Health inspection·December 5, 2025

The following reflects the findings of the California Department of Public Health during the facility's federal recertification survey. Event ID: 1D3A01-H1 State Citation B 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. § 72637. General Maintenance. (a) The facility, including the grounds, shall be maintained in a clean and sanitary condition and in good repair at all times to ensure safety and well-being of patients, staff and visitors. On 8/18/25, at 9:29 a.m., an unannounced survey was conducted at the facility for the facility's federal recertification survey. The facility failed to ensure all 59 residents who lived in the subacute building were free from environmental hazards when: 1. A free-standing propane (flammable gas used for cooking or heating) tank and a propane tank attached to a gas grill were stored indoors in the subacute building in a hallway next to the kitchen and where a year's supply of emergency supplies were stored. 2. Four ceiling mounted televisions (TV) were found partially detached from the ceiling and dangling over four of the 59 current residents (Resident 3, 7, 33 and 69) who were unable to move or protect themselves. These failures placed: 1. All 59 residents at risk of fire and explosion potentially causing serious harm and death and had the potential to disrupt kitchen services for any residents who depended on meals from the kitchen. 2. Residents 3, 7, 33 and 69 under falling equipment hazards which had the potential to cause injuries and dislodge critical life sustaining medical equipment potentially causing death. The failures to ensure all 59 residents who lived in the subacute building were free from environmental hazards resulted in an Immediate Jeopardy situation (IJ, a situation which facility noncompliance has place the health and safety of residents at risk for serious harm, injury, serious impairment or death). The Administrator (ADM) and Director of Nursing (DON) were notified of the IJ on 8/20/25, at 2:23 p.m. The facility submitted an acceptable Plan of Action on 8/22/25, at 2:40 p.m. and based on observation, staff interviews and record review, the IJ was lifted onsite during the recertification survey exit conference on 8/22/25, at 5:20 p.m. 1. During an observation on 8/20/25, at 9:49 a.m., in the hallway on the first floor of the subacute building, two propane tanks, one freestanding and another connected to a gas grill were observed. There were no staff in the area. At the other end of the hallway was the staff break room which had an exit that provided a clear and direct line of sight to the gas grill and propane tanks. The kitchen was located across the hall from where the propane tanks and gas grill were observed. The markings on the propane tanks indicated a "47 lb. (pounds, unit of weight measurement)" tank weight. A review of the facility map titled "[Facility Name] North Top Floor," printed 8/18/25, indicated resident rooms were located on the second floor of the two-floor subacute building, directly above where the gas grill and the two propane tanks were being stored. The second floor also included 17 Residents who were on ventilators (medical equipment that supports or replaces a person's breathing when they cannot breathe adequately on their own). During a second observation in the first-floor hallway of the subacute building on 8/20/25, at 12:17 p.m., the gas grill and the two propane tanks were in the same location. There were no staff in the area. During a concurrent observation and interview on 8/20/25, at 3:55 p.m., with Registered Dietitian (RD), RD was in their office in the same hallway as the gas grill and the propane tanks. The RD stated they were responsible for oversight of kitchen equipment and didn't know who put the gas grill and propane tanks in the hallway. The RD stated the gas grill and propane tanks had been in the hallway for at least a week. During a concurrent observation and interview on 8/20/25, at 4:29 p.m., with Maintenance Supervisor (MS) and RD, MS stated the kitchen was behind the wall across from where the gas grill and propane tanks were located, and the room behind the gas grill and propane tanks was the emergency supply room. RD stated paper products and emergency water were stored in the emergency supply room. The emergency supply room was adjacent to the gas water boiler room. MS stated there were two water boilers which were heated by gas. During an interview on 8/21/25, at 11:40 a.m, with MS, MS stated the propane tanks and gas grill were moved from an outdoor shed into the hallway about a year ago. MS stated they didn't know it was unsafe to store propane tanks indoors. During an interview on 8/22/25, at 11:25 a.m., with DON, DON stated propane tanks stored indoors were a fire hazard. The DON stated the staff lounge on the first floor was used by staff during breaks and lunchtime. The DON stated they expected all staff to report hazardous conditions to the fire safety coordinator. During an interview on 8/22/25, at 11:51 a.m., with ADM, ADM stated MS was the fire safety coordinator for the facility. ADM stated MS was responsible for ensuring the facility was free of fire hazards. During a review of the facility's policy and procedure (P&P) titled, "Fire Safety and Prevention," undated, the P&P indicated flammable items should be stored "in separate areas away from resident living areas" or "store outside." During a review of National Fire Protection Association (NFPA) code titled, "2024 NFPA-58 Liquefied Petroleum Gas Code," dated 2024, the code indicated on "Table 8.3.1" a maximum of "2 lbs." of propane stored in "1 lb." containers was allowed to be stored indoors in a "health care" setting. 