Health inspection·August 4, 2025

Code of Federal Regulations, Title 42, Section 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. California Code of Regulations, Title 22, Section 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 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 6/25/2025, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care and treatment involving Resident 1. The facility failed to ensure Activity Assistant (AA) 1 did not leave Resident 1 unsupervised in Resident 1’s wheelchair inside Resident 1’s room on 6/16/2025 at “approximately” 5:35 pm. As a result of the investigation, the Department determined the facility failed to prevent a fall for Resident 1, by failing to ensure AA 1 provided one-to-one (1:1) supervision to Resident 1 as indicated in Resident 1’s Interdisciplinary Team Meeting/Care Conference, dated 5/1/2023. As a result, on 6/16/2025, at approximately 5:35 pm, Resident 1 fell from Resident 1’s wheelchair and sustained a laceration which measured 2 centimeters (cm) in length by (x) 1 cm in width x 0.5 cm in depth on Resident 1’s left eyebrow, an abrasion to Resident 1’s left elbow (size was not indicated), and multiple abrasions on Resident 1’s left forearm (sizes were not indicated). On 6/16/2025 at 5:45 pm, the paramedics transferred Resident 1 to General Acute Care Hospital (GACH) 1 for further evaluation. A review of Resident 1's Admission Record (AR) indicated the facility admitted Resident 1, a 50-year-old male, to the facility on 6/24/2019, with diagnoses including intellectual disabilities, autistic disorder, and schizoaffective disorder. A review of Resident 1’s History and Physical, dated 12/5/2024, 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 4/16/2025, indicated Resident 1’s cognitive skills (ability to make daily decisions) was severely impaired. The MDS indicated Resident 1 required partial/moderate assistance from staff for personal hygiene and walking. A review of Resident 1's Progress Notes (PN), dated 6/16/2025 and timed at 7:02 pm, indicated on 6/16/2025, “at approximately” 5:35 pm, Resident 1 was found by Helper 1 (AA 1) lying on the floor, on Resident 1’s left side with profusely bleeding on Resident 1’s left eyebrow. The PN indicated Resident 1 was noted with a laceration on Resident 1’s left eyebrow, measured 2 cm in length x 1 cm in width x 0.5 cm in depth. The PN indicated Resident 1 had an abrasion to left elbow and multiple abrasions to Resident 1’s left forearm. The PN indicated (on 6/16/2025) at 5:40 pm, facility’s staff (unidentified) called 911. The PN indicated (on 6/16/2025) at 5:45 pm, the paramedic arrived and transferred Resident 1 to GACH 1 for further evaluation. A review of Resident 1’s Emergency Department (ED) Note Physician (EDNP), dated 6/16/2025 and timed at 6:27 pm, indicated Resident 1 was brought into GACH 1 by Emergency Medical Services. The EDNP indicated Resident 1 had a fall at a Skilled Nursing Facility (SNF). The EDNP indicated Resident 1 had a laceration on Resident 1’s forehead and wound care was provided to Resident 1’s forehead laceration with Steri-Strips (thin, adhesive bandages used to close and support small cuts, wounds, and incisions). During an observation of Resident 1 inside the facility’s activity room, on 6/25/2025 at 11 am, Resident 1 was sitting in a chair with AA 1 providing 1:1 supervision to Resident 1. Resident 1 was noted to have a scab (a dry, rough protective crust that forms over a cut or wound during healing), measured 2 cm in length x 1 cm in width, over Resident 1’s left eyebrow. Resident 1 was noted to have a bruise, the size of a nickel, under Resident 1’s left eye. During a telephone interview on 6/25/2025 at 1:09 pm with Licensed Vocational Nurse (LVN) 3, LVN 3 stated LVN 3 was Resident 1’s assigned nurse during the evening shift (from 3pm to 11 pm) on 6/16/2025. LVN 3 stated, on 6/16/2025, at 5:35 pm, Resident 1 fell on the floor in Resident 1’s room. LVN 3 stated AA 1 was supposed to be watching/supervising Resident 1 when Resident 1 fell (on 6/16/2025, at 5:35 pm). LVN 3 stated an assigned staff (AA 1) needed to “always” watch/supervise Resident 1 due to Resident 1 was impulsive (acting without forethought) and would also “throw tantrums” when Resident 1 became upset. LVN 1 stated Resident 1 would bang Resident 1’s head against “things” when Resident 1 became upset. During a telephone interview on 6/25/2025 at 2 pm with AA 1, AA 1 stated, on 6/16/2025, before Resident 1 fell (unable to recall exact time), LVN 4 had instructed AA 1 to watch/supervise Resident 1 while AA 1 was also supervising other residents (unidentified) in the smoking patio next to the activity room. AA 1 stated Resident 1 was watching television in the activity room when Resident 1 told AA 1 that Resident 1 was going back to Resident 1’s room. AA 1 stated Resident 1’s room was next to the activity room. AA 1 stated Resident 1 wheeled Resident 1 (in the wheelchair) from the activity room to Resident 1’s room and closed Resident 1’s room door behind Resident 1. AA 1 stated, after 30 seconds, AA 1 opened Resident 1’s room door, went into Resident 1’s room and found Resident 1 lying on the floor next to Resident 1’s bed. AA 1 stated Resident 1 was bleeding over Resident 1’s eyes and there was blood on the floor in Resident 1’s room. During an interview on 6/25/2025 at 2:35 pm with LVN 1, LVN 1 stated Resident 1 required 1:1 supervision from facility’s staff (in general). LVN 1 stated assigned staff (staff assigned to provide 1:1 supervision) needed to be with Resident 1 to supervise Resident 1 because Resident 1 had behaviors of throwing tantrums when Resident 1 got upset. During an interview on 6/25/2025 at 3:02 pm with Registered Nurse (RN) 1, RN 1 stated Resident 1 needed 1:1 supervision from staff. RN 1 stated Resident 1 should not have been in Resident 1’s room alone and unsupervised when Resident 1 fell on 6/16/2024 (at 5:35 pm). RN 1 stated, “It was not safe” for Resident 1 to be left unattended by AA 1. During a concurrent interview and record review on 6/26/2025 at 11:40 am with the Director of Nursing (DON), Resident 1’s Interdisciplinary Care Team (IDT) Meeting/Care Conference, dated 5/1/2023, was reviewed. The IDT notes indicated, “Due to resident's (Resident 1) impaired cognition and medications, resident (Resident 1) will be closely monitored for falls.” The IDT notes indicated effective 5/9/2023, the IDT team and the Regional Center’s (a private, non-profit corporation that provided services for individual with developmental delay or disability) staff (RCS) determined that Resident 1 would be provided with helpers to perform 1:1 supervision for Resident 1 daily, for 10 hours a day (time frame was not indicated). The DON stated on 6/16/2025, Resident 1 should have been provided with 1:1 supervision from staff until 7:00 pm (from 9 am to 7 pm). The DON stated after dinner (around 7 pm), Resident 1 would calm down, go to bed and would not need a 1:1 supervision. The DON stated Resident 1 required 1:1 supervision from staff for 10 hours daily since 5/9/2023. During a telephone interview on 6/26/2025 at 12:05 pm with LVN 4, LVN 4 stated LVN 4 was responsible to make the staffing assignment for the evening shift (3 pm to 11 pm) on 6/16/2025. LVN 4 stated LVN 4 had instructed/assigned AA 1 to supervise Resident 1 on 6/16/2025 (from 3 pm to 11 pm). LVN 4 stated AA 1 was supposed to “keep an eye on” Resident 1 “at all times.” A review of the facility's policy and procedure (P&P) titled, "Safety and Supervision of Residents," undated, indicated, “Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.” The P&P indicated, “The interdisciplinary care team shall target interventions to reduce the potential for accidents.” The P&P indicated “Implementing interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff; b. assigning responsibility for carrying out interventions; c. providing training, as necessary; d. ensuring that interventions are implemented; and e. documenting interventions.” The facility failed to ensure AA 1 did not leave Resident 1 unsupervised in Resident 1’s wheelchair inside Resident 1’s room on 6/16/2025 at “approximately” 5:35 pm. As a result of the investigation, the Department determined the facility failed to prevent a fall for Resident 1, by failing to ensure AA 1 provided 1:1 supervision to Resident 1 as indicated in Resident 1’s Interdisciplinary Team Meeting/Care Conference, dated 5/1/2023. As a result, on 6/16/2025, at approximately 5:35 pm, Resident 1 fell from Resident 1’s wheelchair and sustained a laceration which measured 2 cm in length x 1 cm in width x 0.5 cm in depth on Resident 1’s left eyebrow, an abrasion to Resident 1’s left elbow, and multiple abrasions on Resident 1’s left forearm. On 6/16/2025 at 5:45 pm, the paramedics transferred Resident 1 to GACH 1 for further evaluation. These violations have a direct or immediate relationship to the health, safety, or security of Resident 1.