Health inspection·September 10, 2025

42 CFR §483.25(d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 42 CFR § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 22 CCR §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. 22 CCR §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 7/28/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a Facility Reported Incident regarding neglect-injury of unknown origin. After investigation, CDPH determined that the facility failed to implement fall prevention interventions to ensure Resident 1 was adequately monitored. The facility was on notice Resident 1 had a high fall score risk because Resident 1 was confused, legally blind, restless, and was unable to sit still. As a result, Resident 1 had a fall witnessed by Resident 2 (unidentified date and time) that resulted in Resident 1 sustaining a left hip fracture. On 7/22/2025 at 11:30 PM, Resident 1 was transported to the General Acute Care Hospital (GACH) where Resident 1 was admitted and underwent a left femur (thigh bone) intramedullary (inside of a bone) rodding (bones or bone fragments are repositioned into their normal positions) surgery with general anesthesia. During a review of Resident 1's Admission Record, the Admission Record indicted the facility admitted Resident 1, an eighty-six-year-old-female on 5/15/2025 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), other abnormalities of gait (pattern of walking) and mobility (the ability to move), abnormal posture, age-related osteoporosis (a condition in which bones become weak and brittle), vitamin D deficiency, and sensorineural hearing loss (when the inner ear or the nerve connecting the ear to the brain is damaged, making it hard to hear clearly) bilateral (both ears/sides). During a review of Resident 1's Fall Risk Assessment (a nursing tool used to assess how likely someone is to fall, especially for older adults) dated 5/15/2025, the Fall Risk Assessment indicated Resident 1 was legally blind and at high risk for falls. The Fall Risk Assessment indicated Resident 1 was always disoriented (confused) to name, place, and time and had balance problems while standing and while walking. The Fall Risk Assessment assessed Resident 1's Fall Risk as a _____ and recommended the facility staff provide frequent visual monitoring of Resident 1 and to anticipate Resident 1's needs in a timely manner. During a review of Resident 1's Care Plan Report (a structured and individualized document that spells out how a facility will meet a resident's health or personal care needs), dated 5/15/2025, the Care Plan Report indicated Resident 1 was at risk for fall related to Alzheimer's, dementia, and legally blind. The Care Plan Report indicated the goal was to minimize ( the occurrence of falls and /or injury for Resident 1. The Care Plan Report indicated the nursing interventions (an action taken to prevent, treat, or manage a health problem) were to provide Resident 1 with a safe environment, bilateral (both sides) floor mat, keep the call light (a device used by a patient to signal his or her need for assistance) within Resident 1's reach and answer the call light promptly, and place Resident 1's bed in the low position. During a review of Resident 1's Physical Therapy notes dated 5/15/2025, the Physical Therapy notes indicated Resident 1 needed maximum assistance (the individual receiving care can participate in a task or activity, but requires significant assistance from a caregiver or therapist, typically performing only 25% or less of the work according to healthcare resources) to walk 25 feet (take steps for a distance of 25 feet in a straight line). The Physical Therapy notes indicated Resident 1 had balance deficits. During a review of Resident 1's Care Plan Report dated 5/16/2025, the Care Plan Report indicated Resident 1 was at risk for elopement risk as evidenced by impaired cognition (difficulty with thinking, learning, remembering, or making decisions) and memory . The Care Plan Report indicated Resident 1 would ambulate (walk) with assistance and used medication that could cause confusion and disorientation. The Care Plan Report indicated the nursing intervention was to monitor Resident 1's location (whereabouts) "every __ (blank) min (minute)." The Care Plan Report further indicated to document wandering behavior and attempted diversional interventions (the use of recreational and leisure activities to help patients cope with their medical conditions) in the behavior log. The Care Plan Report further indicated the nursing intervention was to provide Resident 1 with assistance during ambulation). The Care Plan Report identified the goal was to maintain Resident 1's safety. During a review of Resident 1's Interdisciplinary Team Conference Record (IDT - refers to a group of healthcare professionals from different fields who collaborate to provide comprehensive patient care) notes dated 5/16/2025, the IDT Conference Record indicated Resident 1 needed maximum