Health inspection·December 11, 2025

1D9F96Code of Federal Regulations, Title 42, Section 483.25(d) Accidents. The facility must ensure that – §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(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. 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 10/24/2025 at 1:20 pm, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to investigate a complaint regarding a resident’s fall. The facility failed to ensure the environment remained as free of accident hazards as possible and residents received adequate supervision for Resident 1 and Resident 2 when: a. Resident 1’s bed sensor pad alarm (an assistive electronic device that makes alerts/sounds to warn caregivers when the resident tries to get up from the bed) did not sound when Resident 1 got up from Resident 1’s bed unassisted by staff and walked to the bathroom. b. The facility’s licensed nursing staff failed to conduct a fall risk assessment or inaccurately assessed Resident 2 as low risk for fall following Resident 2’s falls on 5/31/2025, 8/4/2025, and 10/4/2025. c. The facility’s Interdisciplinary Team failed to conduct a comprehensive root cause analysis (systematic process to identify the underlying reasons a fall occurred, which can then be used to prevent future incidents) of Resident 2’s falls on 5/31/2025, 8/4/2025, and 10/4/2025 and update Resident 3’s care plan interventions to prevent Resident 2 from falling again. As a result, Resident 2 fell on 5/31/2025, 8/4/2025, and 10/4/2025. Resident 2 sustained lacerations to the head from a fall on 5/31/2025 and on 8/4/2025. These failures also had the potential for Resident 1 to sustain injury and/or harm due to falling while in care of the facility. a. A review of Resident 1's Admission Record (AR) indicated the facility admitted Resident 1, a 76-year-old female, on 4/4/2025 with diagnoses including transient cerebral ischemic attack, dysphagia, and dementia. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/12/2025, indicated Resident 1 had moderately impaired cognition. The MDS indicated Resident 1 required supervision or touching assistance from staff for toileting, personal hygiene, and dressing. The MDS indicated Resident 1 required supervision or touching assistance from staff for walking. A review of Resident 1’s Order Summary Report (OSR), dated 10/27/2025, indicated a physician order dated 9/15/2025 for nursing staff to apply bed sensor pad alarm to Resident 1 every shift for safety due to history of falls and to monitor placement of the bed sensor pad alarm every shift. During an observation on 10/27/2025 at 11:22 AM, in Resident 1’s room, Resident 1 got up from Resident 1’s bed and walked alone while using a front wheel walker (FWW, a device used to assist individuals with balance and mobility problems). Resident 1 walked to the restroom on the other side of the room from Resident 1’s bed. Staff did not come to Resident 1’s room. The sensor alarm for Resident 1 did not sound. Resident 1 shut the bathroom door behind Resident 1. During a follow-up interview on 10/27/2025 at 11:41 AM with Resident 1, Resident 1 stated Resident 1 had fallen multiple times at the facility. Resident 1 stated Resident 1 gets dizzy due to chemotherapy. Resident 1 stated Resident 1 was not supposed to walk alone to the bathroom. Resident 1 stated Resident 1 had walked alone earlier (when surveyor observed) without assistance from staff because staff did not always come right away when Resident 1 needed to use the toilet. b. A review of Resident 2's AR indicated the facility admitted Resident 2, a 66-year-old male, on 1/22/2025 and readmitted on 5/3/2025 with diagnoses including encounter for surgical aftercare following surgery on the digestive system, metabolic encephalopathy, and seizures. A review of Resident 2's MDS dated 10/12/2025 indicated Resident 2 was severely impaired in cognitive skills. The MDS indicated Resident 2 required supervision or touching assistance from staff for personal hygiene, bathing and dressing. The MDS indicated Resident 2 required supervision or touching assistance from staff for walking. A review of Resident 2’s General Acute Care Hospital 1 (GACH 1) Emergency Trauma Documentation (ETD) dated 5/31/2025, the ETD indicated Resident 2 presented to GACH 1 Emergency department (ED) on 5/31/2025 with chief complaint of a fall. The ETD indicated Resident 2 hit Resident 2’s head when Resident 2 fell in the facility. The ETD indicated Resident 2 had a 3-centimeter (cm) scalp laceration. The ETD indicated the physician repaired Resident 2’s laceration with three staples. A review of Resident 2’s GACH 2 ED Provider Note (ED Note), dated 8/4/2025, the ED Note indicated Resident 2 presented to GACH 2 ED on 8/4/2025 with a 4 cm laceration to the head due to an unwitnessed fall at the facility. The ED Note did not indicate any treatment for Resident 2’s laceration. During a concurrent interview and record review on 10/27/2025 at 2:20 PM with the Director of Nursing (DON), Resident 2’s Change in Condition Evaluation (CIC) dated 5/31/2025, 8/4/2025, and 10/4/2025 were reviewed. The DON stated Resident 2 had fallen at the facility on five separate occasions since being admitted to the facility. The CIC, dated 5/31/2025, indicated on 5/31/2025 at 1:20 PM, Resident 2 was found on the floor lying on the right side. The CIC indicated Resident 2 had a right head hematoma and a laceration measuring around 3 cm long. The CIC indicated Resident 2’s physician instructed the facility to send Resident 2 via 911 (emergency response) to a General Acute Care Hospital (GACH) due to unwitnessed fall and to treat Resident 2’s hematoma and laceration on Resident 2’s head. The