Health inspection·December 18, 2025

F689 §483.25(d) Accidents. The facility must ensure that - §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. § 72309. Nursing Service. Nursing service means a service staffed, organized and equipped to provide skilled nursing care to patients on a continuous basis. § 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: (B) Development of an individual, written patient 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. § 72523. Patient Care Policies and Procedures (a) (a)Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. An unannounced visit was conducted by California Department of Public Health (CDPH) on 11/14/2025 to investigate a Facility Reported Incident (FRI) regarding an allegation of a Resident 1 fall. The facility failed to ensure: 1. Resident 1 was not left unattended by Certified Nurse Assistant 1 (CNA1). CNA 1 turned her back from Resident 1 who was in a shower chair while in the shower room on 11/2/2025 and the resident fell, which is in violation of the Facility’s Policy and procedure (P&P), titled “Bath, Shower/Tub,” revised 10/2023 2. Resident 1 received adequate supervision and assistance devices in the shower room in accordance with the facility’s P&P on Assistive Devices and Equipment. As a result, Resident 1,who was assessed as dependent on staff for Activities of Daily Living (ADL’s- basic self-care tasks essential for independent living, including bathing, dressing, eating, using the toilet, and moving from place to place) and with poor ability in maintaining sitting balance sustained a fall in the shower room on 11/2/2025 at around 10 AM resulting in a laceration to the forehead. On 11/2/2025 at 10:40 AM, Resident 1 was transferred to General Acute Care Hospital (GACH) where Resident 1 was diagnosed with acute nondisplaced fracture (a break in the bone that has not moved out of position, is recent) of first cervical vertebra (C1, the topmost bone that connects the skull to the spine) right posterior (back) arch, midline forehead hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) with laceration, and blunt head trauma (an injury to the head caused by a forceful impact). A record review of Resident 1's Admission Record indicated the Resident 1, a 86 year-old female, was admitted to the facility on 6/16/2022 with diagnoses that included Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities), cerebral infarction (the death of brain tissue due to a lack of blood flow), and dementia (a progressive state of decline in mental abilities). A record review of Resident 1's care plan (CP), dated 2/5/2025, indicated Resident 1 is dependent on staff for meeting emotional, intellectual, physical and social needs related to cognitive deficits (impairments in mental processes like memory, attention, reasoning, and language), immobility (the state of not moving) and physical limitations. The CP interventions included that Resident 1 needs assistance with ADL as required during the activity. A record review of Resident 1’s Mobility (the ability to move or be moved freely and easily) Assessment, dated 10/22/2025, indicated Resident 1’s mobility and balance was assessed having poor ability to sit up unassisted, poor ability to maintain sitting balance, poor ability to stand, and poor ability to maintain standing balance. A record review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 10/23/2025, indicated Resident 1's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). Resident 1 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, shower/bath, upper and lower body dressing, and putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 was dependent on tub/shower transfer (the ability to get in and out of a tub/shower). During an interview on 11/14/2025 at 2:19 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she observed Resident 1 on the floor of the shower room on 11/2/2025. LVN 1 verified she was working in the facility on 11/2/2025 and she responded to the fall incident in the shower room where Resident 1 was observed lying on the floor. LVN 1 stated CNA 1 told her that she had to leave Resident 1 while in the shower chair because another resident needed her assistance. A record review of Resident 1’s Progress Notes, dated 11/02/2025, timed 10:10 AM, by Registered Nurse (RN ) 1, indicated RN 1 was called to the shower room, and upon arrival, Resident 1 was found lying on the floor with an approximately two-inch laceration to the top of scalp. Paramedics (a person trained to give emergency medical care to people who are injured or ill) arrived at 10:35 AM and transported Resident 1 to GACH at 10:40 AM. A record review of Resident 1’s GACH Trauma Surgery History and Physical (H&P), dated 11/2/2025, indicated Resident 1 was status post ground level fall and on Xarelto (blood thinner medication). Positive head strike (refers to a documented impact to the head that is associated with specific concerning symptoms or physical findings of a potential brain injury, such as a concussion [ traumatic brain injury caused by a bump, blow, or jolt to the head or body that makes the brain move inside the skull] or intracranial bleeding [bleeding inside the skull, which can occur when a blood vessel in or around the brain ruptures or leaks]). Per Emergency Medical Services (EMS) Resident 1 slipped and fell from her shower chair. Resident 1 has a forehead hematoma and laceration. It also indicated the hematoma was at the midline of the forehead with a 1.5-centimeter (cm, unit of measurement) laceration with very light bleeding. A record review of Resident 1’s GACH Trauma Daily Progress Note, dated 11/3/2025, indicated Resident 1’s injuries that included the following: • Acute nondisplaced fracture of C1 right posterior arch – maintain aspen (a type of neck brace designed to provide support, stability, and motion restriction to the neck, mid-back, or lower back to facilitate healing after injury). • Midline forehead hematoma with laceration – status post repair with absorbable suture (a stitch used to close a wound). A record review of Resident 1’s Progress Notes, dated 11/4/2025, timed 10:52 PM, indicated Resident 1 was admitted from GACH with admitting diagnosis of posterior C1 fracture without displacement and midline forehead laceration. Aspen collar (brand of cervical [neck] collar used to support and stabilize the neck after injury or surgery) to be always worn for six (6) weeks. A record review of Resident 1’s Order Summary Report, dated 11/14/2025, timed 3:45 PM, indicated the following orders: • May