assistance with activities of daily living (ADLs - basic tasks needed to take care of oneself), was a fall risk, and was educated to use call lights. During a review of Resident 1's Order Summary Report dated 5/16/2025, indicated for Resident 1 to have bilateral floor mats. During a review of Resident 1's History and Physical (H&P - comprehensive document that records a resident's medical history and a detailed physical examination performed by a health care professional) dated 5/17/2025, the H&P indicated Resident 1 had fluctuating (changing frequently) capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/21/2025, the MDS Resident 1 had severe cognitive impairment. The MDS indicated Resident 1 needed substantial/maximum assistance with toileting. The MDS indicated Resident 1 was dependent on facility staff for showering/bathing. The MDS indicated Resident 1 needed extensive assistance to walk ten feet, to go from a sitting to standing position, and to transfer from chair/bed to chair. The MDS indicated Resident 1 needed partial/moderate assistance to go from sitting to lying position and to go from lying to sitting on the side of the bed. The MDS indicated Resident 1 did not have a fall prior to admission. During a review of Resident 1's Progress Notes dated 7/15/2025 at 11:44 PM, the Progress Notes indicated Resident 1 was noted to be restless, going from one bed to another and, standing and trying to walk by herself in the middle of the night. The Progress Notes indicated Resident 1 was unable to "sit still," unable to calm herself, disoriented and Resident 1 wanted to walk outside her (Resident 1's) room. During a review of Resident 1's Order Summary review dated 7/15/2025, there was an order to monitor Resident 1 for restlessness/inability to sleep every shift. During a review of Resident 1's Progress Notes dated 7/17/2025 at 7:14 AM, the Progress Notes indicated Resident 1 was noted to be restless, going from one bed to another (unidentified), standing and trying to walk by herself in the middle of the night. The Progress Notes indicated Resident 1 was unable to "sit still," unable to calm herself, disoriented, and Resident 1 wanted to walk outside her (Resident 1's) room and unable to determine time (documented the same as the Progress Notes dated 7/15/2025 at 11:44 PM). During a review of Resident 1's Change in Condition (Situation Background Appearance Review, SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/22/2025 at 11:45 PM, the SBAR indicated Resident 1 complained of left hip pain, left knee pain, and left foot pain (pain levels unidentified). The SBAR indicated Resident 1 had a left hip x-ray that showed a fracture of the acetabulum (a cup-shaped socket in the pelvis that forms the hip joint) and was transferred to the emergency department. During a review of Resident 1's GACH Clinical Notes dated 7/26/2025, the Clinical Notes indicated Resident 1 had a mechanical fall (a type of fall that occurs due to an external, physical factor rather than an underlying medical condition) and sustained a left hip intertrochanteric fracture a break in the upper part of the femur). The Clinical Notes indicated Resident 1 underwent under general anesthesia and had a left femur intramedullary rodding surgery. During a review of the facility's Summary of Investigation report dated 7/27/2025, the Summary of investigation report indicated Resident 2 could not recall the date when she (Resident 2) saw and witnessed Resident 1 fall from the bed to the floor. The Summary of Investigation report indicated the facility concluded Resident 1 had a fall witnessed by Resident 2. During an interview on 7/28/2025 at 11:15 AM with the Director of Nursing (DON) and the facility's Administrator (ADM), the DON and ADM stated Resident 1 was currently in the GACH. The DON and ADM stated Resident 1's bed was on hold and the facility would accept Resident 1 back once stable for discharge from the GACH. During an interview on 7/28/2025 at 11:54 AM with the General Acute Care Hospital Registered Nurse (GACHRN), the GACHRN stated Resident 1 was still in the general acute care hospital. The GACHRN stated Resident 1 had a left femur intermedullary rodding. The GACHRN stated Resident 1 was confused, and unable to be interviewed. The GACHRN stated Resident 1 would be discharging from the GACH back to the skilled nursing facility on 7/28/2025. During an interview on 7/28/2025 at 12:51 PM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she (CNA1) was familiar with Resident 1. CNA 1 stated Resident 1 was confused, sometimes combative and sometimes would get agitated. CNA 1 stated Resident 1 was blind and was unable to use a call light. CNA 1 stated the certified nursing assistants (in general) were required to make rounds to monitor the resident. CNA 1 stated she (CNA1) did not document when she (CNA1) would make rounds and could not provide proof when she (CNA1) would do her rounds on Resident 1. CNA 1 stated Resident 1 was totally