Health inspection·October 10, 2025

Regulatory Violations: §72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of resident care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the resident's needs with input, as necessary, from health professionals involved in the care of the resident. Initial assessments shall commence at the time of admission of the resident and be completed within seven days after admission. (B) Development of an individual, written resident 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. (C) Reviewing, evaluating and updating the resident care plan as necessary by the nursing staff and other professional personnel involved in the care of the resident at least quarterly, and more often if there is a change in the resident's condition. (2) Implementing each resident's care plan according to the methods indicated. Each resident's care shall be based on this plan. F-689: Free of Accident Hazards/Supervision/Devices §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. During the investigation, CDPH determined that the facility failed to ensure Certified Nursing Assistant (CNA) 1 followed the facility’s policy and procedure (P&P) titled “Response to Falls” by: 1. Not immediately notifying a licensed nurse after Resident 1, who was at risk for pathological fractures (a bone fracture that occurs in a bone that has been weakened by an underlying disease or condition), experienced a fall on 8/19/2025. 2. Improperly lifting and moving Resident 1 from the floor back to bed prior to a licensed nurse’s assessment. 3. Delaying notification to Licensed Vocational Nurse (LVN) 1 by approximately 20 minutes after the fall occurred. This deficient practice had the potential to cause further injury or complications for Resident 1 following an unwitnessed fall. On 8/19/2025, at approximately 9:00 PM, LVN 1 found Resident 1 shivering and shaking in pain after the fall with a swollen, discolored left foot, and moderate to severe level of pain. The result of an X-ray (imaging technology that creates images of people’s body, including the bones, and is often used in diagnosis fractures), dated 8/19/2025, indicated that the resident had a left foot fracture. On 8/21/2025, Resident 1’s left foot and left leg were placed in a cast for a duration of four weeks. Findings: A review of Resident 1’s Admission Record indicated an 84 year old, female resident, who was originally admitted at the facility on 8/19/2022, and readmitted on 11/27/2024, with diagnoses that included Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities), muscle weakness, dementia (a progressive state of decline in mental abilities), and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). A review of Resident 1’s care plans indicated that Resident 1 is “At risk for pain, muscle weakness or fractures [due to] Vitamin D deficiency,” initiated on 8/27/2022, and revised on 9/26/2023. Interventions in the care plan included for “gentle handling during care to avoid accidental fractures and minimize bone pain.” A review of Resident 1’s History and Physical (H&P), dated 11/29/2024, indicated that the resident does not have the capacity to understand and make decisions. The H&P indicated that the resident has a history of hip fracture. A review of Resident 1’s Morse Fall assessment (an assessment to determine a resident’s fall risk factors), dated 5/20/2025, the Fall assessment indicated that Resident 1 was assessed as a high risk for falls. The Fall Note indicated that Resident 1 had a history of falls. The Falls assessment also indicated that Resident 1 “overestimates or forgets limits” of her ability to walk safely. The Falls assessment did not indicate additional interventions to be added or revised to the resident’s care plan as a result of this Fall assessment. A review of Resident 1’s Minimum Data Set (MDS- a resident assessment tool), dated 8/19/2025, indicated the resident has severely impaired cognition (the ability to process thoughts). The MDS indicated that Resident 1 has impaired range of motion on one side of her body. The MDS indicated that Resident 1 required maximal assistance (helper does more than half the effort) on activities such as moving in bed from left to right, changing positions from sitting to lying, sitting to standing, and transferring to and from a bed to a chair. The MDS also indicated that Resident 1 is dependent (helper does all the effort) on activities such as toileting, lower body dressing, transferring to a toilet, and transferring to a tub or shower. The MDS also indicated that Resident 1 was not able to walk 10 feet at the time of assessment. A review of Resident 1’s care plans indicated that Resident 1 is “At risk for pathological fractures [due to] aging process and osteoporosis,” initiated on 3/4/2023, revised on 9/26/2023. Interventions included for “gentle handling of resident to prevent injury/fractures.” A review of Resident 1’s care plans indicated the resident is “At risk for spontaneous fractures,” initiated on 7/21/2023. The care plan indicated a goal to “decrease potential of fall and resulting to fractures.” The care plan also included interventions initiated on 7/21/2023 to “handle resident