Health inspection·January 23, 2026

The following reflects the findings of the California Department of Public Health during the investigation of a facility-reported incident 2616427 and complaint numbers 2636755 and 2487973. Survey Event ID: 1D7B29-H1 State Citation A was written. §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. § 72311 Nursing Services - 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. On 9/29/25 at 9:30 a.m., an unannounced visit was conducted at the facility to investigate a facility-reported incident and two complaints regarding accident and quality of care allegations. Based on interview and record review, for four of four sampled residents (Resident 7, 90, 80, and 63), the facility failed to develop, revise, or implement individualized written care plans to ensure adequate supervision and safety of residents when: 1. Resident 7 fell out of bed when Certified Nursing Assistant (CNA) 3 looked away while changing Resident 7's brief. Resident 7 sustained multiple injuries that included, a hematoma (when blood collects outside a blood vessel) on the right cheek and around the right eye, intraparenchymal hemorrhage (bleeding that occurs within the brain tissue), and fractures of the left 10th and 11th ribs (when one of the bones in the rib cage cracks, usually as a result of a fall or an accident). Resident 7 was transferred to the hospital for further treatment. 2. Resident 90 fell out of bed while CNA 4 assisted with toileting hygiene. Resident 90 was taken to the hospital via 911 with injuries that included frontal scalp hematoma, displaced fracture (when broken bone fragments move out of alignment, resulting in a gap or misalignment between the bone ends) in the left anterior arch of C1 (front side of the topmost bone in the neck spine), and non-displaced bilateral posterior arch C1 (curved bony arch on the back of the neck spine) fracture (also called Jefferson fracture, a burst fracture of the first bone in the neck spine, usually results from falls from heights onto the top of the head). 3. Resident 80 fell out of bed while CNA 4 provided personal hygiene. This failure had the potential to result in major injuries that included fractures, head trauma or death. 4. Resident 63 left the facility unaccompanied and unsupervised and was found missing for several hours. This failure placed Resident 63's safety at risk and could potentially result in harm. 1. Resident 7 was an elderly male admitted to the facility in April 2025 with diagnoses that included contracture (type of scarring in your soft tissues that causes them to tighten and stiffen) of the right upper arm, muscle spasm, and cerebral infarction (when the blood flow to the brain is disrupted leading to brain tissue death, main reason for disability among people). Resident 7 required substantial/maximal assistance to roll in bed (helper does more than half the effort, helper lifts and holds trunk or limbs and provides more than half the effort). On the evening of 5/30/25, after CNA 4 helped Resident 7 with dinner and left briefly, CNA 4 returned to Resident 7's room to find him on the floor beside his bed. A Post Fall Risk Evaluation dated 5/30/25 indicated Resident 7's fall resulted from poor positioning and improper bed height. During a telephone interview on 10/2/25 at 11:22 a.m., with CNA 4, CNA 4 stated that on 5/30/25, after Resident 7 had dinner, CNA 4 lowered the bed's head. Resident 7 had no bed rails. CNA 4 used the bathroom and returned to find the charge nurse reporting that Resident 7 was on the floor next to his bed. During a review of Resident 7's Minimum Data Set (MDS, an assessment tool used to direct patient care) dated 3/27/25, the MDS indicated Resident 7 had severe cognitive impairment (a person's ability to process and understand information) and impaired functional ability in both upper and lower extremities. Resident 7 was totally dependent on staff for everyday activities, including turning in bed and sitting up from a lying position. During a review of Resident 7's fall care plan last revised 5/21/21, the care plan indicated to anticipate Resident 7's needs, and to provide prompt response to request for assistance. There was no indication that the care plan was revised after the MDS dated 3/27/25 was completed. During a review of "Interdisciplinary Team (IDT, a group composed of individuals from different departments of the facility) Progress Notes" dated 6/2/25, the "IDT Progress Notes" indicated recommendations to prevent future falls that included keeping the bed in the lowest position, and regularly monitoring and repositioning Resident 7. On 6/4/25, five days after Resident 7's fall on 5/30/25, CNA 3, got distracted by Resident 7's roommate during care. CNA 3 did not position Resident 7 safely in the center of the bed while on the right side-lying position, and without side rails. Resident 7 fell out of bed, hitting the floor headfirst and landing on his right side. Resident 7 