dependent (needed complete help from another person to do all or most of their everyday tasks) on the facility's staff for her care. CNA 1 stated Resident 1 was not safe to get up out of bed by herself. During a phone interview on 7/29/2025 at 1:06 PM with Resident 1's Family Member 1 (FAM 1), FAM 1 stated Resident 1 was blind and hard-of-hearing. FAM 1 stated he (FAM1) thought there was a disconnect between staff members at the facility because he (FAM 1) stated when he communicated something to one staff member, he (FAM 1) felt what he (FAM 1) communicated was not passed along to other staff members (unidentified). FAM 1 stated he (FAM1) thought Resident 1 sustained her injury (fractured left hip) sometime between 7/21/2025 and 7/22/2025. FAM 1 stated the floor mats that were supposed to be placed around Resident 1's bed were not always present when he (FAM 1) would visit (unknown date) Resident 1. FAM 1 stated he (FAM 1) would sometimes notice Resident 1's floor mats were placed up against the wall instead of around Resident 1's bed. During a concurrent interview and record review on 7/28/2025 at 1:19 PM with the Quality Assurance Nurse (QA - a nurse who works to make sure patients get the best and safest care possible), Resident 1's Care Plan Report dated 5/16/2025 was reviewed. The QA nurse stated Resident 1 required assistance with ambulation. The QA nurse stated the Care Plan Report did not indicate how often the nursing staff (in general) needed to monitor Resident 1's location. The QA nurse stated the Care Plan Report indicated nursing interventions included to monitor Resident 1's location "every __ (blank) min." The QA nurse stated the licensed nurses should have added an intervention indicating how many minutes Resident 1's location should have been monitored instead of leaving the number of minutes blank. The QA nurse stated the facility did not have a tool for documenting Resident 1's location. The QA nurse stated Resident 1 was blind and confused. The QA nurse stated she (QA nurse) could not produce any documentation that Resident 1 knew how to use her (Resident 1) call light. The QA nurse stated Resident 1's floor mats were sometimes removed by the cleaning/maintenance staff (unidentified) to clean the floor when Resident 1 was up in a chair or out of the room. The QA nurse stated she (QA nurse) could not say how long the floor mats were removed from Resident 1's bed. The QA nurse stated she (QA nurse) could not explain why the facility's staff (in general) did not see Resident 1 got out of her (Resident 1's) bed and fell even though Resident 1's room was directly in front of the nursing station. During an interview on 7/28/2025 at 1:42 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 was confused, hard of hearing, and blind. LVN 1 stated Resident 1 did not have the ability to use her call light. LVN 1 stated that even if the staff would give Resident 1 the call light, Resident 1 would not use the call light. LVN 1 stated she (LVN1) could not explain why the facility created a care plan for Resident 1 to use a call light when Resident 1 did not have the ability to use it (call light). LVN 1 stated Resident 1 had a history of trying to get out of bed by herself and required frequent monitoring. LVN 1 stated the facility placed Resident 1 close to the nursing station and she (LVN1) would look inside Resident 1's room but did not document when she (LVN 1) would monitor Resident 1. LVN 1 stated if the facility did not document interventions, there was no proof the facility was monitoring Resident 1. LVN1 stated Resident 2 told her (LVN1) that Resident 1 fell on an unspecified date and time. During a phone interview on 7/28/2025 at 2:06 PM with Family Member 1 (FM 1) and Family Member 2 (FM 2), FM 1 stated he (FM1) witness Resident 1's floor mats were not on the floor and were against the wall while Resident 1 was in her room. FM 2 stated she (FM2) had some safety concerns. FM 2 stated when she (FM2) would visit (unknow dates) Resident 1, she (FAM2) would see Resident 1 left alone and did not see the facility staff (in general) making rounds for approximately (about) one hour. FM 2 stated Resident 1's privacy curtains were usually drawn (by unidentified staff) and Resident 1 was hard to see when the privacy curtains were drawn. During an interview on 7/28/2025 at 2:21 PM with Registered Nurse 1 (RN 1), RN 1 stated the facility gave Resident 1 a call light because it was the facility's "standard to place the call light beside her (Resident 1). RN 1 stated giving Resident 1 a call light when she (Resident 1) could not use one was not an effective intervention because Resident 1 had not used the call light. When asked for proof that staff (in general) made rounds on Resident 1, RN 1 stated the facility documented when adult briefs (disposable underwear) were changed for Resident 1. RN 1 stated that documentation of adult briefs was not the same as documentation of rounds being performed to monitor Resident 1 an