Health inspection·May 9, 2025

F 689 CFR §483.25 (d)(2) Accidents. The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. §483.25(d) Accidents. The facility must ensure that – §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. § 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. (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. (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. § 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. An unannounced visit was conducted by California Department of Public Health on 3/24/2025 at 10:20 AM to investigate a facility reported incident regarding Reisdent 1’s fall that resulted to a fracture. The facility failed to ensure Resident 1 were free from falls and injury by failing to: 1. Ensure Certified Nursing Assistant 2 (CNA 2) did not leave Resident 1 who was assessed requiring increased assistance performing tasks and the resident would benefit from caregiver (facility staff) supervision to decrease fall risk, without facility staff to supervise Resident 1 sitting in a wheelchair in accordance with Resident 1’s Physical Therapy (PT - healthcare profession that focuses on promoting, maintaining, or restoring health through patient education, physical intervention, disease prevention, and health promotion) Recertification (PTR - documentation to ensure continued PT is necessary by documenting progress, justifying medical necessity). 2. Ensure facility staff provided supervision to Resident 1 while the resident is eating breakfast on 3/11/2025 in accordance with the resident’s Minimum Data Set (MDS – a resident assessment tool). 3. Ensure Resident 1’s Care Plan for high risk for fall was resident centered and was revised on 3/4/2025 to reflect the PTR’s note to increase assistance to the resident to perform task and caregiver supervision to decrease fall risk. These deficient practices resulted in Resident 1 being found on the floor pad (a piece of thick, soft material designed to cushion the impact of a fall) on 3/11/2025 around 7:30 AM and complaining of pain on the right side of the rib cage (a bony structure in the chest that protects vital organs like the heart and lungs and facilitates breathing). Resident 1 had an X-ray (used to generate images of tissues and structures inside the body) of the right ribs on 3/11/2025 due to chest pain and result indicated an acute hairline fracture (tiny cracks in the bone) at fourth and fifth ribs near rib angle (the part where the rib takes a sharp bend, also known as the costal angle, which allows for rib expansion and contraction during breathing). Resident 1 was sent to General Acute Care Hospital (GACH) 2 on 3/11/2025 and was discharged home from GACH 2 on 3/14/2025 with hospice care services (specialized medical care focused on providing comfort, no treatment of injuries or disease, and support for individuals with a life expectancy of six months or less). A review of Resident 1’s Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on 1/30/2025 with diagnoses of dizziness and giddiness, muscle wasting and difficulty walking. A review of Resident 1’s Fall Risk Assessment, dated 1/30/2025, the assessment indicated the resident was at high risk for falls. A review of Resident 1’s MDS, dated 2/4/2025, the MDS indicated the resident was moderately impaired in cognitive skills (the ability to understand and make decisions) for daily decision making. The MDS also indicated the resident required supervision/touching assistance with eating and substantial/maximal assistance with oral hygiene, toileting hygiene, lower body dressing, putting on/taking off footwear, sit- to- stand, chair/bed to chair transfer and walking 10 feet. 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 2/13/2025, the SBAR indicated the resident had an unwitnessed fall (first fall in the facility). A review of Resident 1’s SBAR, dated 2/28/2025, the SBAR indicated Resident 1 had an unwitnessed fall (second fall in the facility). The SBAR indicated Registered Nurse Supervisor (not specified who) assisted the resident to the room, locked Resident 1’s wheelchair and exited the room. The SBAR also indicated that when the Registered Nurse Supervisor came back, the resident was on the floor near the bedside. A review of Resident 1’s PTR dated 3/4/2025, the PTR indicated that the resident required increased assistance to perform tasks and would benefit from supervision in order to decrease fall risk. A review of Resident 1’s Care Plan with focus “High risk for falls”, initiated on 2/28/2025, the Care Plan indicated goals of the resident will be free of falls and the resident will not sustain serious injury. The Care Plan also indicated interventions included to educate the resident about safety reminders. The Care Plan did not indicate it was revised from 3/4/2025 to 3/11/2025 to reflect that the resident required increased assistance to perform tasks and would benefit from supervision in order to decrease fall risk. A review of Resident 1’s Care Plan with focus on “Resident had an actual fall on 2/28/2025”, initiated on 2/28/2025, indicated the resident had an actual fall on 2/28/2025 due to confusion, generalized weakness and poor safety awareness. The Care Plan did not indicate it was revised from 3/4/2025 to 3/11/2025 to reflect that the resident required increased assistance to perform tasks and would benefit from supervision in order to decrease fall risk. A review of Resident 1’s SBAR, dated 3/11/2025, the SBAR indicated Resident 1 had an unwitnessed fall (third fall in the facility). A review of Resident 1’s Progress Notes, dated 3/11/2025 at 8 AM, the Progress Notes indicated resident had an unwitnessed fall and was found on top of a floor pad and resident had pain on the right rib cage. The Progress Notes indicated doctor ordered stat (immediately) X-ray of the right rib cage. A review of Resident 1’s Progress Notes dated 3/11/2025 at 10:38 PM, the notes indicated a call was made to Resident 1's emergency contact to inform of the resident’s X-ray result and doctor ordered for the resident to be transferred to the GACH.  A review of Resident 1’s Radiology (branch of medicine that uses imaging technology to diagnose and treat disease. Example is X-ray) Result Report (done in the facility), dated 3/12/2025, the report indicated Resident 1 had an X-ray of the right rib cage on 3/11/2025 and the result showed acute hairline fractures at fourth and fifth right ribs near rib angle. A review of Resident 1's Progress Notes, dated 3/12/20205 at 10:51 AM, the notes indicated transportation arrived at facility to transfer the resident to GACH 2.  