gently while assisting with [Activities of Daily Living] and transfers.” The care plan also indicated interventions for staff to “handle gently when moving resident.” A review of Resident 1’s Change in Condition (CIC), dated 8/19/2025, timed at 9:11 PM, authored by LVN 1, the CIC indicated that Resident 1 sustained a fall on 8/19/2025. The CIC indicated that (CNA 1) reported noticing discoloration on the resident’s foot. The CIC indicated when LVN 1 assessed Resident 1, she found Resident 1 on the bed and that the top of Resident 1’s left foot was “swollen [with] bluish discoloration.” The CIC indicated that [LVN 1] asked [CNA 1] whether he had noticed the discoloration earlier in the shift. [CNA 1] responded that he saw the discoloration 20 minutes earlier, just before informing LVN 1. The CIC further indicated that [CNA 1] found the “resident on the floor mat and picked [the resident] up and put [the resident] back in bed.” The CIC indicated that Resident 1 had a moderate to severe level of pain. The CIC further indicated that the physician was notified on 8/19/2025 at 9:19 PM with an order for an Xray. A review of Resident 1’s physician’s order, dated 8/19/2025, timed at 9:41 PM and authored by LVN 1, included an order for “STAT (immediately or right now) X-ray (imaging technology that creates images of people’s body, including the bones, and is often used in diagnosis fractures)” of the left foot due to pain. A review of Resident 1’s Pain Assessment note, dated 8/19/2025, timed at 10:28 PM, and signed by LVN 1, the note indicated Resident 1 exhibited indicators of pain such as “non-verbal sounds,” “vocal complaints of pain,” “facial expressions” of pain, and “protective body movements or postures” such as “bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement.” The Note indicated that Resident 1 received Ibuprofen (a pain medication) 600 mg (milligrams, a unit of measuring weight). A review of Resident 1’s Medication Administration Record (MAR) for the month of August 2025, the MAR included a physician order dated 8/19/2025, timed at 10:13 PM, to administer “Ibuprofen Oral Tablet 600 mg give 1 tablet by mouth every 12 hours as needed for moderate pain.” The MAR also indicated that on 8/19/2025 at 10:37 PM, Resident 1 was given the medication for a pain level of seven (7) out of ten (10). The MAR also indicated that on 8/19/2025 at 1:04 PM, Resident 1 was given the medication for a pain level of four (4) out of ten (10). A review of Resident 1’s Radiology Report, dated 8/19/2025, timed at 11:40 PM, the Report indicated that Resident 1 had an “Acute nondisplaced distal fourth metatarsal neck fracture. Possible additionally distal fifth metatarsal neck fracture.” A review of Resident 1’s care plans indicated that Resident 1 had an “actual unwitnessed fall [on] 8/19/2025”, initiated on 8/20/2025. The care plan indicated for Resident 1 to wear a “foot cast (a protective, rigid device, typically made of fiberglass or plaster, that immobilizes a broken bone to hold it in place) on left foot” for a left foot fracture for a duration of four (4) weeks. A review of Resident 1’s Progress Notes included an IDT (Interdisciplinary Team) Notes entry, dated 8/20/2025, timed at 6:41 PM. The IDT Note indicated that the social worker and RN 3 discussed Resident 1’s unwitnessed fall with the resident’s family member, Family Member (FM) 1. The IDT Note indicated that Resident 1’s x-ray result confirmed that the resident suffered a left foot fracture. The IDT Note also indicated that FM 1 did not want Resident 1 to be transferred to the acute hospital. The IDT Note further indicated that FM 1 agreed to the interventions of Podiatry (field of medicine that specializes in the treatment of the feet) consultation, pain management measures, the use of a bed alarm (a device placed over a resident’s bed that emits a sound to notify staff that the resident is attempting to leave the bed), and Physical and Occupational Therapy. A review of Resident 1’s physician orders included an order, dated 8/21/2025, for “Foot cast on left foot for left 4th metatarsal neck fracture every shift for 4 weeks.” A review of Resident 1’s Podiatry (the treatment of the feet and their ailments) Note, dated 8/21/2025, the Podiatry Note indicated information about Resident 1’s fall on 8/19/2025. The Podiatry Note indicated Resident 1 had severe pain after the fall with painful, swollen, edema, ecchymosis to the dorsal aspect of the left foot. The Podiatry Note indicated Resident 1’s range of motion (ROM) was limited due to severe pain on any movement. The Podiatry Note further indicated that Resident 1 had a fracture of the fourth metatarsal (long bone next to the little toe of the foot) of the left foot. The Podiatry Note indicated Resident 1’s left foot and left leg were placed in a cast for a duration of four weeks. During an observation on 9/4/2025 at 9:28 AM, Resident 1 was observed lying in bed. Resident 1 was observed wearing a cast over the left foot. Resident 1 was observed comfortable and without any signs or symptoms of pain. An attempt to interview Resident 1 was conducted, but Resident 1 did not respond or acknowledge the presence of the survey team. During