, limitations in movement or mobility.... As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to range of motion ([ROM] measurable distance and direction a joint or body part can move) and mobility, including gait and balance issues that may lead to falls or fractures.... The care plan will be developed by the interdisciplinary team based on. the comprehensive assessment and will be revised as needed. The care plan will include speci?c interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion... The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. The residents and