Health inspection·January 27, 2026

. The following reflects the findings of the California Department of Public Health (CDPH) during the investigation of a facility reported incident number 2677951. A Class A Citation was written. 42 CFR §483.25 Accidents. (d) The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 42 CFR §483.40. Behavioral Health Services. (a) The facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with §483.71. These competencies and skills set include, but are not limited to, knowledge of and appropriate training and supervision for: §483.40(a)(1) Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, that have been identified in the facility assessment conducted pursuant to §483.71. . . (b) Based on the comprehensive assessment of a resident, the facility must ensure that- (1) A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being; 42 CFR §483.21(b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment 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 admission of the patient and be completed within seven days after admission. 22 CCR § 72521 Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. On 12/9/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident alleging that Resident 1, exhibiting aggressive behavior, kicked and broke a window, resulting in Resident 1 suffering a fracture (a break in a bone) of the right leg. The facility failed to ensure the safety of Resident 1 by failing to: 1. Complete the Wandering Risk and Elopement (departing a healthcare facility or safe area unsupervised and unnoticed) Screening Assessment upon initial admission on 9/26/2025 and on 10/20/2025. 2. Update Wandering and Elopement Risk Assessment after Resident 1was observed displaying exit seeking behavior and trying to leave the facility on 10/11/2025 and 11/4/2025 in accordance with the facility's policy and procedures (P&P) titled "Wandering and Elopement Intervention Protocol Based on Risk Score" dated 1/25/2025. 3. Develop a comprehensive care plan addressing elopement to prevent injuries. 4. Ensure Licensed Vocational Nurses (LVN) 1 and LVN 2, immediately intervened and continuously monitored Resident 1, who was gradually experiencing aggressive behavior by continuously kicking a window on 11/4/2025 while Resident 1 is on 1:1 (dedicated, personalized care where one healthcare professional provides constant, focused support to a single patient) according to Resident 1's SBAR progress note dated 11/4/2025 at 7:10 pm. As a result, On 11/4/2025 at 9:16 pm, Resident 1 sustained an injury after kicking and breaking a window, and was transferred to General Acute Care Hospital (GACH) 1 by Emergency Medical Services (contacted via 911), where the resident was diagnosed with a right tibial plateau fracture (a break in the flat top surface of the shinbone [tibia] where it meets the thigh bone [femur] to form the knee joint) and comminuted fracture of the fibular head and neck (a severe injury where the top, thinner bone on the outside of your lower leg near the knee has shattered into three or more pieces). A review of Resident 1's admission record indicated the facility initially admitted the resident on 9/26/2025 with diagnoses that included major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in enjoyable activities, lasting at least two weeks and significantly interfering with daily life, work, or relationships), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and hypertension (HTN-high blood pressure). A review of Resident 1's care plan (CP) goal on, "The resident is Not an elopement risk/wanderer" dated 9/26/2025 indicated, "the resident's safety will be maintained." The same CP did not indicate that any interventions were put in place to ensure Resident 1's safety. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers) dated 10/11/2025 at 3:05 pm, indicated, "The Resident 1 had two episodes of exit seeking and trying to leave the facility. Resident 1 "was redirected multiple times. Explained to resident the risk of leaving facility without doctors' orders and that it is not safe for her to just leave. Resident expressed that she wants to go home. Resident was redirected back to her room. IDT [Interdisciplinary Team - a coordinated group of healthcare professionals (nurses, doctors, therapists, social workers, dietitians, activities staff, etc.) who work together with the resident and family to create and manage a personalized, holistic care plan, ensuring all medical, social, and functional needs are met for optimal recovery and well-being] was notified. MD [Medical Doctor] was notified." A review of Resident 1's SBAR dated 10/11/2025 at 8:45 pm, indicated, "Resident was noted by morning shift with