2. A review of Resident 7's "Admission Record" indicated Resident 7 was admitted on 1/20/25, with a diagnosis of anoxic brain damage (brain damage due to lack of oxygen), acute respiratory failure, cognitive communication deficit, gastrostomy (tube surgically placed in the abdomen to provide nutrition and medications) and tracheostomy (tube surgically placed in the neck to provide a hole for breathing). During a record review of Resident 7's minimum data set (MDS, an assessment tool to guide resident care), dated 7/28/25, the MDS indicated Resident 7 was dependent on staff to transfer out of bed and for all aspects of care. The MDS indicated Resident 7 was unable to understand others and could not make themselves understood. During a record review of Resident 7's weekly nursing summary titled, "Nursing - Weekly Summary - V3.0," dated 8/15/25, the summary indicated Resident 7 was dependent on staff for transfers and bed mobility. A review of Resident 33's "Admission Record" indicated Resident 33 was admitted on 7/16/25, with a diagnosis of chronic respiratory failure, tracheostomy, gastrostomy, muscle wasting, muscle weakness and "dependence on respirator [ventilator] status." During a record review of Resident 33's MDS, dated 7/2/25, the MDS indicated Resident 33 was dependent on staff to transfer out of bed and for all aspects of care. The MDS indicated Resident 33 was unable to understand others and could not make themselves understood. A review of Resident 3's "Admission Record" indicated Resident 3 was admitted on 3/29/25, with a diagnosis of quadriplegia (loss of function of all limbs), long term use of anti-coagulants (medications used to prevent blood clots and increases risk of bleeding), gastrostomy, tracheostomy, respiratory failure, and cerebral infarction (occlusion of a blood vessel in the brain). During a record review of Resident 3's minimum data set (MDS, an assessment tool to guide resident care), dated 7/29/25, the MDS indicated Resident 3 was dependent on staff to transfer out of bed and for all aspects of care. The MDS indicated Resident 3 was able to understand others but could not make themselves understood. A review of Resident 69's "Admission Record" indicated Resident 69 was admitted on 8/20/25 with a diagnosis of acute respiratory failure, gastrostomy, tracheostomy, anoxic brain damage and long-term use of anti-coagulants. During a record review of Resident 69's nursing assessment titled, "Nursing - Daily Skilled Charting Form - [Facility]," dated 8/20/25, the assessment indicated Resident 69 was dependent on staff for transfers and bed mobility. During a concurrent observation and interview on 8/20/25, at 10:09 a.m., with Registered Nurse 1 (RN 1), the television ceiling mount over an unoccupied bed in room 12 was observed. RN 1 stated the condition of the mount was loose and "dangerous" to potential occupants of the bed. The ceiling mount had a visible gap between the mount base and the ceiling and upon manual manipulation, the mount could be swung back and forth at the base of the mount. During an observation on 8/20/25, at 10:14 a.m., Resident 3, 7 and 33's TV ceiling mounts in their shared room were inspected. All three mounts were over the resident beds with Resident 3, 7 and 33 in their respective beds. A family member was present with Resident 7. All three TV ceiling mounts had a visible gap between the mount base and the ceiling and could be manually swung back and forth at the base of the mount. All three residents were non-interactive. During a concurrent observation and interview on 8/20/25, at 12:40 p.m., with Resident 3's resident representative (RP), RP stated Resident 3's TV mount had been "wobbly" because the ceiling mount was loose. RP stated RP kept hitting their head on the TV because it was too low. RP stated the facility attempted to fix the ceiling mount, but the TV mount was still "wobbly." RP stated they were "scared" the TV was going to fall on top of Resident 3. RP stated they were concerned if staff moved the curtain to where the TV was it could potentially make the TV fall. During a concurrent observation and interview on 8/20/25, at 4:40 p.m., with MS and ADM, the TV ceiling mount in Resident 69's room was inspected. Resident 69 was in bed below the TV mount. MS was able to swing the TV mount manually and stated the mount was loose. MS stated for the loose mounts found in Resident 3, 7 and 33's room, the mounting hardware was not installed into a secure structure and repeated contact by "Hoyer Lifts" (machine used to lift and transfer residents out of bed) caused fasteners to become detached from the ceiling. MS stated some of the loose mounts were held up by only one fastener. During an interview on 8/22/25, at 11:25 a.m., with DON, DON stated Residents 3, 7, 33 and 69 could not protect themselves from environmental hazards and were dependent on staff for safety. During a review of the facility's P&P titled, "Maintenance Service," dated 2001, the P&P indicated "the maintenance department is responsible for maintaining...equipment in a safe and operable manner at all times...functions of maintenance personnel include...maintaining the building in good repair and free from hazards." In violation of the above cited standards, the facility failed to ensure all 59 residents were free from environmental hazards. This failure resulted in all residents at risk of fire and explosion injury and placed Residents 3, 7, 33 and 69 at risk of injury and death due to falling equipment hazard. This violation had a direct or immediate relationship to the health, safety or security of all 59 residents in the subacute building.