CIC indicated 911 was called and that emergency medical services (EMS) took Resident 2 to GACH 1. The CIC, dated 8/4/2025, indicated on 8/4/2025 at 1 PM, Resident 2 was observed on the floor face down, and had a 5 cm long laceration on the forehead with bleeding. Resident 2 was transferred to (GACH 2) via 911 for further evaluation. The CIC, dated 10/4/2025, indicated on 10/4/2025 at 1:20 PM Resident 2 had an unwitnessed fall and was discovered on the floor. The CIC indicated Resident 2 verbalized feeling dizzy and fell. The CIC indicated Resident 2’s physician instructed the facility to send Resident 2 to GACH 3 for further evaluation. During a concurrent interview and record review on 10/28/2025 at 9:49 AM with the DON, Resident 2’s Nursing-Fall Risk Evaluation (FRE) dated 5/22/2025 and 10/4/2025 were reviewed. The DON stated the FRE dated 5/22/2025 inaccurately indicated Resident 2 had no falls in the last 90 days. The FRE dated 10/4/2025 inaccurately indicated Resident 2 was at low risk of falling. The DON stated the FRE dated 5/22/2025 incorrectly indicated Resident 2 was at low risk of falling instead of accurately indicating Resident 2 was at high risk of falling again. The DON stated an FRE was required after each fall to help identify risks of falls prior to the resident falling again. The DON stated if an FRE is completed inaccurately, then residents had the potential to fall again. The DON also stated an FRE was not completed after Resident 2 fell on 5/31/2025. c. During a concurrent interview and record review on 10/28/2025 at 9:49 AM with the DON, Resident 2’s Progress Notes (PN), dated 10/27/2025, was reviewed. The PN indicated the IDT fall review committee met following Resident 2’s falls on 5/31/2025, 8/4/2025 and 10/4/2025. The DON stated the IDT did not conduct a thorough root cause analysis for each of Resident 2’s fall. The DON stated the IDT did not focus on Resident 2’s diagnoses as being a contributing factor to Resident 2’s repeated falls. The DON stated the IDT did not change interventions to prevent Resident 2 from falling but still expected the current interventions to prevent Resident 2 from falling again. The DON stated if the IDT did not conduct a thorough root cause analysis, Resident 2 would likely fall again. During a concurrent interview and record review on 10/28/2025 at 9:49 AM with the DON, Resident 2’s undated Care Plan Report (CPR) was reviewed. The CPR indicated the facility failed to initiate or update Resident 2’s care plan to address Resident 2’s risk of falling again, following Resident 2’s falls on 5/31/2025, 8/4/2025, and 10/4/2025. The DON stated the IDT did not review Resident 2’s care plan following the falls. The DON stated if a resident (in general) had repeated falls then interventions used to prevent the falls must be changed since the current interventions were not working to prevent the falls. The DON stated if resident’s care plan was not updated following a fall, the resident would be more likely to fall again. A review of the facility's undated policy and procedure (P&P) titled, "Fall Management & Prevention Policy,” indicated the purpose of the fall management and prevention policy was, “To minimize the risk of patient/resident falls and fall-related injuries by implementing assessment, prevention, and management strategies …” The P&P indicated the responsibility of the facility’s Clinical and Nursing staff (in general) was to: “Conduct fall risk assessment on admission, transfer, after a fall, or when there is a significant change in condition. Develop and implement individualized fall prevention plans. Document interventions and patient/resident responses in the care record. Educate patients/residents and families on fall risks, prevention measures and safe mobility. Report all falls and near-falls immediately according to facility incident reporting procedures.” The P&P indicated the responsibility of all staff was to “…. Maintain a safe physical environment: clear walkways, adequate lighting, safe flooring, proper use of equipment and assistive device…” The P&P indicated Post Fall (after a resident falls at the facility) Management included: “… Update the individual's care plan and risk status if needed…Convene a multidisciplinary fall review committee (e.g., nursing, PT/OT, risk management, quality/safety) to analyze: The event's chain of events and contributing factors. Whether existing interventions were in place and effective. Recommend and implement corrective actions (e.g., change in intervention plan, staff education, environment modification) …” The facility failed to ensure the environment remained as free of accident hazards as possible and residents received adequate supervision for Resident 1 and Resident 2 when: a. Resident 1’s bed sensor pad alarm did not sound when Resident 1 got up from Resident 1’s bed unassisted by staff and walked to the bathroom. b. The facility’s licensed nursing staff failed to conduct a fall risk assessment or inaccurately assessed Resident 2 as low risk for fall following Resident 2’s falls on 5/31/2025, 8/4/2025, and 10/4/2025. c. The facility’s Interdisciplinary Team failed to conduct a comprehensive root cause analysis of Resident 2’s falls on 5/31/2025, 8/4/2025, and 10/4/2025 and update Resident 3’s care plan interventions to prevent Resident 2 from falling again. As a result, Resident 2 fell on 5/31/2025, 8/4/2025, and 10/4/2025. Resident 2 sustained lacerations to the head from a fall on 5/31/2025 and on 8/4/2025. These failures also had the potential for Resident 1 to sustain injury and/or harm due to falling while in care of the facility. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1 and Resident 2.