change of behavior attempting to get-out of fire door causing alarm to be activated. In evening shift, she [Resident 1] was noted with physical aggressiveness/combativeness during care. She [Resident 1] was very delusional [having a strong, false belief that isn't based in reality and persists even when presented with clear evidence against it, often stemming from mental health conditions] verbalizing she is "Jehova," claiming she is GOD & calling staff devils. Her Physical Aggressiveness poses danger to self & to others. The NP was notified and ordered Haldol 5 mg (milligrams- unit of measurement and Benadryl 50 mg." A review of Resident 1 document titled, "Wandering Risk and Elopement Screening Assessment," dated 10/20/2025, with columns to indicate wandering and elopement behaviors, was blank and bore no initial of the nurse completing the assessment. The only entry is the date "10/20/2025." A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 11/4/2025, indicated the resident had memory problems and had moderate cognitive impairment (poor decision-making requiring cues and supervision). The same MDS indicated Resident 1 had not exhibited wandering behaviors and required supervision or touching assistance to set up or clean-up-assistance for Activities of Daily Living (ADLs) such as toileting hygiene, Shower/bathe, upper and lower body dressing, and putting on/taking off footwear. A review of Resident 1's SBAR progress note dated 11/4/2025 at 7:10 pm, indicated, after dinner, Resident 1 was observed displaying exit seeking behavior and aggression towards staff when re-directed. The same SBAR indicated at approximately 6:30 pm, Resident 1 climbed on her bed and began kicking the window next to her bed. The SBAR indicated, "NP (Nurse Practitioner) gave order of Haldol [used to treat nervous, emotional, and mental conditions e.g., schizophrenia] 5mg IM [intramuscular - Inject into a muscle] x 1 [one dose] and Benadryl [medication used to treat allergies] 25mg IM x 1 dose. and 1:1 monitoring and supervision." The same SBAR indicated that Resident 1 continued to kick the windows using her knees, resulting in the window breaking and called 911 for emergency assistance. Following this, Resident 1 stopped, got down from bed, and continue with non-sensical verbal outburst. The same SBAR indicated that Resident 1 then started complaining on bilateral (both) knee pain pointing towards the knees with limited ROM[Range of motion - is the full extent or limit a joint can move in various directions] and, sat by the bed. A review of Resident 1's Los Angeles Fire Department (LAFD) Patient Care Report dated 11/4/2025 at 9:16 pm indicated that, "Response urgency: Immediate. Dis (Dispatch) Notified on 11/4/2025 at 9:16 pm. Dispatched on 11/4/2025 at 9:17 pm" the paramedics [emergency medical professionals who provide advanced, life-saving care to critically ill or injured people at the scene of an emergency] arrived on scene (facility) at 9:27 pm, and at patient (Resident 1) at 9:29 pm.. The same LAFD Patient Care Report indicated the chief complaint of blunt leg injury (damage to the lower limb caused by a forceful impact, collision, or fall where the skin is not broken or pierced) and provider primary impression of traumatic injury (a sudden, severe physical harm to the body from an external force). A review of Resident 1's GACH document titled, "ISP (Inpatient Specialty Practices) Hospitalist Discharge Summary" dated 11/4/2025, indicated, Resident (Resident 1) was admitted to GACH on 11/4/2025 and discharged on 11/29/2025. The ISP discharge summary document indicated Resident 1 had a consultation with an orthopedic surgeon (medical doctor specializing in diagnosing, treating, preventing, and rehabilitating injuries and diseases of the musculoskeletal system such as bones, joints, ligaments, tendons, muscles, and nerves). Resident 1 had right lower extremity (RLE) external fixator (ex-fix - a medical device used to stabilize broken bones from the outside of the body). Resident 1's admission diagnosis was right tibial plateau fracture and comminuted fracture of the fibular head and neck. During an observation and interview with Resident 1 on 12/9/2025 at 11 am, Resident 1 was in her room sitting in a wheelchair. Resident 1 was observed with dressing to the inner and outer potions of the right knee. Resident 1 stated that she recalled climbing on some sort of table and trying to escape the facility. Resident 1 stated she saw the window as a way out because she just wanted to go home and that no one was listening to her. During an interview on 12/9/2025 at 12:26 PM, CNA (Certified Nursing Assistant) 1 stated that Resident 1 was ambulatory, alert, but mostly