Health inspection·January 30, 2026

The following reflects the finding of the California department of Public Health during Investigation of two complaints. Complaint numbers: 2688742 and 2684648. A Class A citation was issued for complaint number 2688742. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations §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. Title 22, California Code of Regulations § 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. 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. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 12/16/2025, the California Department of Public Health (CDPH, the Department) made an unannounced visit to the facility to investigate a complaint allegation regarding resident neglect and accident. The facility 1. Repeatedly failed to ensure Resident 1, who was assessed having severe cognitive impairment and high risk for falls, remained as free of accident hazards as possible, by providing interventions such as but not limited to non-slip mats, enhanced supervision, toileting schedules, safety devices, or other interventions, resulting in Resident 1 experiencing multiple falls and resulting in injury. 2. Failed to develop an individualized written plan of care within seven days of admission on 11/10/2025 indicating the care to be given with objectives to be accomplished and the professional discipline responsible for each element of care, when Resident 1 was identified as having a high fall risk, but no interventions were implemented for the goal of fall prevention. 3.Failed to evaluate and update Resident 1’s care plan as necessary by the nursing staff and other professional personnel involved in Resident 1’s care after the change in condition of both the first fall 11/16/20205, and the second fall on 11/23/2025, to include appropriate interventions specific to his needs. 4.Failed to assess Resident 1’s requirement for participating in a toilet management program, leading to third fall and injury on 12.1.2025, when Resident 1 slide from bed while attempting to use a urinal and sustained diplopia, a 3 cm forehead laceration, thoracic strain, and left shoulder contusion. 5.Ensure staff adhered to the facility’s policy and procedure titled “Falls – Clinical Protocol” (revised 12/2024), which requires staff and physicians to identify and implement interventions to prevent falls and mitigate clinically significant consequences. As a result of these failures, Resident 1 had multiple unwitnessed falls (11/16/2025, 11/23/2025) and on 12/1/2025 Resident 1 slid from the bed, landing face down on the floor, resulting in a three cm laceration to the left forehead. Resident 1 was transferred to a General Acute Care Hospital (GACH) 1 on 12/2/2025 for generalized pain following the fall, with diagnoses of thoracic spine strain (discomfort in the mid-back, between the shoulder blades and lower ribs, often caused by muscle strain, poor posture, overuse, or joint issues, though more serious causes like nerve compression or fractures exist) and left shoulder contusion (bruise from direct impact, causing pain, swelling, stiffness, and discoloration [black-and-blue] as blood vessels leak under the skin). A review of Resident 1’s Admission Record, the Admission Record indicated Resident 1 was admitted on 11/10/2025 with diagnosis that included acute respiratory failure with hypoxia, other lack of coordination, and other abnormalities of gait (a manner of walking or moving the foot) and mobility (ability to move around freely and easily). A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 11/17/2025, the MDS indicated Resident 1’s cognitive (mental action or process of acquiring knowledge and understanding) skills were severely impaired. The MDS indicated Resident 1 was dependent on oral hygiene, toileting, bathing and dressing. The MDS indicated Resident 1 was also dependent with mobility, helper does all of the effort, with Resident 1 laying on back to roll left and right side, sit on side of bed to lying flat on the bed, lying on the back to sitting on the side of the bed and with no back support, come to a standing position from sitting and transfer to and from a bed to chair. The MDS also indicated Resident 1’s ability to get on and off a toilet commode was not attempted due to medical conditions or safety concerns. A record review of Resident 1’s fall risk assessment dated 11/10/2025, the fall risk assessment indicated score of 14. According to the falls assessment tool, if the total score is above 10, the resident should be considered high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. A record review Resident 1’s admission care plan, for the admission date 11/11/2025, unable to locate documentation of a “high risk for fall” care plan, no care plan initiated and no intervention in place. A review of Resident 1’s “Situation, Background, Assessment, Request (SBAR-communication framework widely used in