Health inspection·September 8, 2025

Code of Federal Regulations, Title 42, Section 483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is— (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). Code of Federal Regulations, Title 42, Section 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices, including but not limited to the following: 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: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (C) An unusual occurrence, as provided in Section 72541, involving a patient. 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 7/21/2025, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility to investigate a facility reported incident regarding an injury of unknown origin. The facility failed to promptly notify Resident 1’s Primary Care Physician/Medical Doctor (MD) 1 of Resident 1’s unwitnessed fall that occurred in Resident 1’s bathroom on 7/16/2025 at 11 pm, and of Resident 1’s complaint of back pain after the fall, in accordance with the facility’s policy and procedure (P&P) titled, “Change in a Resident’s Condition or Status.” The facility failed to ensure: 1. Licensed Vocational Nurse (LVN) 1 notified MD 1 on 7/16/2025, when Certified Nurse Assistant (CNA) 1 notified LVN 1 of Resident 1’s unwitnessed fall in the bathroom on 7/16/2025 at 11 pm. 2. Registered Nurse (RN) 1 notified MD 1 on 7/17/2025, when LVN 1 notified RN 1 of Resident 1’s unwitnessed fall in Resident 1’s bathroom on 7/16/2025 at 11 pm and Resident 1’s complaint of back pain after the fall. 3. RN 2 notified MD 1 on 7/17/2025, after RN 2 received information regarding Resident 1’s unwitnessed fall on 7/16/2025 at 11 pm and Resident 1’s complaint of pain after the fall. As a result of the investigation, the Department determined the facility delayed Resident 1’s treatment and care for the unwitnessed fall that occurred on 7/16/2025 at 11 pm. Resident 1 did not receive treatment and or care for the unwitnessed fall that occurred on 7/16/2025 at 11 pm, until 7/18/2025. On 7/18/2025 at 2:25 am, LVN 1 notified MD 1 of Resident 1’s unwitnessed fall (on 7/16/2025) and of Resident 1’s complaint of lower back pain [reported by Resident 1] after Resident 1’s fall. MD 1 ordered an X-ray of Resident 1’s back lumbar (lower back) and thoracic (mid-back) regions, stat (immediately/at once). The X-ray result showed Resident 1 had an acute L1 compression fracture (a sudden break of the first bone in the lower back often due to a fall or trauma). Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 7/18/2025 at 10:21 pm for further evaluation of acute L1 compression fracture and complained of lower back pain (unrated). A review of Resident 1’s Admission Record, indicated the facility admitted Resident 1, a 78-year-old female, on 7/15/2024, with diagnoses that included metabolic encephalopathy, dementia, and schizoaffective disorder. A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 6/15/2025, indicated Resident 1 was dependent on facility staff for most activities of daily living (ADLs) and required substantial/maximal assistance from facility staff to walk. A review of Resident 1’s Fall Risk Evaluation (FRE), dated 7/15/2025, indicated Resident 1’s FRE score was 14 (14 indicates a high risk of falling) due to conditions such as disorientation, ambulatory incontinence, predisposing diseases, decreased muscular coordination, required use of assistive devices, and taking medications with fall risk side effects. A review of Resident 1’s Change in Condition (CIC) Evaluation signed by LVN 1, dated 7/18/2025, timed at 8:03 am, indicated Resident 1 had an unwitnessed fall in the bathroom on 7/16/2025 at the beginning of the night shift (11 pm to 7 am shift) and Resident 1 complained of lower back pain (unrated pain). The CIC Evaluation indicated LVN 1 notified MD 1 on 7/18/2025 at 2:45 am regarding Resident 1’s unwitnessed fall (on 7/16/2025 at 11 pm), and Resident 1’s complaint of lower back pain. The CIC Evaluation indicated MD 1 ordered an X-ray stat of Resident 1’s back lumbar and thoracic regions. A review of Resident 1’s lumbar spine X-ray result, dated 7/18/2025, timed at 5:21 pm, indicated Resident 1 had an acute L1 compression fracture. A review of Resident 1’s Progress Note (PN) signed by RN 2, dated 7/18/2025, timed at 10:21 pm, the PN indicated Resident 1 was transferred to GACH 1 [on 7/18/2025, at 10:21 pm] due to Resident 1’s complaint of lower back pain. A review of Resident 1’s GACH Computed Tomography (CT) scan report, dated 7/18/2025, timed at 10:29 pm, indicated Resident 1 had a nondisplaced fracture involving the superior endplate of L1. During an interview on 7/23/2025 at 5:55 am with RN 1, RN1 stated on 7/17/2025 at 12:30 am, LVN 1 informed RN 1 that Resident 1 had back pain. RN 1 stated, on 7/17/2025, during the medication pass at 5 am, LVN 1 told RN 1 Resident 1 was found on the floor, on 7/16/2025 at 11 pm. RN 1 stated RN 1 told LVN 1 to complete a CIC form regarding Resident 1’s unwitnessed fall but LVN 1 did not complete the CIC form. RN 1 stated RN 1 did not notify MD 1 of Resident 1’s unwitnessed fall. RN 1 stated RN 1 had to assess Resident 1 after the fall (7/16/2025 at 11 pm), fill out a CIC form, and inform MD 1 of Resident 1’s unwitnessed fall, back pain, or CIC. RN 1 stated RN 1 did not fill out the CIC form. During a concurrent interview and record review on 7/24/2025 at 4 pm with the Director of Nursing (DON), the facility’s P&P titled, “Change in a Resident’s Condition or Status,” dated 5/2017 was reviewed. The P&P indicated the facility