Health inspection·December 24, 2025

483.70(h) Medical records. 483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are— (i) Complete; (ii) Accurately documented; 72543. Patients' Health Records. (f) Patients' health records shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each patient. Such records shall be filed and maintained in accordance with these requirements and shall be available for review by the Department. All entries in the health record shall be authenticated with the date, name, and title of the persons making the entry. 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. California Code, Health and Safety Code - HSC § 1424 (f)(1) A willful material falsification or willful material omission in the health record of a resident of a long-term health care facility is a violation. On 10/21/2025 at 9:55 am, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to investigate a resident-to-resident abuse incident. The facility failed to ensure accurate documentation of the Follow Up Question Report (FUQR – used by facility to document hourly visual monitoring of residents) for Resident 1 and Resident 2 in accordance with the facility’s policy and procedure (P&P) titled, “Policy for Hourly Monitoring of Residents,” by failing to ensure CNA 1, CNA 2, CNA 3, and CNA 6 did not falsify (change something in order to deceive people) Resident 1’s and Resident 2’s FUQR when CNA 1, CNA 2, CNA 3, and CNA 6 documented on Resident 1’s and Resident 2’s FUQR they had visually seen and identified Resident 1 and Resident 2 between the hours of 12 am and 4 am on 10/18/2025, 10/19/2025, and 10/20/2025. As a result of the investigation, the Department determined the facility failed to ensure the safety and security of Resident 1 and Resident 2 when Resident 1 and Resident 2 were not visually checked during hourly monitoring on 10/18/2025 at 12 am and from 2 am to 4 am, on 10/19/2025 at 1 am, and from 3 am to 4 am, and on 10/20/2025 from 12 am to 4 am. As a result, Resident 1 and Resident 2 did not receive adequate monitoring and supervision and placed Resident 1 and Resident 2 at risk for harm. a. A review of Resident 1’s Admission Record (AR) indicated the facility admitted Resident 1, a 27-year-old female, on 6/20/2025 with diagnoses that included schizophrenia, insomnia, and major depressive disorder. A review of Resident 1’s FUQR, dated 10/17/2025 to 10/20/2025, indicated Resident 1 was monitored hourly. The FUQR indicated during the night shift (11 pm to 7 am) on 10/17/2025, Resident 1 was monitored by CNA 1 hourly between the hours of 12 am and 1 am, and at 3 am on 10/18/2025. The FUQR indicated CNA 6 monitored Resident 1 on 10/17/2025 at 11 pm, and on 10/18/2025 at 2 am and at 4 am. The FUQR indicated during the night shift on 10/18/2025, CNA 1 monitored Resident 1 hourly between the hours of 11 pm and 4 am (on 10/19/2025). The FUQR indicated during the night shift on 10/19/2025, CNA 1 monitored Resident 3 hourly between the hours of 11 pm and 4 am (on 10/20/2025). b. A review of Resident 2’s AR indicated the facility admitted Resident 2, a 57-year-old female, to the facility on 5/4/2021 and was readmitted on 2/11/2025, with diagnoses that included paranoid schizophrenia, major depressive disorder, and anxiety disorder. A review of Resident 2’s FUQR, dated 10/17/2025 to 10/20/2025, indicated Resident 2 was monitored hourly. The FUQR indicated during the night shift on 10/17/2025, Resident 2 was monitored hourly by CNA 1 between the hours of 11 pm and 4 am (on 10/18/2025). The FUQR indicated during the night shift on 10/18/2025, CNA 1 monitored Resident 6 hourly between the hours of 11 pm and 2 am (on 10/19/2025). The FUQR indicated CNA 6 monitored Resident 1 and Resident 2 at 3 am and 4 am. The FQUR indicated during the night shift on 10/19/2025, CNA 3 monitored Resident 1 hourly between the hours of 11 pm and 4 am (on 10/20/2025). During a concurrent observation and interview on 10/21/2025 at 12:31 pm with the Program Director (PD), the facility’s video surveillance from 10/17/2025 at 11 pm to 10/18/2025 at 4 am was reviewed. The PD stated the video surveillance started on 10/17/2025 from 11:00:01 pm. The PD stated the camera was positioned in the west wing hallway by the back door. The PD stated there were three doors on the right side of the hall in the camera frame that were visible, and Resident 1 and Resident 2’s room door was second/middle door. The PD stated CNA 1 was the only staff observed entering and exiting Resident 1 and Resident 2’s room. The PD stated no other staff were observed entering or exiting Resident 1 and Resident 2’s room. The PD stated CNA 1 entered the room on 10/17/2025 at 11pm, and again on 10/18/2025 at 1 am. The PD stated CNA 1 did not enter Resident 1 and Resident 2’s room on 10/18/2025 from 12 am to 1 am, from 2 am to 3 am, and from 3 am to 4 am. PD stated no other staff member entered the room on 10/18/2025 from 12 am to 1 am, from 2 am to 3 am, and from 3 am to 4 am. During a concurrent observation and interview on 10/21/2025 at 3:12 pm with the PD, the facility’s video surveillance from 10/18/2025 at 11 pm to 10/19/2025 at 4 am was reviewed. The PD stated the video surveillance started on 10/18/2025 from 11:04 pm. The PD stated the camera was positioned in the west wing hallway by the back door. The PD stated there were three doors on right side of the hall in the camera frame that were visible, and Resident 1 and Resident 2’s room door was second/middle door. The PD stated CNA 2 was observed entering Resident 1 and Resident 2’s room on 10/18/2025 at 11 pm. The PD stated CNA 2 was observed standing in the doorway of Resident 1 and Resident 2’s room on 10/19/2025 at 12 am and again at 2 am. The PD stated no other staff member entered the room on 10/19/2025 from 1 am to 2 am, and from 3 am to 4 am. During a concurrent observation and interview on 10/22/2025 at 9:16 am with the PD, the facility’s video surveillance from 10/19/2025 at 11 pm to 10/20/2025 at 4 am was reviewed. The PD stated