A review of Resident 1's MAR, dated 3/2025, the MAR indicated Resident 1 was given acetaminophen on 3/11/2025 at 8:42 AM for the resident’s pain level of 3/10 and on 3/12/2025 at 9:01 AM for resident’s pain level of 3/10. A review of Resident 1’s GACH 2’s Physician Daily Progress Notes, dated 3/15/2025 at 7:41 AM, the GACH 2’s Physician Daily Progress Notes indicated the resident was discharged home under hospice care. During an interview on 3/24/2025 at 11:44 AM, CNA 2 stated, on 3/11/2025 at 7:15 AM, CNA 2 placed the resident in a wheelchair and gave the resident her breakfast tray on top of the resident’s bedside table. CNA 2 also stated after CNA 2 gave the resident the breakfast tray, CNA 2 left the resident’s room without other facility staff to supervise the resident while the resident is eating (unable to recall what time). In addition, CNA 2 stated when CNA 2 came back to the resident’s room around 7:30 AM, Resident 1 was found on the floor. During an interview on 3/24/2025 at 12:41 PM, LVN 2 stated, on 3/11/2025 after Resident 1’s fall, the resident told LVN 2 that the resident’s rib was hurting. During an interview on 3/24/2025 at 1:08 PM, RN 2 stated, on 3/11/2025 around 7:45 AM, she was called to Resident 1’s room when the resident was found sitting on the floor pad. During a concurrent record review and interview on 3/25/2024 at 10:38 AM, Resident 1’s MDS, dated 2/4/2025, was reviewed. The MDS indicated Resident 1 required supervision/touching assistance with eating. MDS Nurse stated Resident 1 required supervision/touching assistance when eating and facility staff should be present while Resident 1 is eating. During an interview on 3/25/2025 at 3 PM, the Director of Nursing (DON) stated it is not okay to have Resident 1 sit by herself because the resident required supervision while in a sitting position and during mealtime/ while the resident is eating. The DON also stated supervision/touching assistance means facility staff need to be present and supervise Resident 1 while eating. During the same interview and record review with the DON on 3/25/2025 at 3pm, Resident 1's Care Plan for high risk for fall, dated 2/28/2025, and Care Plan for Actual Fall dated 2/28/2025 were reviewed. The Care Plan did not indicate it was revised from 3/4/2025 to 3/11/2025 to reflect that the resident required increased assistance to perform tasks and would benefit from supervision in order to decrease fall risk. The DON stated the care plan was not revised on 3/4/2025 to reflect that the resident required increased assistance to perform tasks and would benefit from supervision in order to decrease fall risk per PTR notes. The DON also stated the care plan should focus on the issues which would be addressed in the interventions, such as the resident requiring supervision while eating due to poor safety judgment. During a concurrent record review and interview on 3/26/2026 at 11:02 AM, Resident 1’s PTR, dated 3/4/2025, was reviewed. The PTR indicated Resident 1 has poor safety awareness resulting in falls and required increased assistance to perform tasks and would benefit from supervision in order to decrease fall risk. DOR stated poor safety, and judgment was the number one cause to Resident 1’s fall. DOR also stated if Resident 1 had supervision last 3/11/2025 during breakfast, the resident’s fall could have been prevented. The DOR stated Resident 1 would always require assistance. During a concurrent record review and interview on 3/26/2025 at 11:02 PM, Resident 1’s Occupational Therapy (OT - a branch of health care that helps people of all ages who have physical, sensory, or cognitive problems) Recertification (OTR), dated 3/4/2025 was reviewed. OTR indicated the resident has poor safety awareness, continued problems in functional mobility, continued problems in Activities of Daily Living (ADL- includes eating) and continued problems in weakness. DOR stated, per Resident 1’s OTR the resident’s safety is a concern while the resident is in wheelchair and the resident would need supervision to prevent falls. The DOR also stated Resident 1 needs moderate assistance while sitting in the wheelchair. During a review of the facility’s Policy and Procedure (P&P), titled “Safety and Supervision of Residents,” revised 7/2017, the P&P indicated resident safety and supervision and assistance to prevent accidents are facility wide priorities. The P&P also indicated resident supervision is a core component of the systems approach to safety and the type and frequency of resident supervision is determined by the individual resident assessed needs and identified hazards in the environment. During a review of the facility’s P&P, titled “Accident and Resident Safety Reporting,” revised 11/21/17, the P&P indicated each resident receives adequate supervision and assistive devices to prevent accidents. The P&P also indicated to provide an environment that is free as possible from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. During a review of the facility’s P&P, titled “Falls and Fall Risk, Managing,” revised 3/2018, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident’s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The facility failed to ensure Resident 1 were free from falls and injury by failing to: 1. Ensure CNA 2 did not leave Resident 1 who was assessed requiring increased assistance performing tasks and the resident would benefit from caregiver (facility staff) supervision to decrease fall risk, without facility staff to supervise Resident 1 sitting in a wheelchair in accordance with Resident 1’s PTR 2. Ensure facility staff provided supervision to Resident 1 while the resident is eating breakfast on 3/11/2025 in accordance with the resident’s MDS 3. Ensure Resident 1’s Care Plan for high risk for fall was resident centered and was revised on 3/4/2025 to reflect the PTR’s note to increase assistance to the resident to perform task and caregiver supervision to decrease fall risk. These deficient practices resulted in Resident 1 being found on the floor pad on 3/11/2025 around 7:30 AM and complaining of pain on the right side of the rib. Resident 1 had an X-ray the right ribs on 3/11/2025 due to chest pain and result indicated an acute hairline fracture at fourth and fifth ribs near ribs. Resident 1 was sent to GACH 2 on 3/11/2025 and was discharged from GACH 2 on 3/14/2025 with hospice care services (specialized medical care focused on providing comfort, no treatment of injuries or disease, and support for individuals with a life expectancy of six months or less). The above violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.