Health inspection·April 2, 2025

42 CFR §483.25(d) Accidents The facility must ensure that – (d)(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. 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. 22 CCR §72311 Nursing Service--General (a)(2) Nursing service shall include, but not be limited to, the following: Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 2/20/2025, the California Department of Public Health (CDPH) received a facility reported incident (FRI) indicating a resident (Resident 1) reported she experienced a fall and was transferred to a general acute care hospital (GACH). On 2/25/2025 at 12:52 PM, the CDPH conducted an unannounced visit at the facility to investigate the FRI. The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 1 did not leave Resident 1 unattended and unsupervised at Nurse’s Station 3, on 2/14/2025. This failure resulted in Resident 1 falling to the ground on 2/14/2025, and sustaining a displaced subcapital left femoral neck fracture (a broken bone in the upper part of the left thigh bone, where the broken pieces are significantly displaced from their normal position) requiring surgical intervention. Resident 1 was a 69-year-old female, originally admitted to the facility on 1/10/2025, and most recently re-admitted to the facility on 2/18/2025 with diagnoses including generalized muscle weakness, left thigh bone fracture, history of falling, dementia (a progressive state of decline in mental abilities), epilepsy (a chronic brain disorder characterized by recurrent seizures, which are brief episodes of abnormal brain activity that can cause involuntary movements, loss of consciousness, or other symptoms), and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). A review of Resident 1’s History and Physical (H&P), dated 1/10/2025, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool), dated 1/13/2025, indicated Resident 1 had memory problems and severely impaired cognition (a significant decline in cognitive abilities that interferes with daily life and independence). The MDS indicated Resident 1 had impairments to her lower extremities (hip, knee, ankle, and foot) on both sides of her body. The MDS indicated Resident 1 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility while in and out of bed. The MDS indicated diagnoses of lack of coordination and generalized muscle weakness. A review of Resident 1’s care plan titled “At risk for fall,”, dated 1/10/2025, indicated staff were to provide frequent visual monitoring of Resident 1 to reduce the risk of falls and/or injury. A review of Resident 1’s Morse Fall Scale Assessment (a clinical assessment tool used to predict a patient's risk of falling), dated 1/11/2025, indicated Resident 1 was at high risk for falls due to impaired gait (an abnormal walking pattern), and forgetfulness and/or overestimation (judging something too highly) of her ability to walk safely. A review of Resident 1’s Change of Condition (COC) assessment, dated 2/14/2025 at 3:10 PM, indicated on 2/14/2025 Resident 1 had a witnessed fall, in the hallway. The COC indicated Resident 1 reported 4 out of 10 pain (0: no pain, 1 to 3: mild pain, 4 to 6: moderate pain, and 7 to 10: severe pain) to her left hip. The COC indicated Resident 1 was administered Tylenol (pain reliever) 650 milligrams (mg, a unit of dose measurement) for pain. The COC indicated Resident 1’s physician was notified of the fall and the physician ordered for an immediate x-ray (a procedure that uses radiation to create images of the inside of the body) to rule out broken bones. A review of the facility record titled “Investigation Statement,” dated 2/14/2025 at 3:10 PM, indicated a handwritten statement by LVN 1 regarding Resident 1’s fall on 2/14/2025. The record indicated on 2/14/2025 (no time specified), Resident 1 was sitting in a wheelchair near the nurse’s station. The record indicated LVN 1 was assisting another resident in the hallway when Resident 1 fell. A review of Resident 1’s COC assessment, dated 2/14/2025 at 9:45 PM, indicated the x-ray revealed Resident 1 had an acute (severe and sudden in onset) left thigh bone fracture related to a witnessed fall. The COC indicated “Resident got up unassisted and lost her balance.” The COC indicated Resident 1 reported 8 out of 10 pain. The COC indicated staff administered Norco 5/325 mg (a combination medication used to relieve severe pain when other pain medication was insufficient) for