Health inspection·April 24, 2026

F689 Code of Federal Regulations, Title 42, Section 483.25 (d) Accidents. The facility must ensure that – §483.25(d)(1) The patient environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each patient 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: (2) Implementing of 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 3/10/2026, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility for the annual recertification survey. The facility failed to provide care and services to prevent a fall by failing to ensure Certified Nursing Assistant 5 (CNA 5) provided two-person physical assistance when turning Resident 2 in bed while changing Resident 2’s adult brief.   This violation resulted in Resident 2’s fall on 11/24/2025 and Resident 2 sustained a right femur fracture from the fall. Resident 2 was admitted to General Acute Care Hospital 1 (GACH 1) for right lower extremity immobilizer and received intravenous antibiotic treatment for pneumonia.   A review of Resident 2's Admission Record indicated the facility admitted Resident 2, a 67-year-old female on 2/13/2024 and readmitted on 12/5/2025 with diagnoses including unspecified fracture of the lower end of the right femur, morbid obesity and muscle weakness.   A review of Resident 2’s Care Plan (CP) for at risk for falls related to bowel/bladder incontinence dated 7/30/2025 indicated a goal to minimize falls and injury. The CP interventions included for staff to provide assistance with Resident 2’s activities of daily living.   A review of Resident 2's Minimum Data Set (MDS) dated 9/14/2025 indicated Resident 2 had intact cognition. The MDS indicated Resident 2 was dependent (helper does all the effort, assistance of 2 or more helpers is required for the resident to complete the activity) on staff for toileting hygiene, lower body dressing, lying to sitting on the side of the bed and chair to bed transfer. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) to roll left and right.   A review of Resident 2’s Situation Background Assessment Request (SBAR) Communication Form dated 11/24/2025 indicated on 11/24/2025 at 9:20 pm, CNA 5 attended Resident 2 for adult brief change. The SBAR indicated, upon turning Resident 2 to the left side, Resident 2 slid off the bed.   A review of Resident 2’s Post Fall Assessment (PFA) dated 11/24/2025 indicated upon turning Resident 2 to the left side by CNA 5 during adult brief change, Resident 2 slowly slid off the bed. The PFA indicated CNA 5 held onto Resident 2, with Resident 2 half kneeling on the floor. A review of Resident 2’s GACH 1 record dated 11/25/2025 indicated Resident 2 was diagnosed at the Emergency Room with a right femur fracture. Resident 2 was placed on right lower extremity immobilizer, and the resident also received intravenous antibiotic for 10 days due to pneumonia.   A review of Resident 2’s GACH 1 femur and knee X-ray report dated 11/25/2025 indicated Resident 2 had a nondisplaced distal femoral fracture with moderate suprapatellar lipohemarthrosis (fat and blood are both present within joint space) and soft tissue.   A review of Resident 2’s Nursing Admission Assessment dated 12/5/2025 at 11:00 p.m. indicated Resident 2 was readmitted back to the facility after 11 days hospitalization at GACH 1.   A review of Resident 2’s History and Physical dated 12/8/2025 indicated Resident 2 had the capacity to understand and make decisions.   During an interview on 3/10/2026 at 9:40 a.m. with Resident 2, Resident 2 stated Resident 2 had a fall on 11/24/2025.   During an interview on 3/12/2026, at 1:52 p.m., Resident 2 stated she slipped from the bed while being changed. Resident 2 stated there was one female CNA (CNA 3) who assisted Resident 2 with changing Resident 2’s adult brief. Resident 2 stated she fell face down to the right side of her bed. Resident 2 stated Resident 2 felt pain (not rated) in Resident 2’s right leg and injured the right knee from the fall.   During an interview on 3/13/2026 at 9:45 a.m., CNA 3 stated that when changing a dependent resident, Resident 2 would require two people assisting the resident regardless of the resident’s weight. CNA 3 stated that when the resident was morbidly obese, two staff were required to assist the resident to prevent the resident from rolling out of bed while being turned while changing the adult brief. CNA 3 stated for Resident 2, two people were required while changing Resident 2’s adult brief. CNA 3 stated Resident 2 needed two people working with Resident 2 because Resident 2 was dependent and morbidly obese. CNA 3 stated Resident 2 required two people assisting Resident 2 at all times. CNA 3 stated having only one staff working with Resident 2 was against the facility policy on Fall Management Program.   During an interview on 3/13/2026 at 10:01 a.m., CNA 4 stated Resident 2 was bed bound and dependent on staff. CNA 4 stated two staff were required to change and turn a dependent resident (Resident 2). CNA 4 stated it was important to change Resident 2 with two people assistance for safety.   During an interview on 3/13/2026 at 10:40 a.m., the Director of Nursing (DON) stated on 11/24/25, Resident 2 fell and sustained a fracture. The DON stated when changing Resident 2, Resident 2 would need 2 to 4 staff to help with task, depending on Resident 2’s strength. The DON stated having at least two staff when turning or changing Resident 2 was important for Resident 2’s safety to prevent a fall.   During an interview on 3/13/2026 at 11:22 a.m., the DON stated CNA 5 was the only staff present while changing Resident 2 on 11/24/2025 that resulted in Resident 2’s fall.   During an interview on 3/13/2026 at 11:32 a.m., the DON stated CNA 5 made a “bad judgement” and CNA 5 should have asked for help for additional staff. The DON stated CNA 5 was by herself while changing Resident 2 on 11/24/2025 that resulted in Resident 2’s fall.   During an interview on 3/13/26 at 12:01 p.m., the Assistant Director of Nursing (ADON) stated Resident 2 was a dependent resident who had bladder and bowel incontinence. The ADON stated Resident 2 wore an adult brief and had to be changed by staff. The ADON stated there had to be one staff on each side of the bed for repositioning, changing, and transferring Resident 2. The ADON stated Resident 2 needed two staff assistants for safety. The ADON stated Resident 2’s fall and fracture could have been avoided if there were two staff changing Resident 2.   A review of the facility’s Policy and Procedure (P&P), titled, “Fall Management Program,” revised November 21, 2024, indicated it was the policy of the facility to provide the highest quality care in the safest environment for the residents residing in the facility. A review of the facility’s P&P titled “Activities of Daily Living (ADLs), Supporting” revised July 2024, indicated residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The facility failed to provide care and services to prevent a fall by failing to ensure CNA 5 provided two-person physical assistance when turning Resident 2 in bed while changing Resident 2’s adult brief.   This violation resulted in Resident 2’s fall on 11/24/2025 and Resident 2 sustained a right femur fracture from the fall. Resident 2 was admitted to GACH 1 for right lower extremity immobilizer and received intravenous antibiotic treatment for pneumonia. The above violation 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 Resident 2.