Health inspection·August 13, 2025

F744 Code of Federal Regulations, Title 42, Section 483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. 42 CFR §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 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. 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: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 6/26/25, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident regarding quality of care and patient safety/falls. As a result of the investigation, the CDPH determined the facility failed to ensure Patient 1 who had diagnosis of dementia, had a history of falls, and was assessed as a high fall risk on 6/1/25, received care needs and services to prevent a fall from occurring on 6/19/25. The facility failed to: 1. Ensure that Licensed Vocational Nurse (LVN) 2 monitored and promptly redirected Patient 1 when Patient 1 got up from a wheelchair unassisted while Patient 1 was at Nurses’ Station 1 on 6/19/25 [at around 10 am]. 2. Develop and implement a care plan for Resident 1 that included adequate oversight to mitigate fall risk. 3. Ensure staff followed the facility's policy and procedure (P/P) titled, “Dementia Care,” dated 10/2017, which called for the development and implementation of plans of care to meet the patients’ needs and preferences. As a result, on 6/19/25, at approximately 10 am, Patient 1 fell out of a wheelchair in front of Nurses’ Station 1. Patient 1 sustained fractures of the left 8th, 9th, and 10th ribs. A review of Patient 1’s Admission Record (AR) indicated Patient 1, an 81-year-old male, was originally admitted to the facility on 8/7/24 with diagnoses that included dementia, a history of falling, cognitive communication deficit, difficulty in walking and impulse disorder. A review of Patient 1’s untitled Care Plan (CP), dated 8/8/24, revised 5/9/25, indicated Patient 1 was at risk for falls related to dementia, the aging process, poor safety awareness, and a history of falls. The CP interventions included anticipating and meeting Patient 1’s needs, promptly response to all Patient 1’s requests for assistance and removing any potential causes of falls if possible. A review of Patient 1’s History and Physical (H&P) dated 1/27/25 indicated Patient 1 did not have the capacity to understand and make decisions. The H&P indicated Patient 1 had an unstable gait, balance, or stability, and increased risk for falls. A review of Patient 1’s Minimum Data Set (MDS) dated 3/25/25 indicated Patient 1’s cognitive skill was severely impaired. The MDS indicated Patient 1 required partial/moderate assistance from staff for transfers, and walking. A review of Patient 1’s Fall Risk Evaluation (FRE) dated 6/1/25 indicated Patient 1’s fall risk score was 15 (a score of 10 or higher indicated high risk for fall) due to Patient 1 requiring the use of assistive devices while standing and walking and had one to two falls in the past 3 months. The FRE directed nursing staff focus on Patient 1’s risk for falls with a goal of Patient 1 to be free of falls, and interventions to assist Patient 1 with ambulation and transfers. A review of Patient 1’s Situation, Background, Assessment, and Recommendation (SBAR) Form dated 6/1/25 at 11:50 pm indicated Patient 1 had a fall, was unresponsive to verbal questions, and sustained an open skin tear to the left side of Patient 1’s face due to the fall.  A review of Patient 1’s Risk for Falls Care Plan (CP) dated 6/1/25 indicated Patient 1 was transferred to General Acute Care Hospital 2 (GACH 2) Emergency Department (ED) on 6/1/25 due to a fall on 6/1/25. The CP interventions included assisting Patient 1 with walking, transferring, and placing Patient 1 in front of the Nurses’ Station for monitoring. A review of Patient 1’s Fall Investigation Report (FIR) dated 6/19/25 at 10:16 am indicated on 6/19/25 at 10 am, Patient 1 got up from Patient 1’s wheelchair and fell on the floor in front of Nurses’ Station 1. The FIR indicated LVN 2 was on the computer with the Activities Director (AD) in Nurses’ Station 1 on 6/19/25 [at 10 am]. The FIR indicated LVN 2 and the AD saw Patient 1 walking towards Nurses’ Station 1 unassisted, but LVN 2 and the AD were not able to get to Patient 1 in time because “the incident happened too fast.”  