pain. The COC indicated Resident 1’s physician gave an order for Resident 1 to be a transferred to a GACH for evaluation and treatment of the left thigh bone fracture. A review of Resident 1’s progress note, dated 2/14/2025 at 11:45 PM, indicated Resident 1 was transferred to the GACH on 2/14/2025 at 11:30 PM. A review of Resident 1’s GACH record titled “History and Physical,” dated 2/15/2025 (untimed), indicated Resident 1 was brought to the GACH after falling onto her left side while trying to walk. The record indicated a plan to admit Resident 1 to the medical-surgical unit (a unit for patients recovering from surgery, preparing for surgery, or managing various medical conditions). A review of Resident 1’s GACH record titled “Radiology Report,” dated 2/15/2025 at 2:23 AM, indicated an x-ray was taken of Resident 1’s left hip. The record indicated Resident 1 had a displaced subcapital left femoral neck fracture. A review of Resident 1’s facility progress note, dated 2/15/2025 at 1:42 PM, indicated Resident 1 was admitted to the GACH and in the process of being referred to, and evaluated by, an orthopedic physician (a physician who treats injuries and diseases involving muscles, bones, joints, ligaments, and tendons) for a possible left hip hemiarthroplasty (surgical replacement of half of the hip joint) related to her fracture. A review of Resident 1’s GACH record titled “Discharge Summary Notes,” dated 2/17/2025 at 8:07 AM, indicated a final diagnosis of acute left femoral neck fracture. The record indicated Resident 1’s conservator (a person appointed by a court to manage her care) declined to provide consent for orthopedic surgery (a surgical procedure on the musculoskeletal system), and Resident 1 was to be discharged back to the facility. A review of Resident 1’s facility progress note, dated 2/18/2025 at 11:45 AM, indicated Resident 1 was re-admitted to the facility on 2/18/2025. During a telephone interview with LVN 1, on 2/26/2025 at 9:14 AM, LVN 1 stated she was Resident 1’s Charge Nurse the afternoon of 2/14/2025, and was aware Resident 1 was at risk for falls. LVN 1 stated she was supervising Resident 1 at the nurse’s station and there were no other staff present when Resident 1 fell. LVN 1 stated she did not ask any staff member to supervise Resident 1 before leaving the resident unattended at the nurse’s station. LVN 1 stated she was down the hall from Resident 1, with her back towards the resident, when she heard Resident 1’s wheelchair alarm. LVN 1 stated she turned around and saw Resident 1 standing up and holding onto the armrest of her wheelchair for support. LVN 1 stated she was too far away from Resident 1 to intervene, and she observed Resident 1 fall to the ground onto her left side. LVN 1 stated Resident 1 denied any pain during the shift, prior to the fall, but complained of pain to her left hip after the fall. LVN 1 stated she should not have left Resident 1 unattended and unsupervised at the nurse’s station. LVN 1 stated the fall could have been prevented if Resident 1 was not left unsupervised. During a telephone interview on 2/26/2025 at 4:43 PM, with Registered Nurse (RN) 1, RN 1 stated Resident 1’s care plan intervention of “frequent visual monitoring” meant Resident 1 should not be left unattended. RN 1 stated to implement this intervention, Resident 1 should always be within a supervising staff member’s line of sight. RN 1 stated leaving a resident who required frequent visual monitoring unattended could result in a fall and injury. During a concurrent interview and record review, on 2/27/2025 at 1:02 PM, with the Director of Nursing (DON), the facility’s policy and procedure (P&P) titled “Safety and Supervision of Residents,” revised 1/2025, was reviewed. The DON stated the P&P indicated resident supervision was a core component for resident safety. The DON stated LVN 1 should not have left Resident 1 unattended because Resident 1 was known as a high risk for falls. The DON stated LVN 1 should have ensured another staff was supervising Resident 1, before leaving the resident at the nurse’s station. The facility failed to: 1. Ensure LVN 1 did not leave Resident 1 unattended and unsupervised at Nurse’s Station 3, on 2/14/2025. This failure resulted in Resident 1 falling to the ground on 2/14/2025, and sustaining a displaced subcapital left femoral neck fracture requiring surgical intervention. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.