sustained swelling around the right eye and forehead, leading to a large hematoma and the right eye being swollen shut. Resident 7 was taken to the hospital. During a telephone interview on 9/30/25 at 10:29 a.m. with CNA 3, CNA 3 stated, on the evening shift of 6/4/25, CNA 3 cleaned Resident 7's perineal area and turned him to the right side without ensuring they were centered on the bed. While changing Resident 7's brief, CNA 3 got distracted by the roommate, causing Resident 7 to fall out of bed headfirst, followed by their right side. There were no bed rails attached. After the incident, CNA 3 stated he received training on providing distraction-free care and prioritizing the residents being attended to. During a review of Resident 7's Hospital "Trauma History and Physical (THP)" dated 6/4/25, the "THP" indicated Resident 7 arrived at the Emergency Department with a large hematoma and swelling around the right eye, causing it to be swollen shut. Imaging (process of making pictures of the parts of the body not visible to the naked eye such as x-rays or scans) results indicated mildly displaced (when broken ends of a bone do not align properly) acute fractures of posterior left 10th and 11th ribs and a 9 mm x 7 mm x 11 mm acute intraparenchymal hemorrhage in posterior right frontal lobe. Resident 7 was prescribed Keppra (an anticonvulsant) 750 milligrams (mg) twice daily for seven days. During a review of Resident 7's "Progress Notes" dated 6/16/25, the "Progress Notes" indicated Resident 7 returned to the facility after 12-day stay at the hospital. 2. Resident 90 was an elderly female admitted to the facility in September 2024 with diagnoses that included muscle weakness, activity limitations due to disability, and repeated falls. During a concurrent interview and record review on 10/3/25 at 12:09 p.m. with Minimum Data Set Coordinator (MDSC), Resident 90's MDS dated 5/9/25 was reviewed. MDSC stated Resident 90's MDS indicated Resident 90 was totally dependent on staff with rolling from back to side while in bed and required two-person assistance. During a review of Resident 90's fall care plans dated 4/7/25, the fall care plans did not include interventions specific to Resident 90's care needs as identified by the MDS assessment. During a telephone interview on 10/2/25 at 11:22 a.m. with CNA 4, CNA 4 stated he was new and unaware that Resident 90 needed two-person assistance for daily activities. CNA 4 stated he turned Resident 90 on her side to clean her back when Resident 90 reached for something at the bedside and fell out of bed. CNA 4 stated he would have asked for help if he had known about the need for two-person assistance. During a telephone interview on 10/2/25 at 12:37 p.m. with Licensed Vocational Nurse (LVN) 9, LVN 9 stated Resident 90 was totally dependent on staff with turning, repositioning, and toileting. During a review of Resident 90's "SBAR Summary for Providers (SBAR)" dated 5/9/25, the "SBAR" indicated, on 5/9/25, CNA 4 called for help after Resident 90 rolled out of bed while being cleaned. The SBAR indicated Resident 90 was found face down on the floor, likely reaching for something beside the bed. Resident 90 sustained a bump on the forehead and had a blood pressure reading of 177/100 millimeter mercury (mmHG) (normal is 120/80). During a review of Resident 90's "Health Status Note (HSN)" dated 5/10/25, the "HSN" indicated the following blood pressure readings for Resident 90: 01:00- BP 166/101 01:30- BP 188/106 02:00- BP 200/106 02:30- BP 210/106 0:300- BP 210/109 The "HSN" indicated, Resident 90 received BP medications which were ineffective. Resident 90 became unresponsive and was transported to the hospital via 911. During a review of Resident 90's "Emergency Department Note (EDN)" dated 5/10/25 at 4:39 a.m., the "EDN" indicated Resident 90 arrived at the ED with a cervical collar (neck brace, designed to prevent one's head or neck from moving after an injury) in place and a hematoma on top of her head. During a review of Resident 90's "CT (computerized tomography)" of cervical spine dated 5/10/25, the "CT" indicated Resident 90 had a displaced fracture through the left anterior arch of C1 and bilateral posterior C1 arch fractures. During a review of Resident 90's "Internal Medicine Discharge Summary (IMDS)" dated 5/14/25, the "IMDS" indicated Resident 90 should wear a cervical collar (neck brace) for three months around the clock. 