Foundation Skilled Nursing: Fall Prevention Failures - CA
The inspection, triggered by a complaint, resulted in a citation for actual harm. Not a risk of harm. Not a potential deficiency. Actual harm, to actual residents.
The citation falls under F0689, the federal tag governing accidents and supervision. Inspectors reviewed the facility's own Falls-Clinical Protocol, a document the nursing home had written and dated back to September 2012. The policy described a layered system of response: identify residents with fall histories, have the physician review gait, balance, and medications after more than one fall, keep collecting information until either a cause is found or it's determined no cause can be found, then implement interventions and keep adjusting them if the falls continue.
The policy acknowledged, in its own language, that frail elderly residents face greater risk of serious consequences from falls. It acknowledged that some residents fall repeatedly. It described exactly what staff and physicians were supposed to do in those cases.
Inspectors found the facility wasn't doing it.
The report does not specify how many residents were affected beyond noting the number as "few," a CMS designation that typically means one to two residents. It does not name them. What it documents is a gap between the protocol the facility wrote for itself and the care residents received when they kept falling.
That gap is the violation.
Falls are among the most serious and common hazards in skilled nursing facilities. For a frail elderly person, a single fall can mean a broken hip, a head injury, a rapid decline. A second fall, or a third, can mean death. The federal oversight system treats fall prevention not as a courtesy but as a core safety obligation, one that requires facilities to assess, intervene, reassess, and keep working the problem until the falling stops or every reasonable option has been exhausted.
Foundation Skilled Nursing's own policy reflected that understanding. After more than one fall, the policy said, the physician should review the resident's gait, balance, and current medications. Staff and physician together would collect and evaluate information. If underlying causes couldn't be found or fixed, staff would try various relevant interventions. If a resident kept falling, the staff and physician would re-evaluate and consider other possible reasons.
The word "will" appears throughout the policy. Not "should when possible." Not "may consider." Will.
Inspectors found the facility's response to residents who kept falling did not match what that document required.
The complaint-based inspection, which covered only the issues raised in the complaint rather than a full house review, produced a finding at the highest level of individual harm short of immediate jeopardy. That distinction matters. A deficiency at the actual harm level means inspectors concluded that residents were hurt, not merely that they might have been.
Foundation Skilled Nursing has not publicly responded to the findings. The inspection report does not include any statement from facility administration.
What the report leaves behind is a picture of a nursing home that put considerable effort into writing a fall prevention policy, a policy detailed enough to address isolated falls and repeat falls and falls with injury and falls without identified cause, and then did not follow it when residents needed it most.
The policy ends with a directive: if the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling. For the residents inspectors identified, that re-evaluation either didn't happen or didn't happen the way the policy required.
They kept falling. The protocol sat in a binder somewhere. And the gap between those two facts is what federal inspectors came to Fresno to document.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Foundation Skilled Nursing from 2025-08-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 4, 2026 · Our methodology
Foundation Skilled Nursing in FRESNO, CA was cited for violations during a health inspection on August 12, 2025.
The inspection, triggered by a complaint, resulted in a citation for actual harm.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.