Health inspection·December 2, 2025

The following citation reflects the results of the California Department of Public Health’s investigation of complaint numbers 2609564 and 2616478. The investigation was limited to the specific complaints and does not represent the findings of a full inspection of the facility. The facility was found to be not in compliance with 42 CFR 483.1-483.75 - Subpart B - Requirements for Long Term Care Facilities. State Class AA citation 230022736 was issued for complaint numbers 2609564 and 2616478 at Title 42 CFR §483.25(d)(1),(2) 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. 22 CCR § 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 the 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 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 each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. §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. On 9/8/25 at 12:07 p.m., the Department made an unannounced visit to the facility to investigate a fall that caused a head injury. Restorative Nursing Assistant H (RNA H) left Resident 4 alone outside on a patio for 30 minutes. During that time, Resident 4 fell and sustained a subdural hematoma (bleeding between the brain and its lining). This failure to provide supervision led to a major head injury, emergency hospitalization, a significant decline in quality of life, and ultimately, Resident 4’s death. Findings During a review of facility policy titled “Assessing Falls and their Causes”, revised March 2018, indicated “falls are a leading cause of morbidity and mortality among the elderly in nursing homes.  Falling may be related to underlying clinical or medical conditions, overall functional decline, medication side effects, and/or environmental risk factors.  Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly.” During a review of Resident 4’s Facility Admission Record, printed 9/8/25. indicated that Resident 4 was admitted on 12/14/21, with diagnoses that included Vascular Dementia (a condition where the brain doesn't get enough blood flow, causing problems with memory and thinking), hemiplegia and hemiparesis (weakness and difficulty moving one side of the body) following nontraumatic intracerebral hemorrhage (a stroke, where brain tissue is damaged by a leaking blood vessel), and muscle weakness. During a review of Resident 4’s Minimum Data Set (MDS: a standardized resident assessment and care screening tool), dated 7/29/25, section C-Cognitive patterns, the ability to think clearly, reason and remember) indicated a Brief Interview for Mental Status (BIMS, a test for memory and thinking ability) was conducted. BIMS scores range from 0-15 with a score of 13-15 correlating to intact cognition; however, Resident 4 scored 99, indicating the resident was unable to fully participate in the assessment due to his mental state, and was likely confused.  The MDS Section GG-Functional Abilities indicated that Resident 4’s functional status required one-person assistance with bed mobility, transfers, and Resident 4’s ability to walk was “unsteady”. A review of Resident 4’s Care Plan for falls, last revised on 8/4/25, indicated “[Resident 4] had [history] of falls [related to] weakness, poor balance, impaired in communication, impaired decision making ability, poor safety awareness, incontinence (unable to control urine flow or bowels), on cardiac meds (heart medications), on narcotics (strong pain medications) and diagnosis of CVA (a stroke, where brain tissue is damaged by a leaking blood vessel) with left sided weakness.” This Care Plan for falls indicated interventions for Resident 4 that included “activities that minimize the potential for falls while providing diversion and distraction. [Resident 4] needs a safe environment with even floors free from spills and/or clutter…Educate [Resident 4]/family/caregivers about safety reminders and what to do if a fall occurs.” This care plan also indicated “[Resident 4] has an ADL (activities of daily living) self-care performance deficit [related to] CVA with left hemiplegia, impaired cognition, impaired in communication, poor endurance”, with interventions listed including “Provide appropriate assistance in all ADLs.”  This Care Plan for falls also indicated that staff should provide Resident 4 with “prompt response to all requests for assistance.”  This Care Plan for falls also indicated “[Resident 4] needs a safe environment with even floors free from spills and/or clutter, adequate, glare-free light; a working and reachable call light, and the bed in low position….” A review of Resident 4’s activity “Care Plan Report”, revised 8/4/25, indicated “preferred activities are sitting in the sun.”  This Care Plan Report also indicated that Resident 4 “needs activities that minimize the potential for falls while providing diversion and distraction.” This Care Plan Report did not indicate how to provide those activities, or what kind of supervision was needed.  