healthcare to ensure clear, concise, and organized information exchange among team members.) Communication Form,” dated 11/16/2025 timed at 4:16 a.m., the SBAR indicated Resident 1 slid out of bed and found sitting on the floor at bedside with no visible injuries or bruises noted and Resident 1 denied any acute pain. A record review of Resident 1’s fall risk assessment dated 11/16/2025, indicated score of 19. A review of review of the care plan titled “Resident 1 noted sliding out of bed”, dated 11/16/2025, the care plan intervention indicated fall precautions implemented such as bed at lowest locked position and frequent visual checks done by staff to ensure safety and monitoring. A review of Resident 1’s care plan titled, “Risk for fall” initiated 11/17/2025, the care plan indicated anticipate and meet Resident 1’s needs, Resident 1 needs prompt response to all request for assistance and follow facility fall protocol. A review of Resident 1’s “Occupational Treatment (OT) Encounter Notes”, dated 11/17/2025, the notes indicated Resident 1’s functional status as total dependence with dressing, toileting and bathing and unable to sit or stand ADL. The notes indicated Resident 1 required extra time to initiate and complete given task. The notes also indicated that Resident 1’s cognitive status and nursing care required were complexities and barriers impacting OT therapy session. A review of Resident 1’s “SBAR Communication Form”, dated 11/23/2025 timed at 9:06 p.m., the SBAR indicated Resident 1 was found on the floor by his bedside. A review of Resident 1’s “SBAR Communication Form”, dated 12/1/2025 timed at 10:30 p.m., the SBAR indicated a loud sound came from Resident 1’s room and Resident 1 was found lying on the floor on his left side faced down. The SBAR further indicated Resident 1 had been attempting to use urinal on the edge of his bed until he slipped off the bed. The SBAR also indicated Resident 1 sustained a laceration on his left forehead above the eyebrow and reported a pain level of 7/10 and when assessed using the “two-finger” test, stated he were seeing 4 fingers(double). During an interview on 12/16/2025 at 4:02 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 depends totally on assistance with ADL’s including toileting. LVN 1 stated Resident 1 was incontinent and able to tell the staff when he is wet. LVN 1 stated Resident 1’s uses the urinal only when his spouse is present. LVN 1 stated that after Resident 1 fell on 11/16/2025, the care plan should be floor mat, frequent (every hour and a half) visual checks and addressing why Resident 1 fell. Since there is no care plan done none of this intervention was implemented. LVN 1 said when Resident 1 fell again, the nurse needed to determine why he fell, review his medications, and assess whether confusion, attempts to get up, or anxiety caused the fall. LVN 1 said finding the cause of the second fall is necessary to change the care plan and prevent more falls. LVN 1 said, “If the care plan stays the same with no changes to interventions Resident 1 can get hurt and it means we are not doing our job properly”. LVN 1 said the LVN assigned to the resident initiates care plan changes, and the RN completes the assessment, follows up with the physician, and revises the care plan further. LVN 1 said the goal is to prevent Resident 1 from falling again and getting injured. During an interview on 12/17/2025 at 11:06 a.m. with LVN 2, LVN 2 stated Resident 1 responds verbally with episodes of confusion, especially at night. LVN 2 stated Resident 1 tries to get out of bed by pulling his upper body using the side rails. LVN 2 stated while assisting CNA 1 with another resident room, LVN 2 and CNA 1 heard a loud bang sound that came from Resident’s 1 room. When they went to Resident 1’s room, they found Resident 1 on the floor with the urinal next to him and urine on the floor. LVN 2 stated that Resident 1 told him, on 12/1/2025 after Resident 1 fell, he was at the edge of the bed trying to use the urinal and slipped out of bed. LVN 2 said he cannot confirm if Resident 1 slipped as described because Resident 1’s cognition is impaired. LVN 2 said he forgot to update the care plan after the fall on 12/1/2025 and learned about it from Medical Records staff the next day. LVN 2 said he completed the care plan on paper the day after the fall and gave it to Medical Records. LVN 2 said he did not verify whether Medical Records received the care plan he submitted. During a concurrent interview and record review on 12/17/2025 at 12:07 p.m., with RN 1, Resident 1’s care plan dated 11/10/2025 and 11/17/2025 and fall risk assessment dated 11/10/2025 and 11/16/2025 were reviewed. The fall risk assessment dated 11/10/2025 showed a score of 14. The admission care plan dated 11/10/2025 indicated no documented safety concern and did not address the risk of falls. RN 1 stated Resident 1 was high risk for falls based on fall assessment