Health inspection·November 4, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint numbers 2635397 and 2638873. Representing the Department, HFEN #44253 A Class B Citation was written. Regulations Violated: 22 CCR § 72521 Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. 22 CCR § 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 such other pertinent information related to such occurrences as the local health officer or the Department may require. On 10/10/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint allegation regarding fall with injury for Resident 1. The facility failed to report a major accident/unusual occurrence and report within 24 hours for Resident 1 to CDPH. On 10/4/2025 at 8:40 AM, Resident 1 fell in the facility patio and sustained a right thigh bone fracture (break in a bone). Resident 1 suffered six out of 10 pain level (6/10 numerical pain assessment where zero (0) is no pain and 10 is severe pain) to the right hip. Resident 1 was transferred to a general acute care hospital (GACH) for further evaluation and treatment via non-emergency medical transportation. This deficient practice had the potential result in a delay of an onsite inspection by the CDPH to ensure the residents' injury and accidents were investigated and had the potential to place other residents at further risk for falling and or with injuries. A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 1/25/2022 and readmitted on 10/9/2025 with diagnoses including intertrochanteric fracture of right femur (right thigh bone break), right sided hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (mild or partial weakness or loss of strength on one side of the body)  and dementia (a progressive state of decline in mental abilities). A review of the Minimum Data Set (MDS - resident assessment tool) dated 7/14/2025, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 1 required substantial assistance ( helper does more than half the effort) from staff for walking 10 feet and the MDS indicated Resident 1 used a walker. A review of Resident 1's Change of Condition (COC - a communication tool used by healthcare workers when there is a change of condition among the residents) form, dated 10/4/2025, indicated at 8:40 AM Registered Nurse 1 (RN 1) was passing by the smoking patio and saw the Resident 1 trip on the chair. RN 1 ran to try to catch the resident, but it was too late since Resident 1 had already landed on his right side. Resident 1 verbalized pain on the right hip with pain scale of 6/10 and no bruising or wounds were observed on Resident 1's body at that time. The COC further indicated the facility notified the nurse practitioner (NP), who ordered Resident 1 to have x-ray of both hips, both legs and pelvis. The COC also indicated the x-ray results indicated Resident 1 had acute (sudden onset) fracture of the proximal (closer to the origin, attachment point, or center of the body) right femur (thigh bone), the resident was transferred to a GACH via non-emergency ambulance. A review of Resident 1's Resident Transfer Record, dated 10/4/2025, indicated that on 10/4/2025 at 1:35 PM, the facility transferred Resident 1 to GACH due to acute fracture after a fall. A review of Resident 1's GACH Admission Record indicated GACH admitted Resident 1 on10/4/2025 at 6:28 PM due to a fall and femoral neck fracture. A review of Resident 1's GACH XR (x-ray) Hip 2 view dated 10/4/2025 at 6:58 PM, indicated Resident 1 had "a comminuted fracture ( a type of bone fracture where the bone breaks into multiple pieces) through the right intertrochanteric region." A review of Resident 1's GACH Physician H&P General dated 10/5/2025, indicated Resident 1's chief pain was right hip pain... Resident 1 had significant bruising (discoloration of the skin caused by the leakage of blood from damaged blood vessels into the surrounding tissues) and swelling to the right mandibular (jaw) area x-ray done and negative for fracture. A review of Resident 1's GACH physician order, dated 10/8/2025, indicated that on 10/8/2025, GACH discharged Resident 1 back to the facility. A review of Resident 1's GACH Discharge Instructions, dated 10/8/2025 indicated Resident 1 could bear weight on the right lower extremity as tolerated. The discharge instruction indicated the dressing on Resident 1's hip to remain in place and the dressing to be kept clean and intact. The discharge instruction indicated Resident 1 should return to a clinic for wound check and staple removal in two weeks. A review of Resident 1's Social Service Note, dated 10/9/2025, indicated the facility readmitted Resident 1 from the GACH on 10/8/2025. During an interview on 10/10/2025 at 10 AM, Resident 1 stated he broke his right hip. Resident 1 further stated he doesn't remember how he broke his hip nor did he remember going to the hospital. During a phone interview on 10/10/2025 at 1:56 PM, Registered Nurse Supervisor (RN) 1 stated that on 10/4/2025 around 8:30 AM or 8:40 AM, RN 1 saw Resident 1 in the patio area of the facility. RN 1 stated saw Resident 1 bump his foot on a bench on the patio then fell onto the right side. RN 1 stated Resident 1 complained of hip pain. RN 1 further stated Resident 1 received an x-ray which showed the resident sustained a right leg fracture and per physician order the facility transferred Resident 1 to a GACH. During an interview on 10/10/2025 at 2:53 PM, the Administrator (ADMIN) stated Resident 1 fell on Saturday [10/4/2025] in the morning. Resident 1 had an x-ray that showed he sustained a fracture and was transferred to a GACH. ADMIN further stated the facility did not report the incident to the State Survey agency. A review of the facility policy and procedures (P&P) titled, "Unusual Occurrences," dated 10/10/2025 indicated, "Purpose: To ensure all unusual occurrences are reported and/or follow up on as required. Content: The facility is to report unusual and currencies to the local health department within 24 hours of each occurrence." The facility failed to report a major accident/unusual occurrence and report within 24 hours for Resident 1 to the CDPH. On 10/4/2025 at 8:40 AM, Resident 1 fell in the facility patio and sustained a right thigh bone fracture. Resident 1 suffered 6/10 pain level to the right hip. Resident 1 was transferred to a GACH for further evaluation and treatment via non-emergency medical transportation. . This deficient practice had the potential result in a delay of an onsite inspection by the CDPH to ensure the residents' injury and accidents were investigated and had the potential to place residents at further risk for injuries. These above violations had a direct relationship to the health, safety, and security of Resident 1.