Health inspection·October 22, 2025

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. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. 22CCR §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. On 9/29/2025 at 8:00 a.m., the California Department of Public Health (CDPH) received a complaint indicating the facility was having a lot of falls. On 9/30/2025 at 9:30 a.m., the CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: Implement its policy and procedure (P&P) titled, "Unusual Occurrence- CA", which indicated the facility shall report unusual occurrences within twenty-four (24) hours by telephone and confirmed in writing, to the local health officer and the Department (CDPH), when Resident 1 sustained a right hip fracture (broken bone) after falling at the facility on 9/8/2025 and did not report to the CDPH. As a result, there was a delay in the investigation by the CDPH. Findings: Resident 1 was a 102-year-old female, initially admitted to the facility on 1/2/2025 and readmitted on 9/12/2025. Resident 1's diagnoses included displaced fracture of the right femur (thigh bone), falls, and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) A review of Resident 1's History and Physical (H&P) dated 1/3/2025, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 7/9/2025, indicated Resident 1 had severe cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 required setup and clean-up assistance to supervision or touching assistance (helper provides verbal cues and/or touching/steading and/or contact guard assistance) for Activities of Daily Living (ADLs) such as toileting, transferring (the ability to transfer to and from a bed to a chair, wheelchair, toilet or commode) and walking. A review of Resident 1's "Change in Condition Evaluation" (COC) dated 9/8/2025 indicated Resident 1 had a witnessed fall and was found sitting on her buttocks next to the end of her bed. The COC indicated Resident 1 was guarding her right hip with complaints of pain. The COC indicated the physician recommended Resident 1 to be transferred to a General Acute Care Hospital (GACH) via 911 for further evaluation. A review of Resident 1's X-ray (medical imaging procedure that captures images of structures inside the body) result dated 9/8/2025 indicated Resident 1 had a fracture of the right hip. During an interview on 10/1/25 at 4:45 p.m., with the Administrator (ADM), the ADM stated the facility did not report Resident 1's fall incident with injury (right hip fracture) to the CDPH because it was witnessed (by Resident 1's roommate's family). The ADM stated the facility only reported unwitnessed falls with injuries. The ADM also stated falls with injuries were not classified as unusual occurrences because people fell every day. A review of the facility's P&P titled, "Unusual Occurrence-CA", dated 01/2021 indicated it is the policy of the facility that an unusual occurrence will be reported accurately and completely on a timely basis. The P&P indicated unusual occurrences which threaten the welfare, safety or health of patient, personnel or visitors shall be reported by the facility within twenty-four (24) hours either by telephone and confirmed in writing to the local health officer and the department. The facility failed to Implement its P&P titled, "Unusual Occurrence- CA", which indicated the facility shall report unusual occurrences within twenty-four (24) hours by telephone and confirmed in writing, to the local health officer and the CDPH when Resident 1 sustained a right hip fracture (broken bone) after falling at the facility on 9/8/2025 and did not report to the CDPH. As a result, there was a delay in the investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety or security of Resident 1.