confused. CNA 1 stated that the resident would run away when confused, would push the door and try to run to the elevator in the facility. CNA 1 stated that most of the times Resident 1, "was with it (moments of mental clarity)," related well and communicated well. CNA 1 stated that she was not aware Resident 1 had 1:1 sitter (a designated staff member-such as a CNA, technician, or nurse-assigned dedicated staff member to monitor/stay with a single high-risk patient providing constant supervision to prevent falls, self-harm (suicide), wandering, or harm to others, acting as a safety measure often when patients are confused, suicidal, or agitated). CNA 1 stated that Resident 1 would say things like "I see your millions (money) coming through." During an interview on 12/9/2025 at 2:04 PM, LVN 1 stated that Resident 1 has periods of confusion, is an elopement risk, and tried to find exits/entrances. LVN 1 stated that Resident 1 had verbalized that she wanted to go home on multiple times. LVN 1 stated that on 11/4/2025 after dinner at around 5 pm to 6 pm, LVN 1 contacted a NP when Resident 1 was exhibiting exit seeking behavior and got agitated when staff tried to redirect the resident. LVN 1 stated that this was the first time he had observed Resident 1 get agitated and was not aware of any other episodes/incidents of Resident 1 getting agitated before 11/4/2025. LVN 1 stated the NP ordered 1:1 and some intramuscular medications (Haldol and Benadryl). LVN 1 stated that he sat (as a 1:1 sitter) with the resident and would switch out with someone when other residents needed something. LVN 1 stated that he administered the IM medication to Resident 1 and the resident remained in bed. LVN 1 stated that he was sitting at the resident's bedside when Resident suddenly got up in bed and started kicking the window with both legs at approximately 6:30 pm but was unable to state how long. LVN 1 stated that he yelled for help in the hallway and that LVN 2, who was working as desk nurse (an administrative nurse who works primarily at a central nursing station rather than providing direct, hands-on care at the bedside) that day (11/4/2025), came into the room. LVN 1 stated that the window was shattered, and a few pieces of glass fell on Resident 1's bed. LVN 1 stated that he did not stop the resident because he did not want to risk getting injured because he is relatively smaller. The resident stopped kicking the window and then complained of right knee pain. Resident 1 was assisted off the bed onto the wheelchair (WC) by a few nurses (LVN 1, LVN 2 and other nurses that LVN 1 could not recall). Resident 1 was evaluated by LVN 1 as well as LVN 2 (who was working as a desk nurse) with no visual injuries. However, Resident 1 had decreased range of motion (to the right knee). stated that he (LVN 1) provided 1:1 service continuously from the time 1:1 was ordered at 6:30 pm until Resident 1 was transferred to GACH via 911 around 9 pm. He (LVN 1) was also assigned to provide care to 28 residents . All CNAs were busy, so he took it upon himself to be the 1:1 sitter for Resident 1. LVN 1 stated that he did not inform the DON or the administrator that Resident 1 needed an extra staff to supervise and 1:1 monitoring for safety even though he (LVN 1) still had the full assignment and duties as a charge nurse and was therefore incapable of continuing 1:1 monitoring. During an interview on 12/9/2025 at 3:12 PM, LVN 2, who was working as a desk nurse on 11/4/2025 and also covers as a charge nurse, LVN 2 stated she worked on 11/4/2025 on the 3 pm to 11 pm shift and is familiar with Resident 1. Resident 1 has days when she displayed behaviors such as exit seeking as well as talking about stories that did not make sense such as stating that she was God and could fly. Resident 1 was at risk for elopement and could be redirected. LVN 2 stated she remembered that on 11/4/2025 sometime after dinner, LVN 1 was calling for help because Resident 1 was in the room and on top of the resident's bed and was kicking and broke the window because the resident was trying to leave. LVN2 did not observe Resident 1 with bleeding or cuts even from kicking and breaking the window. LVN 2 stated Resident 1's bed had broken shards of glass and that LVN 1 and LVN 2 assisted Resident 1 from the bed onto a wheelchair. LVN 2 stated that Resident 1 complained of right knee pain. LVN 1 stated she completed a body check on Resident 1 and observed that Resident 1 had decreased ROM to the right knee with no swelling. LVN 2 stated she called 911 twice. The first time was when Resident 1 started to kick the window while standing in bed. LVN 2 stated after 5 minutes she called 911 a second time because Resid