3. Resident 80 was an elderly male who was admitted to the facility in December 2011 with diagnoses that included dementia (decline in mental ability, including memory, thinking, and problem-solving skills, severe enough to interfere with daily life) weakness, parkinsonism (slow movements and tremors) and glaucoma (buildup of fluid in the eye, which increases the pressure and damages the nerve leading to vision loss). During a review of Resident 80's "HSN," dated 9/25/25, the "Progress Notes" indicated, on 9/25/25 at 9:30 p.m., Resident 80 fell out of bed while CNA 4 changed Resident 80's brief. Resident 80 was found on the floor lying on the left side. During a telephone interview on 10/2/25 at 11:22 a.m. with CNA 4, CNA 4 stated Resident 80 was turned on the left side, away from CNA 4, while CNA 4 cleaned Resident 80's back. CNA 4 stated he cleaned Resident 80 with his left hand while his right hand was on Resident 80's shoulder. CNA 4 stated he released his hold to grab a brief, causing Resident 80 to fall from the bed and land on the opposite side. During a joint interview on 9/30/25 at 3:50 p.m. with Director of Nursing (DON) and Registered Nurse Consultant (RNC), DON stated, during patient care, such as changing briefs or performing perineal care, staff should turn patients towards them, not away. RNC stated there was no policy for this as it is a basic skill learned in school. During an interview on 10/1/25 at 12:03 p.m. with Director of Staff Development (DSD), DSD stated CNA 4 had experienced "missteps" while providing care for three residents. DSD stated all three residents (Resident 7, 80 and 90) fell out of bed during CNA 4's care and that CNA 4's employment was terminated as of 10/1/25. CNA 3 resigned from the facility few weeks after the incident. During a review of the facility's policy and procedure (P&P) subtitled "Person-Centered Care Planning" last revised 8/21/19, the P&P indicated the care plans must be prepared by Interdisciplinary Team (IDT, a group composed of individuals representing the different departments of the facility) that included the physician, registered nurse, and the CNA in charge of the patient and must be reviewed and revised by the IDT after each MDS assessment." 4. During a review of Resident 63's Face Sheet (FS), the FS indicated Resident 63 was admitted on 6/7/25 with multiple diagnoses that included dementia, chronic kidney disease stage (a condition where the kidneys gradually lose its ability to filter waste products from the blood, leading to buildup of toxins and other substances in the body), cirrhosis of the liver (a liver disease characterized by the irreversible destruction of liver cells and the formation of scar tissue), and alcohol dependence (the state of relying on alcohol for support). During a review of Resident 63's Elopement Evaluation (EE), dated 6/13/25, the EE score indicated the resident is at risk for elopement (unsupervised departure of a patient). During a review of Resident 63's Minimum Data Set (MDS, a resident assessment tool) dated 9/18/25, Resident 63 indicated a score of 8 on his Brief Interview for Mental Status (BIMS, an assessment to detect cognitive impairment) indicating moderate cognitive impairment. During an interview on 9/29/25 with the administrator (ADM) on 9/29/25 at 10:35 a.m., ADM stated the elopement of Resident 63 was an unusual occurrence and was a mystery how the resident left the facility. ADM stated Resident 63 had a wanderguard (a discreet wearable device that tracks movement and triggers automated security responses when a resident nears a restricted area). ADM stated he did not know how the resident was able to leave without triggering the alarm, because they checked the wanderguard and it was functioning when he was found in the morning and assisted back to the facility. During a review of the progress note (PN) for Resident 63, dated 9/10/25 02:57 a.m., the PN indicated Certified Nursing Assistant (CNA) 5 made round few minutes to 2 a.m., and did not find Resident 63 and informed the nurse. Staff searched for Resident 63 but the resident was not found, and the police was called. During a review of the PN dated 9/10/25 at 9:32 a.m., the PN indicated Resident 63 was found wandering on the street of facility and three staff walked the resident back to the facility. During a review of the IDT (Interdisciplinary team) note dated 9/10/25, the IDT note indicated Resident 63 was missing at approximately 2 a.m. The IDT note indicated Resident 63 was found at approximately 8:30 a.m.. During a review of "Acute Care" note dated 9/12/25, the note indicated Resident eloped last night and was found in the morning of 9/10/25 two blocks from the facility, sweeping floors outside a nearby store. During a concurrent interview and record review on 10/1/25 at 4:15 p.m., with the Director of Staff Development (DSD), DSD stated the elopement for Resident 63 was on 9/10/25 night and Licensed Vocational Nurse (LVN) 8 was the charge nurse that night and came on duty at 11 p.m. DSD stated they were supposed to check on the resident every two hour maximum. DSD stated if everything happened in between, they should be checking. When asked if they had documentation for checking rounds for Resident 63 every two hours, DSD looked at Resident 63's electronic record and stated there was nothing and printed out the bowel incontinence flowsheet, indicated the record for task: B&B - Bowel elimination. There was no documentation of the staff rounding every two hours on Resident 63 an