Health inspection·September 19, 2025

F656 §483.21(b) Comprehensive Care Plans §483.21(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. 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: (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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. § 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. An unannounced visit was conducted by California Department of Public Health on 8/6/2025 at 9:25 AM to investigate a facility reported incident regarding Resident 1’s fall. The facility failed to: 1. Ensure Resident 1 received adequate supervision and assistance to prevent accidents and injuries, by failing to provide the assistance needed to Resident 1, who was assessed to be dependent (helper does all effort needed to complete activity) when facility staff left her alone and unassisted while she was toileting on 7/21/2025, and by failing to ensure Resident 1’s wheelchair sensor pad alarm (a fall prevention device placed under a resident to trigger an alarm when pressure is removed/ movement is detected) was properly positioned under the resident’s buttock during use on 8/6/2025. 2. Develop and implement a comprehensive person-centered care plan (a document that outlines the facility’s plan to provide personalized care to a resident based on the resident’s needs) for Resident 1 when after noting Resident 1’s decline in the cognitive skills (ability to understand and make decisions), mobility (ability to move or be moved) and function for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) assistance, based on the “Change of Condition Minimum Data Set (MDS – a resident assessment tool), dated 7/16/2025 the facility did not create or document an up-to-date, evidence-based patient-centered care plan appropriate to her higher support needs. This deficient practice resulted in Resident 1 having an unwitnessed fall and being found sitting in front of the toilet in the resident’s restroom after the resident was left unattended by facility staff on 7/21/2025. Resident 1 experienced left inner thigh pain with a rating of 7 out of 10 (a tool for assessing pain intensity using scale 0 to 10, where 0 represents no pain and 10 represents the worst pain imaginable). Resident 1 underwent x- ray (an imaging study that takes pictures of bones and soft tissues) of left upper leg (femur/ thigh bone) on 7/21/20245 and result showed a left acute minimally displaced intertrochanteric fracture (a break in the upper part of the thigh bone [femur], specifically in the area between the femoral neck and the lesser trochanter [a bony prominence or projection on the femur near the hip joint, serving as an attachment site for muscles], where the broken pieces have shifted out of alignment). Resident 1 was sent to General Acute Care Hospital (GACH) emergency room (ER) on 7/21/2025, admitted to the GACH’s medical surgical unit (a specialized area where patients receive care for a wide range of medical and surgical conditions. These units handle patients recovering from surgery, managing chronic illnesses, or requiring treatment for acute medical issues) on 7/22/2025 and underwent left hip open reduction internal fixation (ORIF- a surgical procedure used to treat fractures or dislocations by realigning the broken bones and stabilizing them with screws, plates, or rods) on 7/25/2025. Resident 1 stayed in the GACH from 7/22/2025 until 7/28/2025 (7 days). In addition, this failure placed Resident 1 at risk for another fall with the possibility of injury and/ or complications to Resident 1’s acute minimally displaced intertrochanteric fracture. 1. A review of Resident 1’s Admission Record, the Admission Record indicated Resident 1 is a 95- year- old female resident who was originally admitted to the facility on 2/3/2025, with diagnoses that included cerebral infarction (also known as a stroke, a condition where part of the brain tissue dies due to a lack of blood supply) and dementia (a progressive state of decline in mental abilities). The admission records also indicated diagnosis of history of falling with onset (the first date that a resident experiences the first symptoms of a medical condition) on 2/3/2025 and repeated falls with onset date of 4/16/2025. A review of Resident 1’s “Fall Risk Evaluation,” dated 7/14/2025, the Fall Risk Evaluation indicated Resident 1 is at a high risk of falls. A review of Resident 1’s MDS dated 7/16/2025, the MDS indicated Resident 1 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 1 was dependent (helper does all effort needed to complete activity) with toileting hygiene (the ability to maintain perineal hygiene [refers to the care and cleaning of the region between the genitals and the anus]), shower/bathing and lower body dressing and substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with personal hygiene and upper body dressing. The MDS indicated Resident 1 had impairments on both lower extremities (hips, knees, ankles, feet), substantial/maximal assistance with sit to stand mobility (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and toilet transfers (the ability to get on and off a toilet or commode) were not evaluated due to medical condition or safety concerns. The MDS also indicated a bed and wheelchair alarm were used in Resident 1’s care. A review of Resident 1’s “Change of Condition (COC)/Situation, Background, Assessment, Recommendation (SBAR-a communication tool used by healthcare workers when there is a change of condition among the residents) Interact Assessment Form,” dated 7/21/2025, the COC/ SBAR Assessment Form indicated Resident 1 had an unwitnessed fall at 8:50 AM and was found sitting in front of the toilet in the resident’s restroom. The COC/ SBAR Assessment Form indicated the assigned Certified Nursing Assistant (CNA) 2 assisted Resident 1 onto a shower chair and into the resident’s restroom, then left [the restroom] to grab something from Resident 1’s bed. The COC/SBAR indicated CNA 2 then found Resident 1 sitting on the restroom floor. The COC Assessment Form also indicated Resident 1 stated the resident tried to stand up to grab the toilet paper in front of the resident when Resident 1 lost her balance and fell onto the floor. The COC/ SBAR Assessment Form indicated at 2:43 PM, Resident 1 complained of left inner thigh pain with a rating of 7 out of 10 and Norco (the brand name of a medication that combines two pain-relieving drugs: hydrocodone and acetaminophen) 5-325 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) was administered to Resident 1. A review of Resident 1’s “Medication Administration Record (MAR),” dated 7/21/2025, the MAR indicated Resident 1 received 1,000 mg of Tylenol (brand name for acetaminophen; a pain medication) for 6 out of 10 left thigh pain and Norco for 7 out of 10 left extremity (left leg) pain. A review of Resident 1’s “Order Summary Report,” dated 7/21/2025, the Order Summary Report indicated for a statim (stat- urgent, without delay) x-ray of left upper leg (femur) due to complaints of pain status post (s/p - after) fall. A review of Resident 1’s “Radiology Results Report,” dated 7/21/2025, the Radiology Results Report indicated findings of a left minimally displaced acute intertrochanteric fracture. A review of Resident 1’s “Order Summary Report,” dated 7/21/2025, the Order Summary Report indicated to transfer to GACH ER for further evaluation related to acute minimally displaced intertrochanteric fracture due to s/p fall 7/21/2025. A review of Resident 1’s GACH records titled “History & Physical (H&P),” dated 7/22/2025, the H&P indicated Resident 1 chief complaint of left hip fracture after a mechanical fall with a left minimally displaced acute intertrochanteric fracture and Resident 1 was complaining of significant pain with movement. The H&P also indicated, Resident 1 was admitted to GACH’s medical surgical unit. A review of Resident 1’s GACH records titled “Consultation: Orthopedic Surgery,” dated 7/22/2025, the Consultation form indicated Resident 1 was scheduled for left hip ORIF on Friday 7/25/2025 at 2:00 PM. A review of Resident 1’s GACH record titled “Progress Note,” dated 7/25/2025 and timed 10:00 AM, the Progress Note indicated Resident 1 was in the recovery room status post ORIF to treat acute left hip fracture. A review of Resident 1’s GACH “Femur X-ray Radiology Report,” dated 7/25/2025, the Radiology Report indicated Resident 1 was s/p left hip surgery (date not indicated) with a compression screw and nail now noted within the left femur. A review of Resident 1’s GACH “Patient Discharge Summary,” dated 7/28/2025, the Discharge Summary indicated Resident 1 had an ORIF on the left hip and will be discharged back to the facility. A review of Resident 1’s “MAR,” (from the facility) dated 7/28/2025, the MAR indicated Resident 1 was admitted at the facility on 7/28/2025. The MAR also indicated Resident 1 received Tylenol 650 mg for 3 out of 10 left femur fracture pain. A review of Resident 1’s “Falling Star Program” care plan, revised 7/29/2025, the care plan indicated Resident with falls [in the facility] on 6/8/2025, 7/14/2025 and 7/21/2025 with the goal to reduce risk of falls and/or injury through appropriate intervention(s) daily until the next assessment. The care plan also indicated Resident 1 overestimates her ability to perform tasks independently. A review of Resident 1’s “MAR,” dated 8/4/2025, the MAR indicated Resident 1 received Norco 5-325 mg for 10 out of 10 for left toe pain. During an interview on 8/6/2025 at 10:04 AM with Resident 1, Resident 1 stated she cannot remember what happened with her fall, but she was currently still having left leg pain. During an interview on 8/6/2025 at 1:03 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated when she started caring for Resident 1 around 4/2025, Resident 1 was more independent with care, alert and not cognitively confused and used a front wheel