Health inspection·November 26, 2025

Welfare & Institutions Code CFR(s): 15630(b)(1) Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that he or she has experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone immediately or as soon as practicably possible, and by written report sent within two working days. California Code, Health and Safety Code - HSC § 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours 22 CCR § 72523 - Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be implemented to ensure that patient-related goals and facility objectives are achieved. 22CCR §72541 - Unusual Occurrences Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. On 9/29/2025, the California Department of Public Health (CDPH) received a complaint indicating Resident 1 fell on 9/18/2025 and was sent to a general acute care hospital (GACH). On 10/8/2025, the CDPH conducted an unannounced visit to the facility to investigate the allegation. During the onsite visit, it was determined on 10/7/2025, Resident 2 fell, non-displaced fractures of left superior pubic ramus (a recent, stable break in the left upper pelvic bone that has not been moved out of alignment), however, the facility did not report to the CDPH. The facility failed to report to the CDPH within 2 hours, as indicated in the facility's policy and procedure (P&P) titled, "Elderly/Dependent Adult Abuse," when: 1). On 9/18/2025, Resident 1 fell and sustained a bump (swelling under the skin) on the right side of the forehead and suffered pain (intensity not specified). 2). On 10/7/2025, Resident 2 fell, and sustained an acute transverse, non-displaced fractures of left superior pubic ramus. As a result, there was a delay in an investigation by CDPH and the potential to lead to further harm and neglect. a). Resident 1 was an 83-year-old male, originally admitted to the facility on 11/8/2024 and re-admitted on 2/11/2025. Resident 1's diagnoses included encephalopathy (a group of conditions that cause brain dysfunction), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and difficulty walking. A review of Resident 1's "Fall Risk Assessment," dated 2/11/2025 indicated Resident 1 was high-risk for fall due to intermittent confusion or poor safety awareness, was chair bound and had one (1) to two (2) predisposing conditions (factors that make a person more susceptible to developing a particular disease, trait, or behavior). A review of Resident 1's physician's progress notes dated 3/21/2025, indicated Resident 1 was on behavior monitoring for agitation and inability to sit still. The physician's progress notes indicated Resident 1 had difficulty walking/ weakness, observe fall precaution and assist the Resident. A review of Resident 1's undated care plan, titled "At risk for fall and injury," indicated interventions to answer call lights promptly, keep or maintain bed at low position if needed, keep environment hazard free from clutters and wet spots, and visual checks at least every two hours as needed to provide timely assistance with activities of daily living. A review of Resident 1's Minimum Data Set (MDS- a Resident assessment tool) dated 7/11/2025, indicated Resident 1 had clear speech, sometimes understood, and responds adequately to simple, direct communication only. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) with toileting, personal hygiene and shower/bathe self. A review of Resident 1's Change of Condition (COC) dated 9/18/2025 indicated Resident 1 had an unwitnessed fall. The COC indicated Resident 1 was observed on a right-side-lying position on the floor, in front of his wheelchair. The COC indicated Resident 1 was assessed and a bump on the right side of his forehead was noted. The COC indicated Resident 1 did not have any skin injuries. The COC indicated Resident 1 was moaning occasionally and had facial grimace. The COC indicated Resident 1 was sent to a general acute care hospital (GACH) for evaluation. During an interview on 10/8/2025 at 2:22 p.m. with the Director of Nursing (DON), the DON confirmed Resident 1 sustained a bump on the head and suffered pain (pain level unspecified). The DON stated Resident 1's fall on 9/18/2025 was not reported to the State Agency because there was no change in Resident 1's level of consciousness and vital signs were stable. b). Resident 2 was a 74-year-old female, originally admitted to the facility on 9/14/2024 and re-admitted on 5/6/2025. Resident 2's diagnoses included repeated falls, muscle weakness, and difficulty in walking. A review of Resident 2's Progress Notes dated 9/3/2025 indicated Resident 2 was a poor historian. The progress notes indicated Resident 2 was agitated and confused most times. The progress notes indicated facility staff was to observe safety precautions for Resident 2. A review of Resident 2's MDS, dated 9/16/2025 indicated Resident 2 had clear speech but had difficulty communicating some words or finishing thoughts but was able, if prompted or given time. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half of the effort) from staff with eating, upper body dressing and personal hygiene. The MDS indicated Resident 2 required partial/ moderate assistance with walking 10-50 feet, sitting to stand, chair/bed-to-chair transfer and tub/shower transfer. A Review of Resident 2's "Fall Risk Assessment" dated 9/16/2025 indicated Resident 2 was a high risk for falls due to intermittent confusion or poor safety awareness. The fall risk assessment indicated Resident 1 had 1-2 falls in the past 3 months. A review of Resident 2's COC dated 10/7/2025, at 11:45 a.m. indicated Resident 2 had an unwitnessed fall. The COC indicated Resident 2 was observed lying on her back, on the floor of her room. The COC indicated Resident 2 verbalized she was trying to go to the bathroom and while walking, she slid to the floor. The COC indicated Resident 2 had pain (level not indicated) in the left buttocks and left groin area. The COC indicated Resident 2's physician ordered radiology (X-Ray-process of taking pictures to diagnose and treat diseases) on the left hip and pelvis (the large bony structure near the base of the spine to which the hind limbs or legs are attached in humans). A review of Resident 2's "Radiology Results Report" dated 10/7/2025 at 5:37 p.m. indicated acute transverse, non-displaced fractures of left superior pubic ramus (a recent, stable break in the left upper pelvic bone that has not been moved out of alignment). A review of Resident 2's Physician Order dated 10/7/2025 at 10:39 p.m. indicated to transfer Resident 2 to the GACH for further evaluation and treatment. During a concurrent interview and record review on 10/09/2025 at 1:38 p.m., with the DON, the facility's P&P titled, "Elder/Dependent Adult Abuse," dated 11/19/2023 was reviewed. The P&P indicated to report immediately but not later than 2 hours, if serious bodily injury occurred and not later than 24 hours if there was no serious bodily injury. The DON stated the facility received Resident 2's x-ray result on 10/7/2025 at 10:30 p.m. indicating non-displaced fractures of left superior pubic ramus. The DON stated she called the State agency (SA) office on 10/8/2025 at 10 a.m. (11 and a half hours later) to report Resident 2's fall incident with fracture. The DON stated Resident 1's fall was not reported because the resident did not complain that he was hurt and there was no change in his level of consciousness. The DON stated failure to report Resident 2's fall with injury (fracture) within 2 hours delayed the CDPH's investigation. A review of the facility's P&P titled "Elder/Dependent Adult Abuse," dated 11/19/2023, indicated the facility should report to the SA any reasonable suspicion of a crime against a resident or, or is receiving care from the facility, immediately but not later than 2 hours when serious bodily injury occur, and not later than 24 hours, if no serious bodily injury occur. A review of the facility's Administrative Manual, titled "Unusual Occurrence Reporting," dated 3/28/2024, indicated the facility should report Unusual Occurrences which affect the health and safety of a resident, to the Department of Health Care services within 24 hours. The manual indicated the facility should make a telephone report to the Department of Health Care Services Complaints and Counselor Certification Division, within 1 working day for any events including any facility-related injury of any resident which caused any changes in condition and requires medical treatment. The facility failed to report to the CDPH within 2 hours, as indicated in the facility's P&P titled "Elderly/Dependent Adult Abuse," when: 1). On 9/18/2025, Resident 1 fell and sustained a bump on the right side of the forehead and suffered pain. 2). On 10/7/2025, Resident 2 fell, and sustained an acute transverse, non-displaced fractures of left superior pubic ramus. As a result, there was a delay in an investigation by CDPH and the potential to lead to further harm and neglect. These violations had a direct or immediate relationship to the health, safety, or security of Residents 1 and 2.