A review of Patient 1’s SBAR Form dated 6/19/25 and timed at 10:25 am indicated [on 6/19/25, at 10 am], Patient 1 got up from Patient 1’s wheelchair and fell on the floor in front of Station 1. A review of Patient 1’s SBAR Form dated 6/20/25 and timed at 7:15 pm indicated Patient 1 was “observed” grimacing in pain upon palpation of Patient 1’s left lower quadrant. The SBAR indicated Patient 1’s Primary Physician/Medical Doctor (MD 1) recommended Patient 1 to get an X-ray. A review of Patient 1’s X-ray Report dated 6/21/25 indicated the reason MD 1 ordered an X-ray of Patient 1’s ribs was due to Patient 1 having acute pain due to trauma. The X-ray Report indicated Patient 1 had an acute nondisplaced fracture of the left 8th, 9th, and 10th ribs. During an interview on 6/26/25 at 10:06 am with LVN2, LVN 2 stated Patient 1 was “a fall risk” and Patient 1 had a history of getting up (from bed and or wheelchair) unassisted. LVN 2 stated, on 6/19/25, at “approximately 10 am”, LVN 2 and the AD were on the computer in Nurses’ Station 1 looking for some information. While looking for information on the computer, LVN 2 and the AD heard another patient (unidentified) make a sound to alert others that something was about to happen. LVN 2 and the AD went outside of Nurses’ Station 1 and found Patient 1 lying on Patient 1’s left side, on the floor. LVN 2 stated Patient 1 complained of pain but Patient 1 was not able to state where the pain was. Patient 1 was placed near Nurses’ Station 1 so LVN 2 could monitor Patient 1’s behavior of getting up from Patient 1’s wheelchair due to Patient 1 being at a high risk for falls and having recurring behavior of getting up while sitting on wheelchair. During an interview on 6/26/25 at 3 pm with LVN 1, LVN 1 stated Patient 1 was constantly trying to get up from Patient 1’s bed and or wheelchair unassisted. Patient 1 needed one-to-one care. Patient 1 would get up out of the wheelchair unassisted even when a staff member was sitting in front of Patient 1. LVN 1 stated, on 6/19/2025, Patient 1 was taken to the activity room for the morning activities, but Patient 1 was brought back in front of Nurses’ Station 1 quickly due to Patient 1 trying to get up while sitting in Patient 1’s wheelchair. During an interview on 6/26/25 at 3:46 pm with the Activities Director (AD), the AD stated, on 6/19/25 (unable to remember exact time), the AD walked up to Nurses’ Station 1 and saw Patient 1 in Patient 1’s wheelchair in front of Nurses’ Station 1. The AD stated the AD went inside Nurses’ Station 1 and asked LVN 2 for assistance on the computer. While looking for information on the computer with LVN 2, the AD heard a crashing noise. The AD walked around to the front of Nurses’ Station 1 and saw Patient 1 lying on Patient 1’s left side on the floor. Patient 1 liked to stand up a lot and forgot to use Patient 1’s wheelchair. During a concurrent interview and record review on 6/26/25 at 3:53 pm with the Assistant Director of Nursing (ADON), Patient 1’s Physician’s Order dated 1/24/25 was reviewed. Patient 1’s Physician’ s Order dated 1/24/25 indicated for staff to monitor Patient 1 for episodes of getting up from the wheelchair and the bed unassisted every shift. The ADON stated Patient 1 had a history of getting up from Patient 1’s wheelchair unassisted and needed to be monitored. A review of the facility’s Policy and Procedure (P&P) titled, “Dementia Care,” dated 10/2017 indicated, “The Interdisciplinary Team would seek to identify and address the root cause of challenging patient behaviors to determine whether there is a medical, physical, environmental cause of the behavior. The P&P indicated the IDT would develop plans of care and implement interventions to understand and address behaviors as a form of communication and modify the environment and daily routines to meet the patient’s needs/preferences.” A review of the facility’s P&P titled, “Fall Management Program,” revised March 2021 indicated the purpose of the facility’s Fall Management Program was to provide patients a safe environment that minimizes complications associated with falls. The facility will implement a Fall Management Program that supports providing an environment free from fall hazards. The facility failed to: 1. Ensure that LVN 2 monitored and promptly redirected Patient 1 when Patient 1 got up from a wheelchair unassisted while Patient 1 was at Nurses’ Station 1 on 6/19/25 [at around 10 am]. 2. Develop and implement a care plan for Resident 1 that included adequate oversight to mitigate fall risk. 3. Ensure staff followed the facility's P&P titled, “Dementia Care,” dated 10/2017, which called for the development and implementation of plans of care to meet the patients’ needs and preferences. As a result, on 6/19/25, at approximately 10 am, Patient 1 fell out of Patient 1’s wheelchair, in front of Nurses’ Station 1. Patient 1 sustained fractures of the left 8th, 9th, and 10th ribs. The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Patient 1.