Health inspection·December 18, 2025

Code of Federal Regulations, Title 42, Section 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. The comprehensive care plan must describe the following: California Code of Regulations, Title 22, Section 72311. Nursing Services-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: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 11/5/25 at 9:45 am, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to investigate an anonymous complaint regarding resident falls. The facility failed to implement and revise the care plan for Resident 1 who was assessed at high risk for falls in accordance with the facility’s policy and procedure (P&P) titled, “Falls by a Resident” by failing to ensure: 1. Resident 1 was supervised and assisted while walking in the hallway on 9/6/25 in accordance with Resident 1’s fall risk care plan. As a result, Resident 1 fell on 9/6/25 and sustained bruises, swelling, and an open wound on the forehead. 2. Resident 1’s fall risk care plan was revised with new interventions after Resident 1 fell on 9/6/25. As a result, Resident 1 fell on 11/1/25 and sustained bruises on the right side of the forehead, on the right eye, and on the right side and left side of the face.   A review of Resident 1’s Admission Record (AR), indicated Resident 1, a 77-year-old female, was admitted to the facility on 8/21/25 with diagnoses that included metabolic encephalopathy, other abnormalities of gait and mobility, and anxiety disorder.   A review of Resident 1’s Nursing Admission Assessment (NAA), dated 8/21/25, indicated Resident 1’s skin condition upon admission included: 1) upper lip abrasion, 2) right cheek bluish discoloration, 3) right shoulder bluish discoloration, 4) knee scabs, and 5) left under arm bluish discoloration.   A review of Resident 1’s Fall Risk Evaluation (FRE) form, dated 8/21/25, indicated Resident 1’s risk for fall was rated high risk with a score of 12. The form indicated a total score of 10 or above represented high risk for fall.   A review of Resident 1’s care plan titled, “At Risk for Fall/Injury related to History of Falls Prior to Admission,” the care plan indicated an initiation date of 8/21/25 with a goal date of 11/2025 (November 2025). The care plan indicated the re-evaluation date was 11/2025 (November 2025). The care plan interventions included to provide visual checks to Resident 1 at least every two hours, to keep room well lighted, to maintain the resident’s bed in lowest position, to ensure brakes are applied during transfers in and out of bed/chair, to assess for side effects from meds as cause of fall, optometry/ophthalmology consult and follow up as needed, and laboratory tests as ordered by the physician. The care plan indicated it has not been revised since it was initiated on 8/21/25.     A review of Resident 1’s History and Physical (H&P), physician’s clinical evaluation and examination of the resident), dated 8/22/25, indicated Resident 1 did not have the capacity to understand and make medical decisions. The H&P also indicated Resident 1 needed fall precautions.   A review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool), dated 8/25/25, indicated Resident 1 had severely impaired cognition for daily decision making. The MDS indicated Resident 1 required partial/moderate assistance (helper does more than half the effort) to walk and transfer.   A review of Resident 1’s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 9/6/25, indicated Resident 1 “had a fall in the hallway while ambulating with FWW [front-wheeled walker].” Resident 1 lost balance and hit the left side of Resident 1’s forehead on the floor. The SBAR indicated Resident 1 had a “bump to the front of left forehead.” The SBAR did not indicate, and there was no documented evidence in Resident 1’s medical record, that a staff member supervised or assisted Resident 1 to walk with a FWW when Resident 1 fell on 9/6/25. Upon review of Resident 1’s medical record, there was no care plan regarding Resident 1’s fall on 9/6/25 found in the medical record. Resident 1’s care plan titled, “At Risk for Fall/Injury related to History of Falls Prior to Admission,” dated 8/21/25, was not updated after Resident 1 fell on 9/6/25.   A review of Resident 1’s FRE, dated 9/6/25, indicated Resident 1’s risk for fall was rated high risk with a score of 16. The form indicated a total score of 10 or above represented high risk for fall.   A review of Resident 1’s Nurses Notes from 9/6/25 through 9/9/25 indicated Resident 1 was on monitoring and Neuro-check (neurological exam, a group of questions and tests to check for disorders of the nervous system often performed after a suspected head injury) after a fall with “bruising to left forehead.”   