Health inspection·November 25, 2025

22 CFR § 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. 22 CFR § 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. On 10/10/2025, the California Department of Public Health (CDPH) received a facility reported incident indicating Resident 2’s Family Member (FM) 1 pulled down his pants and screamed at Resident 1. On 10/16/2025, the CDPH conducted an unannounced complaint investigation at the facility. The facility failed to follow its policy and procedure (P&P) titled, “Unusual Occurrence Reporting” which indicated the facility will report occurrences that interfered with the facility’s operations and affect the welfare, safety, or health of residents, employees, or visitors to appropriate agencies within 24 hours by not reporting when: 1. On 10/9/2025, FM 1 told the administrator, “If I went to jail today, somebody would have to die” 2.On 10/10/2025, FM 1 told Licensed Vocational Nurse (LVN) 2, “I will light this place up, I will place the gun at my feet and wait for the police to arrest me.” These deficient practices resulted in the delay of an onsite visit from the CDPH and had the potential to result in harm to the residents, visitors and staff in the facility. 1a. Resident 1 was a 73-year-old female, admitted to the facility on 8/17/2020 with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (also known as stroke, a loss of blood flow to a part of the brain ) affecting the right dominant side and anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life). A review of Resident 1’s Minimum Data Set (MDS- a resident assessment tool), dated 8/7/2025, indicated Resident 1’s cognition (process of thinking) was intact. The MDS indicated Resident 1 required setup or clean up assistance with eating, oral hygiene, toileting, and personal hygiene. A review of Resident 1’s Brief Capacity Evaluation, dated 10/10/2025, indicated Resident 1 had decision-making capacity for medical decisions. A review of Resident 1’s Situation, Background, Assessment, and Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 10/9/2025, indicated Resident 1 had an argument with Resident 2’s Family Member (FM) 1, who yelled at Resident 1, allegedly pulled down his pants, and closed Resident 1’s curtain. The SBAR indicated Resident 1 felt intimidated and disrespected by FM 1’s gesture. During an interview on 10/16/2025 at 8:46 a.m., with Resident 1, Resident 1 stated, on 10/9/2025, she asked FM 1 to step out of the room so she could use the restroom and she saw FM 1’s pants were down to his knees. Resident 1 stated FM 1 refused, pointed at her, told her to “shut up”, and pulled her curtain closed. Resident 1 stated she screamed for help and many staff members; which included the Social Services Assistant (SSA), the Infection Preventionist Nurse (IPN), the Director of Nursing (DON), and the Administrator (ADM); came to her room to investigate the incident. Resident 1 stated after the incident, police officers came to the facility and left. Resident 1 stated after the incident, FM 1 paced back and forth in the room and in the hallway and told her and other staff to “shut up”. Resident 1 stated although Resident 2 was no longer in the facility, FM 1 came back to the facility, on 10/10/2025, which resulted in a security guard being present in the lobby. During an interview on 10/16/2025 at 2:56 p.m., with the ADM, the ADM stated, on 10/9/2025, she was summoned to Resident 1’s bedside because Resident 1 was arguing with FM 1. The ADM stated FM 1 was angry that Resident 1 was reporting him for exposing his buttocks to her and FM 1 stated that was untrue. The ADM stated law enforcement were called and when they arrived, the police officer interviewed FM 1. The ADM stated, at approximately 7 p.m., in the facility’s parking lot, FM 1 approached her and said to her, “If I went to jail today, somebody would have had to die. You don’t get it, you don’t know my history, my reputation means everything to me.” The ADM stated she told FM 1 to not speak that way as it could be taken seriously instead of him venting his frustration. The ADM stated FM 1 left the facility’s property after Resident 2 was sent to the GACH for medical evaluation. 1b. Resident 2 was an 83-year-old, initially admitted to the facility on 6/20/2025 and readmitted on 8/18/2025. Resident 2’s diagnoses included metabolic encephalopathy (change in how the brain works due to an underlying condition) and vascular dementia (a decline in cognition caused by damage to the blood vessels in the brain. A review of Resident 2’s History and Physical (H&P), dated 8/19/2025, indicated Resident 2 did not have the capacity to understand and make decisions. A review of Resident 2’s MDS, dated 7/19/2025, indicated Resident 2’s cognition was severely impaired. The MDS indicated Resident 2 was dependent on staff’s assistance with eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. 2. During an interview on 10/16/2025 at 1:23 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, on 10/10/2025, she saw FM 1 speaking aggressively to the maintenance personnel and stepped in between them. LVN 2 stated she and the SSD walked out of the facility with FM 1 to try and calm him down. LVN 2 stated after approximately 30 to 40 minutes of attempting to calm FM 1 down, FM 1 began speaking nonsense and stated demons were talking to him. LVN 2 stated FM 1 told her, “If something happens to my mom, I will light this place up, I will place the gun at my feet and wait for the police to arrest me.” LVN 2 stated once FM 1 made his statement, the police were called to the facility to assist in removing FM 1 from the property. During an interview on 10/16/2025 at 3:16 p.m., with the ADM, the ADM stated, on 10/10/2025, FM 1 returned to the facility to submit a grievance and became agitated with the staff. The ADM stated after the incident between Resident 1 and FM 1, on 10/9/2025, FM 1’s statement to the ADM and FM 1’s statement to LVN 1 were not reported to the CDPH because the events were connected. The ADM stated FM 1’s threats on 10/9/2025 and 10/10/2025 should have been reported to the CDPH to provide updates on the increasing safety risk and harm to residents in the facility. The ADM stated she should have reported the incidents to the CDPH as the lack of reporting resulted in a delayed investigation by the CDPH, and placed the residents and staff at risk of harm. A review of the facility’s policy and procedure (P&P) titled, “Unusual Occurrence Reporting”, revised 1/2022, the P&P indicated the facility would report “occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees, or visitors”. The P&P indicated, “Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations.” The facility failed to follow its policy and procedure (P&P) titled, “Unusual Occurrence Reporting” which indicated to report occurrences that interfered with the facility’s operations and affect the welfare, safety, or health of residents, employees, or visitors to appropriate agencies within 24 hours by not reporting when: 1. On 10/9/2025, FM 1 told the administrator, “If I went to jail today, somebody would have to die”; 2. On 10/10/2025, FM 1 told Licensed Vocational Nurse (LVN) 2, “I will light this place up, I will place the gun at my feet and wait for the police to arrest me.” These deficient practices resulted in the delay of an onsite visit from the CDPH and had the potential to result in harm to the residents, visitors and staff in the facility. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.