During a review of Resident 4’s “Progress Note: Alert Note” dated 9/1/25, indicated “Resident was found on the ground outside the patio. Resident 4 was found to be unresponsive to verbal or tactile stimuli (trying to cause a patient to respond verbally or physically), he has a pulse and has shallow breathing." The Progress Note also indicated Resident 4 was unresponsive, had unstable vital signs, and was soon transported to local hospital for evaluation. This Progress Note also indicated “according to investigation of fall, [RNA H] took [Resident 4] outside to the patio, and [Resident 4] was found on the ground afterward.” During a review of facility records titled “Fall Incident Occurrence 9/1/2025,” which included a written statement by the facility’s Infection Preventionist Licensed Vocational Nurse (IP LVN) describing Resident 4’s fall on 9/1/25. The IP wrote, “As I was running down the hallway with a staff member, I asked her what happened, and she said they found him outside on the ground. I asked her who took him outside and why wasn't there someone with him. She said she doesn't know.” The statement also indicated, “I questioned [RNA H] why she took [Resident 4] outside, why did she take him outside if she was not going to stay with him, why didn't she stay with him, why didn't she ask for someone to stay with him if she couldn't stay with him, why didn't she let someone know that she left him outside, and why didn't she let his nurse know.” The IP further documented, “[RNA H] was very distraught and crying. She said she was sorry; she confirmed with me that she didn't think to let anyone know.” The statement indicated that the IP explained to RNA H that confused residents cannot be left alone outside without staff supervision. During a review of Registered Nurse C’s (RN C) untitled written statement, dated 9/1/25, indicated “[RNA H] did not tell me when she took [Resident 4] outside to the patio.  And I did not know [Resident 4] was outside until his CNA told me that he is on the ground.”  During an interview with Certified Nursing Assistant J (CNA J) on 9/17/25 at 1:07 pm, CNA J stated he had worked at the facility in the past and had cared for Resident 4 several times. CNA J confirmed he was the assigned CNA for Resident 4 on the morning of 9/1/25. RNA H assisted Resident 4 at breakfast while CNA J performed other routine duties. An unknown staff member passed by and informed CNA J that Resident 4 was yelling on a patio. CNA J stated he did not know where the patio was located and began searching for it. CNA J stated, “I started looking for [Resident 4] right away.” CNA J stated he found Resident 4 on the ground of the central patio, next to his wheelchair, groaning. CNA J called for help, and other staff responded. CNA J stated that prior to the fall, no staff member verbally informed him that Resident 4 was on the patio. He also stated that he had no verbal contact with RNA H before the fall and said, “I didn’t speak to [RNA H] until afterwards.” During an interview with RNA H on 9/11/25 at 10:25 am, RNA H stated she had cared for Resident 4 many times in the past. She stated, “Yes, they had a high fall risk wristband on.” RNA H explained that she took Resident 4 onto the facility patio in a wheelchair and left him there alone. She stated she did not see anyone at the nursing station desks at that time. RNA H reported that she placed Resident 4 on the patio at approximately 8:30 a.m. on the morning of 9/1/25 and found him on the ground at approximately 9:00 a.m. RNA H stated that she made a mistake by leaving Resident 4 alone on the patio. During a review of local Hospital A records titled “History and Physical Examination” (H&P) by Medical Doctor (MD) X, dated 9/1/2025, the H&P indicated that Resident 4 was taken via ambulance to Hospital A’s emergency room immediately following the fall. The H&P indicated Resident 4 was assessed and received advanced Computer Tomography (CT) (a special type of camera that takes detailed images of inside the brain and body) to look for injuries.  The CT of the brain results indicated “CT Brain without Contrast (imaging that does not use special contrast dyes inside the body) 9/1/25 Impression: 1. Small acute left frontotemporal (the area of brain between the ears and forehead) subdural hematoma causing 3 millimeter of left-to-right midline or subfalcine shift (a small bleed inside the brain, that pushes the brain against the skull).  The H&P also showed “Fall leading to subdural hematoma.”  