the video surveillance started on 10/19/2025 from 11:04 pm. The PD stated the camera was positioned in the west wing hallway by the back door. The PD stated there were three doors on the right side of the hall in the camera frame that were visible, and Resident 1 and Resident 2’s room door was second/middle door. The PD stated CNA 3 was observed entering and exiting Resident 1 and Resident 2’s room on 10/19/2025 at 11pm. The PD stated no staff member, or residents were observed entering or exiting the room on 10/20/2025 from 12 am to 4 am. The PD stated CNA 3 was observed on CNA 3’s phone most of the video. During a telephone interview on 10/22/2025 at 12:12 pm with CNA 3, CNA 3 stated CNA 3 went into Resident 1 and Resident 2’s room on 10/19/2025 not long after CNA 3’s shift started. CNA 3 stated both Resident 1 and Resident 2 were sleeping. CNA 3 stated CNA 3 sat in a chair by the room next door to Resident 1 and Resident 2’s room. CNA 3 stated, “I usually check my residents every hour, but I didn’t check them every hour that night I guess, but I documented I did.” CNA 3 stated CNA 3 could not see into Resident 1 and Resident 2’s room if CNA 3 was on CNA 3’s phone. CNA 3 stated when CNA 3 did hourly checks on residents, CNA 3 must go inside the residents’ room to check on them. CNA 3 stated, “It’s really hard to see both residents from the doorway. When you’re in the doorway, you can’t visualize both residents.” During a telephone interview on 10/22/2025 at 1:12 pm with CNA 1, CNA 1 stated CNA 1 worked the night shift of 10/17/2025. CNA 1 stated, “I was supposed to check on [Resident 1 and Resident 2] every hour, but I was very tired that night.” CNA 1 stated, “I documented I checked on [Resident 1 and Resident 2] every hour or something like that.” CNA 1 stated it was important to actually check on the residents to make sure they were safe. CNA 1 stated if CNA 1 did not check on the residents to make sure they were safe they could get sick, fall out of bed, get hurt, and that it was possible for the roommates to hurt each other. CNA 1 stated, “I’m supposed to look at them.” During an interview on 10/22/2025 at 2:09 pm with the Director of Staff Development (DSD), the DSD stated that unless otherwise indicated, all residents were monitored hourly. The DSD stated that staff were supposed to visualize each resident for their safety and to ensure they were alive, well, and breathing. The DSD stated this was done 24 hours a day, seven days a week. The DSD stated if staff were not checking on the residents, “Anything could happen.” The DSD stated residents could be choking, or not breathing, and that hourly checks ensured their safety to prevent them from harm. The DSD stated it was possible a resident could abuse their roommate if staff were not checking on the residents every hour. During an interview on 10/22/2025 at 2:47 pm with Licensed Psychiatric Technician (LPT) 1, LPT 1 stated CNAs were supposed to do hourly visual checks on residents. LPT 1 stated it was important for CNAs to do hourly visual checks because incidents like suicide could happen. LPT 1 stated, “We need to make sure they’re (residents) alive and assess their behavior.” LPT 1 stated incidents like resident-to-resident abuse could occur if staff were not checking on the residents hourly. During an interview on 10/22/2025 at 2:56 pm with the Director of Nursing (DON), the DON stated the facility’s standard was to check on residents every hour. The DON stated whoever documented the monitoring must lay eyes (to see or look at the resident) on the resident or visualize the resident, “To make sure they (residents) were okay.” The DON stated if CNAs or staff were not visualizing the residents every hour it posed a safety risk to the residents. The DON stated if not visualized hourly residents could fall and be unable to ask for help, residents could go into another resident’s room, and it could put the residents at risk for resident-to-resident abuse. A review of the facility’s P&P titled, “Policy for Hourly Monitoring of Residents,” dated 5/2024, indicated it was the policy of the facility to provide an atmosphere that was safe and secure for all residents and staff. The P&P indicated that each CNA was assigned a zone or area in the unit and would observe the location of resident assigned in their section, each hour, and document the location in the facility’s electronic medical record (EHR). The P&P indicated in documenting resident location in the EHR, staff were making an honest and accurate entry that they visually saw and identified the resident. The P&P indicated the monitoring allowed the staff to account for each resident and ensured that each resident was free from distress. A review of the facility's P&P titled, "[Facility] Policy on Documentation in Point Click Care (EHR)”, updated 1/2022, indicated all entries were to be made by the nurse who provided the nursing care or made the observation. The facility failed to ensure accurate documentation of the FUQR for Resident 1 and Resident 2 in accordance with the facility’s P&P titled, “Policy for Hourly Monitoring of Residents,” by failing to ensure CNA 1, CNA 2, CNA 3, and CNA 6 did not falsify Resident 1’s and Resident 1’s FUQR when CNA 1, CNA 2, CNA 3, and CNA 6 documented on Resident 1’s and Resident 2’s FUQR they had visually seen and identified Resident 1 and Resident 2 between the hours of 12 am and 4 am on 10/18/2025, 10/19/2025, and 10/20/2025. As a result of the investigation, the Department determined the facility failed to ensure the safety and security of Resident 1 and Resident 2 when Resident 1 and Resident 2 were not visually checked during hourly monitoring on 10/18/2025 at 12 am and from 2 am to 4 am, on 10/19/2025 at 1 am, and from 3 am to 4 am, and on 10/20/2025 from 12 am to 4 am. As a result, Resident 1 and Resident 2 did not receive adequate monitoring and supervision and placed Resident 1 and Resident 2 at risk for harm. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1 and Resident 2.