an interview on 9/4/2025 at 10:05 AM with CNA 2, CNA 2 stated Resident 1 cannot stand up without assistance from facility staff. CNA 2 stated if a resident is observed on the floor, the resident must not be moved, and the licensed nurse must be informed immediately. During a phone interview on 9/4/2025 at 10:16 AM with CNA 1, CNA 1 stated that on 8/19/2025, between 8:30 PM to 9 PM, he was walking by the facility hallway, outside Resident 1’s room when he saw that Resident 1 was not in bed. CNA 1 stated he saw Resident 1’s feet were on the floor. CNA 1 stated when he went inside Resident 1’s room, he found Resident 1 lying on the floor, face up. CNA 1 stated Resident 1 did not complain of pain nor exhibited signs of pain while on the floor. CNA 1 stated Resident 1 verbally asked for help. CNA 1 then stated that he lifted the resident up from the floor by wrapping his arms around the resident’s body, under the armpits, then lifted the resident and carried the resident to the bed. CNA 1 added he did not ask for help because the other nursing staff were busy. CNA 1 stated he “didn’t need the charge nurse” to move the resident back to bed because the resident was not “not heavy.” During the same phone interview on 9/4/2025 at 10:16 AM with CNA 1, CNA 1 stated it was only when Resident 1 was in bed, the resident complained of pain. CNA 1 further clarified that Resident 1 did not express that the resident experienced pain while on the floor, nor did CNA 1 observe the presence of pain from Resident 1 while the resident was on the floor. During a follow-up phone interview on 9/4/2025 at 11:31 AM with CNA 1, CNA 1 re-stated that Resident 1 complained of pain only after he had put the resident back in bed. CNA 1 also stated he only noticed the bruising when Resident 1 was in bed. CNA 1 added after placing Resident 1 in bed, upon observing the bruising in the left foot, and Resident 1’s complaint of pain, he became busy and was not able to inform the nurse immediately. During a phone interview on 9/4/2025 at 11:48 AM with LVN 1, LVN 1 stated that on 8/19/2025, between 9:10 PM to 9:20 PM, CNA 1 approached her at the Nursing Station to report discoloration on Resident 1’s foot. LVN 1 stated that upon entering the resident’s room, LVN 1 observed Resident 1 lying in bed with a swollen, bluish left foot and the resident was “shivering and shaking” in pain. When LVN 1 asked CNA 1 about the discoloration, LVN 1 stated that CNA 1 had noticed it approximately 20 minutes earlier. LVN 1 further stated that after further questioning, CNA 1 disclosed that he had found Resident 1 on the floor and had returned her to bed without notifying LVN 1 at the time. During the same phone interview on 9/4/2025 at 11:48 AM with LVN 1, LVN 1 stated CNA 1 should have informed the licensed nurses on 8/19/2025 immediately that Resident 1 was on the floor. LVN 1 added the licensed nurses must assess Resident 1 before she was moved because any injury sustained by the resident “could get worse” if she was moved. LVN 1 stated CNA 1 did not provide a reason why he did not notify the licensed nurses upon finding Resident 1 lying on the floor on 8/19/2025, immediately. During a phone interview on 9/4/2025 at 12:43 PM with Registered Nurse (RN) 1, RN 1 stated on the evening of 8/19/2025, CNA 1 reported to LVN 1 that Resident 1’s left foot had a “bruise.” RN 1 stated upon her arrival inside Resident 1’s room, Resident 1 was already in bed. RN 1 stated she assessed Resident 1’s left foot and found that it was “swollen” and “seemed like there was fracture.” RN 1 stated Resident 1 also complained of pain when the left foot was touched. During an interview on 9/4/2025 at 2:47 PM with RN 2, RN 2 stated when a CNA finds a resident on the floor, the CNA should inform the licensed nurse immediately. RN 2 stated it is important for a licensed nurse to assess any resident who is found on the floor prior to being moved. RN 2 stated moving a resident prior to a licensed nurse’ assessment could potentially cause a fracture and the “situation could get worse.” RN 2 stated that a licensed nurse should also be present when the resident is moved from the floor to the bed, because it is part of the assessment to identify if the resident has pain in any part of the body, including the feet and legs. During a concurrent interview and record review on 9/4/2025 at 4:43 PM with the Director of Nursing (DON), Resident 1’s medical records were reviewed, including the CIC, dated 8/19/2025 authored by LVN 1. The DON stated the CIC indicated that Resident 1 was found to have discoloration on the left foot. The DON stated the CIC also indicated CNA 1 assigned to Resident 1, failed to inform LVN 1, immediately that Resident 1 was found on the floor beside the resident’s bed. Furthermore, the DON added that the CIC indicated CNA 1 had returned Resident 1 back to bed without notifying LVN 1. During the same interview on 9/4/2025 at 4:43 PM with the DON, the DON stated CNA 1 should have informed the licensed nurses on 8/19/2025, as soon as CNA 1 found Resident 1 lying on the floor. The DON stated prior to moving Resident 1, the licensed nurse should have assessed the resident to look for the presence o