This H&P indicated Resident 4’s condition as poor prognosis (recovery or long-term survival is not likely). During an interview with Medical Doctor Z (MD Z) on 9/26/25 at 9:35 am, MD Z confirmed that they were one of the treating physicians for Resident 4 and performed the medical assessment on 9/1/25. MD Z stated, “I identified a small bleed, a subdural hematoma.” MD Z also stated, “Yes, it’s absolutely a major injury, any bleed in the brain is a big deal. There was also midline shift (when bleeding and pressure inside skull becomes strong enough to push brain to one side), that was concerning.” MD Z stated that a major injury like this could negatively impact a person’s quality of life. During a review of records titled “Progress Note: Interdisciplinary Team (IDT- a group of professionals from different disciplines who collaborate to provide care for the resident) Note”, dated 9/3/2025, indicated that they brought Resident 4 back to the facility on 9/2/25 after treatment at the local hospital and placed him on Hospice Care (treatment and care that focuses on comfort near the end of life). During an interview with Family Representative (FP) on 9/9/25, FP stated they observed moderate to severe changes in Resident 4’s condition following the fall on 9/1/25. FP stated, “[Resident 4] doesn’t talk as much, he’s not aware anymore.” When asked about the fall incident, FP stated, “It’s my understanding that some nurse took [Resident 4] outside, left him there, and then he fell out and cracked his head.” FP stated that while the facility informed them about the fall, staff told FP, “We had eyes on the patio doors.” FP stated, “the facility shouldn’t leave anyone unsupervised.” During a review of records titled “Communication/Inservice 1:1”, dated 9/5/2025, indicated the Director of Staff Development (DSD) provided specialized training to RNA H following Resident 4’s fall incident on 9/1/25. The Communication Inservice indicated the main topic of “Supervision and Safety,” and indicated, “if a resident is fall risk or disoriented, then supervision will be provided throughout the entirety of their time outside.” During an interview with the IP LVN on 9/24/25 at 9:37 am, IP LVN stated she interviewed RNA H immediately following the fall incident on 9/1/25. IP LVN stated she asked RNA H, “Why didn’t you let anyone know where he was?” and RNA H replied, “I didn’t think to let anyone know.” IP LVN stated that RNA H did not inform Resident 4’s assigned staff of his location on the patio. IP LVN stated, “RNA H should have told more people, she should have known better.” During an interview with RN C on 9/11/25 at 10:07 am, RN C stated they had cared for Resident 4 many times over the past few years and knew Resident 4’s abilities and habits. RN C stated that Resident 4 depended on staff for all mobility, including use of a wheelchair. RN C stated she was the assigned bedside nurse for Resident 4 on 9/1/25, the day the fall incident occurred. RN C stated she had not been informed that Resident 4 was sitting on the patio in his wheelchair. RN C stated that Resident 4 should have received more supervision on the patio, stating, “Yes, in my professional opinion, [Resident 4] should have had more supervision.” During an interview with Licensed Vocational Nurse E (LVN E) on 9/11/25 at 10:35 am, LVN E stated that Resident 4 did not have adequate supervision alone on the patio.  LVN E stated that Resident 4’s fall “could have been prevented if we knew about it, or he was being supervised.” LVN E also stated that verbal communication was the best way to provide safe and competent care to residents. During an interview with Facility Administrator (Admin) on 9/8/25 at 12:30 pm, Admin stated “[RNA H] admitted there was nobody at the nursing station [after placing Resident 4 on patio alone].” Admin also stated that “depending on the level of visual supervision, if staff had been at the nursing station, [the patio] would have been safe.” During an observation of the facility’s patio courtyard on 9/8/25 at 12:40 pm, it was noted that the patio measured approximately 15 feet wide and 25 feet long and was located in the center of the building. The patio remained uncovered and open to the sky. The observer identified numerous potted plants, decorations, a metal table, an umbrella, and metal chairs on the patio. The large double doors leading to the patio consisted of clear glass and were positioned directly next to the central nursing desk. The observer found the doors moderately heavy and confirmed they did not open automatically. The observation revealed that staff seated at any of the nursing station desks could visualize only approximately 50% of the patio. The second nursing desk lacked a clear line of vision onto the patio. During an interview with Activities Director (AD) on 10/15/25 at 2:00 pm, AD stated that Resident 4’s Care Plans had included going outside on facility patios. AD stated that Resident 4’s Plan of Care did not include directions for staff on how to supervise Resident 4 outside on patios. AD stated that residents sitting outside on the patio could not be visualized with direct line of sight at all times from AD’s office and stated that patio doors would have to be open to hear residents calling for help. During an interview with CNA Q on 10/15/25 at 1:25 pm, CNA Q stated that staff can’t leave [Resident 4], or someone like him. [Resident 4] who was disoriented. If [residents] ar