A review of Resident 1’s Status Post Fall Assessment (SPFA) completed by the physical therapist (PT), dated 9/8/25, indicated Resident 1 fell on 9/6/25 at 2:50 pm. The SPFA indicated Resident 1 was confused and did not remember falling. The SPFA indicated Resident 1 had bruises, swelling, and an open wound on the forehead. The assessment indicated Resident 1 needed supervision at all times according to the PT recommendations.   A review of Resident 1’s SBAR and Nurses Notes, dated 11/2/25, indicated Resident 1 had a fall in Resident 1’s room, next to the wheelchair and the bed. Resident 1 was found sitting on Resident 1’s buttocks on the floor and was assessed with a right knee abrasion and a small bump to the right side of the head.   A review of Resident 1’s SPFA completed by the PT, dated 11/3/25, indicated, “Resident remembered falling, but doesn’t want to give detailed report.” The SPFA indicated Resident 1 fell on 11/1/25 at 11:30 pm in Resident 1’s bedroom. The SPFA indicated Resident 1 had bruises on the right side of the forehead, on the right eye, and on the right side and left side of the face. The SPFA indicated Resident 1 needed supervision at all times according to the PT recommendations.   During a concurrent interview and record review on 11/5/25 at 1:55 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated LVN 1 was familiar with Resident 1’s care. LVN 1 stated LVN 1 was aware of Resident 1’s fall on 11/2/25. LVN 1 stated Resident 1 sustained a discoloration around the right eye from Resident 1’s fall on 11/2/25. LVN 1 reviewed Resident 1’s care plan titled, “At Risk for Fall/Injury related to History of Falls Prior to Admission,” dated 8/21/25, and stated the care plan was not changed or updated after 8/21/25. LVN 1 stated the facility’s post fall protocol included assessing the resident for injury, completing a change of condition or SBAR, completing a fall incident report, completing a Status Post Fall Assessment (SPFA) by the rehabilitation department, a review of the fall incident report and the SPFA by the Interdisciplinary Team (IDT), the IDT making recommendations for resident’s continued care, and updating or creating a fall care plan.   During an interview on 11/5/25 at 2:11 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated, “When a resident falls, you check with the resident and ask what happened. You check the resident for injuries, and take vitals, then complete an incident report and update the care plan right away or initiate one if there is none.”   During a concurrent interview and record review on 11/6/25 at 1:31 pm with the Director of Nursing (DON), the DON reviewed Resident 1’s care plan for “At Risk for Fall/Injury related to History of Falls prior to Admission,” dated 8/21/25, and stated the care plan was not updated after the 11/1/25 fall. The DON stated the care plan should be created or updated within 72 hours of a resident’s fall to develop interventions or revise interventions to reduce the risk of future falls.   A review of the facility’s current P&P titled, “Falls by A Resident,” revised 7/2017, indicated, “It is the policy of the facility that if a resident sustains a fall, an incident report will be completed. A post fall assessment is also completed to identify factors that may have contributed to the fall. A care plan or an update to an existing care plan will then be generated…A post fall assessment is completed to identify possible causative factors that could have contributed to a fall. The information is then used to formulate a plan of care in an attempt to prevent further falls or accidents…The licensed nurse will complete the form as follows: Document on the post fall assessment that the care plan was updated to reflect an action plan or approaches developed for prevention of falls; If there is an existing care plan for falls, it should be updated to reflect newly identified risk factors or approaches developed; If there was no existing care plan, a care plan for prevention of falls will be developed.” The facility failed to implement and revise the care plan for Resident 1 who was assessed at high risk for falls in accordance with the facility’s P&P titled, “Falls by a Resident” by failing to ensure: 1. Resident 1 was supervised and assisted while walking in the hallway on 9/6/25 in accordance with Resident 1’s fall risk care plan. As a result, Resident 1 fell on 9/6/25 and sustained bruises, swelling, and an open wound on the forehead. 2. Resident 1’s fall risk care plan was revised with new interventions after Resident 1 fell on 9/6/25. As a result, Resident 1 fell on 11/1/25 and sustained bruises on the right side of the forehead, on the right eye, and on the right side and left side of the face. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.