Health inspection·October 8, 2025

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. 22 CCR §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. 22 §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 other pertinent information related to such occurrences as the local health officer or the Department may require. On 8/22/2025, the California Department of Public Health (CDPH) received a complaint indicating Resident 7 had fallen and bruised her head. On 9/3/2025, the CDPH conducted an unannounced visit to the facility to investigate the allegation. The facility failed to: 1. Follow its Policy and Procedure (P&P) titled "Unusual Occurrence Reporting," Reporting and Investigating," which indicated unusual occurrences will be investigated and reported to the CDPH within 24 hours, after Resident 7's unwitnessed fall which resulted in a hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) to the right forehead. As a result, there was a delay in an investigation by CDPH. Findings: Resident 7 was a 72-year-old female initially admitted to the facility on 6/8/2020 and readmitted on 8/20/2025, with diagnoses of polyarthritis (the inflammation or involvement of five or more joints as the same time), muscle weakness, and difficulty in walking. A review of Resident 7's History and Physical (H&P), dated 7/24/2025, indicated Resident 7 could make needs known but could not make medical decisions. A review of Resident 7's Minimum Data Sheet ([MDS]- a resident assessment tool), dated 8/27/25, indicated Resident 7's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired. The MDS indicated Resident 7 required partial/moderate assistance (helper does more than half the effort) for toileting hygiene, showers, and putting on footwear. The MDS indicated Resident 7 had a fall in the last two to six months prior to admission/entry or reentry to the facility. A review of Resident 7's Situation Background Assessment and Recommendation (SBAR), dated 8/16/2025, indicated Resident 7 had an unwitnessed fall. The SBAR indicated Certified Nurse Assistant (CNA) found Resident 1 sitting on the floor in her room with a big bump on her right forehead. A review of the computed tomography ([CT]- a diagnostic imaging that process detail pictures inside the body) scan of Resident 7's General Acute Care Hospital (GACH), dated 8/16/2025, indicated Resident 7 had a right frontal hematoma. A review of Resident 7's physician order titled, "Order Summary Report," dated 8/22/2025, indicated to monitor for skin breakdown of the hematoma /bump on the right side of forehead. During an interview on 9/3/2025 at 3:51 p.m., with the Administrator (ADM), the ADM stated he was not aware Resident 7 fell and had a bump on her forehead. The ADM stated he did not investigate the incident. The ADM stated an unwitnessed fall was considered an unusual occurrence and had to be reported to CDPH. The ADM stated the incident should have been investigated to prevent recurrence and ensure interventions were implemented to improve Resident 7's care. During a concurrent interview and record review on 9/3/2025 at 4:19 p.m. with the Assistant Director of Nursing (ADON), the facility's policy and procedure (P&P) titled, "Unusual Occurrence Reporting," dated 6/2024, was reviewed. The P&P indicated the facility would report allegations of abuse and unusual occurrences that affect the welfare, health, or safety of residents by phone and in writing to the appropriate State or Federal agencies within 24 hours. The ADON stated Resident 7 had an unwitnessed fall with a bump on her head. The ADON stated the unwitnessed fall with injury should have been reported to the CDPH within 24 hours of the incident. The ADON stated the purpose of reporting within 24 hours was to avoid and prevent further falls. The facility failed to: 1. Follow its P&P titled "Unusual Occurrence Reporting," Reporting and Investigating," for Resident 7 by failing to report and investigate an allegation of an unwitnessed fall which resulted in a hematoma to the right forehead within 24 hours to CDPH. As a result, there was a delay in an investigation by CDPH. This violation had a direct or immediate relationship to the health and safety of Resident 7 and other residents in the facility.