be up in wheelchair daily as tolerated, ordered on 11/4/2025. • Monitor cervical brace for a proper fit and skin integrity, check for signs of skin breakdown, swelling or redness. Every shift for 6 weeks. Ordered on 11/5/2025. • May be up in reclining wheelchair, ordered on 11/14/2025. During a concurrent observation in Resident 1’s room and interview on 11/14/2025 at 12:25 PM with the Director of Nursing (DON), Resident 1 was sitting in a reclining wheelchair, in a reclining position. The DON stated Resident 1 started using the reclining wheelchair when Resident 1 was readmitted back to the facility on 11/4/2025. During an interview on 11/14/2025 at 1:39 PM with CNA 2, CNA 2 stated Resident 1 required total assistance during shower and to prevent Resident 1 from falling, CNAs should always be near Resident 1. CNA 2 also stated facility’s shower chair cannot be reclined. CNA2 stated a reclining shower chair could have benefitted Resident 1’s poor sitting balance to prevent Resident 1 from falling forward. On 11/14/2025 at 2:04 PM, CNA1 was contacted by phone but was not available. During a concurrent interview and record review on 11/14/2025 at 3:25 PM with the Director of Rehabilitation (DOR), Resident 1’s Mobility Assessment dated 10/22/2025 was reviewed. The DOR stated Resident 1 has poor posture (the position in which you hold your body, both when moving and when still like sitting) and poor trunk control wherein Resident 1 has the tendency of leaning to sides and leaning forward which could result in a fall. The DOR stated Resident 1 should be in a reclined position while being seated in a chair like a shower chair and wheelchair to prevent sliding and leaning forward that can result in a fall. The DOR stated that when a reclining shower chair is tilted, it could prevent residents from leaning forward, while under close supervision can prevent a resident from falling. The DOR stated that per Mobility Assessment, Resident 1 was assessed to have poor ability to roll from side to side, poor ability to sit up unassisted, poor ability to maintain sitting balance, poor ability to stand, and poor ability to maintain standing balance. Resident 1 required total assistance (a situation where a person is unable to complete an activity without full physical help) while seated in a wheelchair or shower chair. During an interview on 11/14/2025 at 3:58 PM with MDS nurse (MDSN), MDSN stated, prior to Resident 1’s fall , she had observed Resident 1 leaning on the side because of poor trunk control. MDSN stated Resident 1’s both upper extremities are impaired, that means Resident 1 is at risk for injury because she does not have the control to push back to normal position to prevent falling. MDSN stated Resident 1 could have benefited with the use of a reclining wheelchair or shower chair to prevent the resident from falling. MDSN stated reclining shower chairs can be used for safety for residents who have poor balance and poor trunk control because the reclining position makes it harder for residents to lean forward. MDSN verified that Resident 1 did not and should have a care plan for leaning on the side and for poor mobility and balance. MDSN stated care plan interventions such as recommendation from rehabilitation, and reclining wheelchair could have benefited Resident 1. MDSN stated all licensed nurses and Department heads including the DOR can initiate and revise the care plans. MDSN stated it was important to develop a care plan for Resident 1’s poor mobility and balance for the entire care team to know the specific care for Resident 1. On 11/14/2025 at 4:08 PM, CNA1 was contacted by phone but was not available. During an interview on 11/14/2025 at 4:20 PM with the DON, the DON confirmed that Resident 1 was not using a reclining wheelchair before the fall incident on 11/2/2025, and facility did not have a reclining shower chair to use for residents with poor balance and poor trunk control. The DON verified that there was no care plan developed for Resident 1’s poor mobility and balance. The DON stated, “Rehabilitation department should have started a care plan”. The DON also stated, “CNA 1 turned her back from Resident 1, and when she turned back, Resident 1 is already on the floor.” The DON stated the fall could have been prevented if CNA 1 did not turn her back from Resident 1. The DON stated Resident 1 is now using a reclining wheelchair because of Resident 1’s tendencies of leaning forward. A reclining shower chair would have benefited Resident 1. A record review of Facility’s undated Policy and Procedures (P&P) titled, “Care Plans, Comprehensive Person – Centered,” indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs is developed and implemented for each resident. A record review of Facility’s P&P, titled “Bath, Shower/Tub,” revised 10/2023, the P&P indicated to stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. A record review of Facility’s undated P&P titled, “Assistive Devices and Equipment,” the P&P indicated devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include wheelchairs. A record review of the Facility’s P&P titled, “Activities of Daily Living (ADLs), Supporting,” dated 2022, the P&P indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). A resident’s ability to perform ADLs will be measured using clinical tools, including the MDS. Total Dependence – Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. The facility failed to ensure: 1. Resident 1 was not left unattended by CNA1. CNA 1 turned her back from Resident 1 who was in a shower chair while in the shower room on 11/2/2025 and the resident fell, which is in violation of the Facility’s Policy and procedure (P&P), titled “Bath, Shower/Tub,” revised 10/2023 2. Resident 1 received adequate supervision and assistance devices in the shower room in accordance with the facility’s P&P on Assistive Devices and Equipment. As a result, Resident 1, who was assessed as dependent on staff for Activities of Daily Living (ADL’s- basic self-care tasks essential for independent living, including bathing, dressing, eating, using the toilet, and moving from place to place) and with poor ability in maintaining sitting balance sustained a fall in the shower room on 11/2/2025 at around 10 AM resulting in a laceration to the forehead. On 11/2/2025 at 10:40 AM, Resident 1 was transferred to GACH where Resident 1 was diagnosed with acute nondisplaced fracture of C1 right posterior arch, midline forehead hematoma with laceration, and blunt head trauma. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.