shall promptly notify the resident’s attending physician of changes in the resident’s medical/mental condition and/or status. The DON stated facility licensed nurses did not follow the P&P when both licensed nurses (LVN 1 and RN 1) did not notify MD 1 of Resident 1’s unwitnessed fall [on 7/16/2025, at 11 pm] and Resident 1’s complaint of pain after Resident 1’s fall. During a telephone interview on 7/25/2025 at 10:24 am with MD 1, MD 1 stated MD 1 received a text from the facility on 7/18/2025 at 2:25 am indicating Resident 1 was found on the floor at the beginning of the shift [11 pm] on 7/16/2025, and Resident 1 was complaining of back pain after the fall. MD 1 stated MD 1 responded to the text and ordered a stat X-ray of the lumbar and thoracic regions for Resident 1. MD 1 stated the licensed nurses needed to call MD 1 right after Resident 1 fell (on 7/16/2025 at 11 pm) because “The sooner we address the problem the better.” MD 1 stated MD 1 would have ordered X-rays right away and would have sent Resident 1 to the hospital for further evaluation of any complaint of pain after a fall. MD 1 stated MD 1 expected facility’s licensed nurses to inform MD 1 of any change in a resident’s condition right away because “the residents could hit their head after a fall and have bleeding or injuries.” MD 1 stated notifying MD 1 on 7/18/2025 regarding Resident 1’s unwitnessed fall that occurred on 7/16/2025 (at 11 pm) was considered a delay in care. During a telephone interview on 7/25/2025 at 12:13 pm with RN 2, RN 2 stated RN 2 assessed Resident 1 on 7/17/2025 (unable to remember exact time) per the DON’s instruction due to Resident 1’s unwitnessed fall on 7/16/2025 and Resident 1’s complaint of back pain after the fall. RN 2 stated RN 2 assessed Resident 1’s range of motion to see if Resident 1 had pain. RN 2 stated RN 2 did not document RN 2’s assessment in Resident 1’s medical record and did not notify MD 1 regarding Resident 1’s fall (7/16/2025 at 11 pm) and Resident 1’s complaint of pain after the fall. RN 2 stated when a resident had a CIC, RN 2 must assess the resident, notify the physician right away, and document the interventions in the resident’s medical record. During a telephone interview on 7/25/2025 at 1:40 pm with LVN 1, LVN 1 stated, at the start of the night shift (11 pm) on 7/16/2025, CNA 1 informed LVN 1 Resident 1 was found on Resident 1’s bathroom floor. LVN 1 stated, after Resident 1’s fall, LVN 1 entered Resident 1’s room (on 7/16/2025, unable to remember exact time) and Resident 1 complained of back pain. LVN 1 stated LVN 1 did not inform MD 1 on 7/16/2025 or on 7/17/2025 regarding Resident 1’s fall and complaint of pain but LVN 1 informed RN 1 of Resident 1’s unwitnessed fall and back pain on 7/17/2025. LVN 1 stated on 7/18/2025, when LVN 1 returned to work, LVN 1 filled out the CIC Evaluation form for Resident 1 and notified MD 1 (on 7/18/2025) at 2:25 am of Resident 1’s unwitnessed fall that occurred on 7/16/2025 at 11 pm, and Resident 1’s complaint of back pain after the fall. LVN 1 stated that for any CIC, LVN 1 must assess the resident, inform the resident’s physician of the CIC right away, and document in the resident’s medical record. A review of the facility’s P&P titled, “Change in a Resident’s Condition or Status,” dated 5/2017, the P&P indicated, the facility shall promptly notify the resident, his or her attending physician, of changes in the resident’s medical/mental condition and/or status. The P&P indicated the nurse will notify the resident’s attending physician or physician on call when there has been an accident or incident involving the resident. The P&P indicated prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. The P&P indicated the nurse will record in the resident’s medical record information relative to changes in the resident’s medical/mental condition or status. The facility failed to promptly notify MD 1 of Resident 1’s unwitnessed fall that occurred in Resident 1’s bathroom on 7/16/2025 at 11 pm, and of Resident 1’s complaint of back pain after the fall, in accordance with the facility’s P&P titled, “Change in a Resident’s Condition or Status.” The facility failed to ensure: 1. LVN 1 notified MD 1 on 7/16/2025, when CNA 1 notified LVN 1 of Resident 1’s unwitnessed fall in the bathroom on 7/16/2025 at 11 pm. 2. RN 1 notified MD 1 on 7/17/2025, when LVN 1 notified RN 1 of Resident 1’s unwitnessed fall in Resident 1’s bathroom on 7/16/2025 at 11 pm and Resident 1’s complaint of back pain after the fall. 3. RN 2 notified MD 1 on 7/17/2025, after RN 2 received information regarding Resident 1’s unwitnessed fall on 7/16/2025 at 11 pm and Resident 1’s complaint of pain after the fall. As a result of the investigation, the Department determined the facility delayed Resident 1’s treatment and care for the unwitnessed fall that occurred on 7/16/2025 at 11 pm. Resident 1 did not receive treatment and or care for the unwitnessed fall that occurred on 7/16/2025 at 11 pm, until 7/18/2025. On 7/18/2025 at 2:25 am, LVN 1 notified MD 1 of Resident 1’s unwitnessed fall (on 7/16/2025) and of Resident 1’s complaint of lower back pain (reported by Resident 1) after Resident 1’s fall. MD 1 ordered an X-ray of Resident 1’s lower back and mid-back regions, immediately, which the X-ray result showed Resident 1 had an acute L1 compression fracture. Resident 1 was transferred to GACH 1 on 7/18/2025 at 10:21 pm for further evaluation of acute L1 compression fracture and complained of lower back pain. The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.