walker (FWW- is a mobility aid with 2 wheels on the front legs, that helps provide stability and balance while walking) before experiencing multiple falls. LVN 1 stated prior to the resident’s fall on 7/21/2025, Resident 1 was noted to need assistance from 2 certified nursing assistants (CNAs) with transfers. During an interview on 8/6/2025 at 1:32 PM with the CNA 2, CNA 2 stated she was taking care of Resident 1 on 7/21/2025 when the fall occurred. CNA 2 stated she assisted Resident 1 onto a shower chair (assistive equipment designed to provide a safe and stable seating option in a shower or bathtub) and moved the shower chair to the toilet so that Resident 1 can use the restroom prior to the resident’s shower. CNA 2 stated, CNA 2 left Resident 1 unattended in the restroom to grab wipes from Resident 1’s bed. CNA 1 stated when CNA 2 was outside the restroom to grab the wipes, CNA 2 then heard a noise that was “really heavy,” went back into the restroom and found Resident 1 sitting on the floor in front of the toilet. During an interview on 8/6/2025 at 1:45 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was assigned to Resident 1 on 7/21/2025 and responded to Resident 1 after the fall and was not there when the fall occurred. LVN 2 stated Resident 1 was in the restroom, when CNA 2 left Resident 1 alone while the resident was using the toilet to grab something from Resident 1’s bed, then Resident 1 had an unwitnessed fall. Resident 1 is known for trying to be independent with activities of daily life (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) despite needing assistance and has a history of falls in the facility. During an interview on 8/7/2025 at 2:42 PM with LVN 3, LVN 3 stated she noticed Resident 1 has experienced changes in the resident’s cognition and dependence levels since working with the resident 3 weeks ago. Resident 1 has periods of cognitive confusion, attempts to be independent with ADLS when Resident 1 believes she can complete the task. Resident 1 should not have been left alone in the restroom by CNA 2 on 7/21/2025 because it was unsafe for Resident 1 with the resident’s cognition and history of falls. LVN 3 also stated leaving Resident 1 alone in the restroom was unsafe because there was no alarm on the shower chair to alert staff if she (Resident 1) was attempting to move and without the alarm or staff supervision, staff cannot ensure resident is safe and does not fall. In addition, Resident 1 ultimately had a fall requiring hip surgery after being left alone in the restroom. During a concurrent interview and record review on 8/7/2025 at 3:03 PM with the Minimum Data Set Nurse (MDSN), Resident 1’s MDS dated 6/18/2025, Change of Condition MDS dated 7/16/2025 and Resident 1’s medical chart dated 2/3/2025 through 8/7/2025 were reviewed. The MDSs indicated the following from 6/18/2025 and 7/16/2025: a. Resident 1’s cognitive skills declined from moderately impaired noted on 6/18/2025 to severely impaired noted on 7/16/2025. b. Resident 1’s functional eating ability declined from setup or clean-up assistance (helper helps only prior to or following the activity completion) noted on 6/18/2025 to supervision or touching assistance (helper provides verbal cues, touching/steadying and/or contact guard assistance during activity) noted on 7/16/2025. c. Resident 1’s oral hygiene ability declined from supervision or touching assistance noted on 6/18/2025 to partial/moderate assistance noted on 7/16/2025. d. Resident 1’s toileting hygiene (the ability to maintain perineal hygiene [refers to the care and cleaning of the region between the genitals and the anus]) ability declined from partial/moderate assistance noted on 6/18/2025 to dependent (helper does all effort needed to complete activity) noted on 7/16/2025. e. Resident 1’s ability to transfer from chair to bed/bed to chair and complete position change of sit to stand/ stand to sit, declined from supervision or touching assistance noted on 6/18/2025 to substantial/maximal assistance (helper does more than half the effort needed to complete the activity) noted on 7/16/2025. f. Resident 1’s ability to complete toilet transfers (the ability to get on and off a toilet or commode) and walk (varied distances of 10 feet [ft- plural for foot, a unit of length equal to 12 inches], 50 ft and/or 150 ft) declined from supervision or touching assistance ted on 6/18/2025 to not attempted due to medical condition or safety concerns noted on 7/16/2025. Resident 1’s medical chart did not indicate a care plan was initiated for Resident 1’s decline in cognitive and functional abilities. The MDSN stated Resident 1’s current care plan only reflected Resident 1 with moderately impaired cognitive skills and did not reflect her current condition of severely impaired cognitive skills. Resident 1’s medical chart did not reflect any specific interventions for Resident 1’s functional ability with ADLs, only bowel and bladder function,