on 11/10/2025 and staff should have initiated a care plan for risk for falls. The fall risk assessment dated 11/16/2025 S/P fall showed a score of 19. RN 1 said staff did not initiate care plan for actual fall on 11/16/2025. RN 1 stated she was the RN on duty when Resident 1 had another fall on 12/1/2025. RN 1 stated care plan should have been revised with changes in the interventions based on findings why Resident 1 keeps falling. RN 1 stated there should be a care plan addressing Resident 1’s behavior with interventions such as frequent safety reminders and hourly check on Resident 1. RN stated it is important to have an updated, current care plan to prevent falls from recurring of which could result in injury or possible death. During an interview on 12/17/2025 at 2:40 p.m., with Director of Nursing (DON), DON stated a care plan is done on admission and reviewed and revise it as needed. The DON stated staff should have revised Resident 1’s care plan after the fall on 11/23/2025 and completed a fall risk assessment. The DON stated it is important to assess what was missing from the initial care plan and change or add interventions based on their effectiveness. The DON stated staff must determine why the fall occurred and identify factors that explain the residents’ behavior that increases fall risk so they can address them. The DON stated after a fall, staff must review the care plan, identify needed changes, and determine additional interventions. The DON said the care plan guides the care provided to the residents, and if staff fail to update it, the facility is not taking steps to prevent another fall. The DON further stated the plan of care becomes ineffective when staff do not update the care plan. The DON said failing to include a known issue in the care plan can lead to more falls and potentially cause injuries. A review of the GACH 1 records titled “Emergency Department Reports” (EDR) dated 12/2/2025, the EDR indicated Resident 1’s presented for the GACH Emergency Department with generalized body pain after a fall and laceration to the left eyebrow. The EDR indicated Resident 1’s visit diagnosis as forehead laceration, closed Head injury, cause of injury - accidental fall, thoracic spine strain and left shoulder contusion. The CT (Computed Tomography, a powerful imaging test [also called CAT scan] used to see inside the body, creating detailed slices of bones, organs, and soft tissues) Head finding/report dated 12/2/2025, indicated positive for mild left frontal scalp swelling and negative for other significant findings. A review of the facility’s policy and procedures (P&P) titled, “Falls – Clinical Protocol”, dated 2/2024, the P&P indicated, “For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. If the fall is unclear…or if the individual continuous to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors”. The P&P also indicated, “Based on preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls to address the risks of clinically significant consequences of falling…The staff and physician will monitor and document the individual’s response to interventions intended to reduce falling or the consequences of falling”. A review of the facility’s fall prevention potential intervention dated 12/2024 nursing measures indicated toileting schedule, proper positioning, and use of non-slip material to prevent sliding. A review of facility’s P&P titled, “Care Plans – Baseline”, dated 12/2024, the P&P indicated, to assure that a resident’s immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of admission. A review of the facility’s P&P titled, Care Plans, Comprehensive Person-Centered”, dated 12/2024, the P&P indicated, The Care Planning process will facilitate resident and/or representative involvement, include an assessment of the resident’s strengths and needs, and incorporate the resident’s personal and cultural preferences in developing the goals of care. A review of the facility’s P&P titles, “Care Planning – Interdisciplinary Team”, dated 12/2024, the P&P indicated, our facility’s care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. The facility 1. Repeatedly failed to ensure Resident 1, who was assessed having severe cognitive impairment and high risk for falls, remained as free of accident hazards as possible, by providing interventions such as but not limited to non-slip mats, enhanced supervision, toileting schedules, safety devices, or other interventions, resulting in Resident 1 experiencing multiple falls and resulting in injury. 2. Failed to develop an individualized written plan of care within seven days of admission on 11/10/2025 indicating the care to be given with objectives to be accomplished and the professional discipline responsible for each element of care, when Resident 1 was identified as having a high fall risk, but no interventions were implemented for the goal of fall prevention. 3.Failed to evaluate and update Resident 1