Failure to Report Unusual Occurrence After Resident Fall With Head Laceration
Summary
The facility failed to report an unusual occurrence to the California Department of Public Health within 24 hours after Resident 4 had an unwitnessed fall and sustained lacerations to the back of the head that required two staples before being sent to an acute care hospital. Resident 4 was admitted in November 2025 with diagnoses of a right femur fracture, abnormalities of gait and mobility, and mild cognitive impairment. During an interview, Resident 4 stated the fall occurred in the shared bathroom when a family member from the other room suddenly opened the door while holding the doorknob, causing the resident to lose balance and fall. During record review and interview, the ADON stated the incident was not reported because the fall was believed to have been witnessed by a family member and therefore did not require reporting to CDPH. However, the EHR documented the event as an unwitnessed fall with injury, and the ADON acknowledged that the resident’s head injury required two staples. The facility policy titled Unusual Occurrence Reporting stated that unusual occurrences are to be reported to the appropriate agency within 24 hours by telephone and then confirmed in writing.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Missing Separate Charge Nurse on Evening Shift: The facility failed to designate a separate charge nurse for the 3:00 PM to 11:00 PM shift, instead having the medication/treatment nurse also serve as charge nurse. The Staff Reporting Form showed no designated charge nurse for three reviewed shifts, and the DON and Administrator both confirmed this practice during interview, despite the state standard requiring a charge nurse to supervise total nursing activities on that shift.
Failure to Meet Minimum Nursing Staffing Ratio: The facility did not ensure nursing staff provided the required 2.8 hours of direct nursing care per resident per 24 hours on multiple days reviewed. The staffing grid showed ratios below the minimum standard on several days, and the DON confirmed nightshift shortages were reported to her, while the Administrator stated the facility used the state minimum requirement ratio for daily staffing.
Failure to Meet Minimum Nursing Staffing Ratio: The facility did not ensure nursing staff provided the required 2.8 hours of direct nursing care per resident per 24 hours on two reviewed days. The PBJ report showed excessively low weekend staffing, and the staffing grid documented ratios of 2.63 and 2.7, both below the state minimum. The Administrator confirmed the facility did not meet its established staffing level and stated the reports did not generate email alerts.
Failure to Report Resident Fracture: A resident with normal cognition developed persistent wrist pain and was sent to the ED, where x-rays confirmed fractures of the radius and ulna. The Adm could not provide documentation that the fracture had been reported to the State Agency, despite facility policy requiring reportable unusual occurrences to be submitted within 24 hours.
Unqualified Social Services Director: The facility failed to staff and supervise the social services dept with a qualified social worker. The SSD had been a CNA before taking the role, had only a high school education, and did not meet the job description’s requirement for a bachelor’s degree in SW or Human Services plus supervised SW experience. Facility policies and Title 22 required social work services to be directed by a qualified social worker, and the deficiency affected all 20 residents.
Unqualified Social Services Director: The facility failed to ensure the social services department was directed by a qualified SSD for all 47 residents. The OM was acting as SSD for about two weeks after the prior SSD left, but had no documented 2 years of social work experience and only had two weeks of training with the prior SSD. The prior SSD stated they were not trained or licensed as a social worker and did not have a bachelor’s degree, despite the job description listing a bachelor’s degree in SW or Human Services and 2 years of supervised social work experience.
Missing Separate Charge Nurse on Evening Shift
Penalty
Summary
The facility failed to comply with state nursing facility staffing requirements by not designating a charge nurse responsible for supervision of the total nursing activities during the 3:00 PM to 11:00 PM shift, separate from the medication/treatment nurse assignment, for three reviewed shifts. The facility policy titled, Staffing, stated that the facility maintains adequate staffing on each shift to ensure residents' needs and services are met. However, the Staff Reporting Form showed no designated charge nurse for the 3:00 PM to 11:00 PM shift on 07/28/26, 07/29/26, or 07/30/26. The Minimum Standards for Institutions for the Aged or Infirm for Rule 45.4.1 Nursing Facility required a registered nurse or licensed practical nurse to serve as charge nurse and be responsible for supervision of the total nursing activities during the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts. During interview, the DON stated he served as charge nurse until approximately 4:30 PM on some days and then the medication/treatment nurses also served as charge nurses after that time. The DON acknowledged the facility did not designate a separate charge nurse from the medication/treatment nurse role and was unaware the standard required a designated charge nurse separate from the medication/treatment nurse assignment for the 3:00 PM through 11:00 PM shift. The Administrator confirmed the medication/treatment nurses also served as charge nurses during that shift and stated the purpose of a separate charge nurse was to provide supervision of nursing services while allowing the medication/treatment nurse to focus on medication administration and treatments.
Failure to Meet Minimum Nursing Staffing Ratio
Penalty
Summary
The facility failed to comply with state nursing facility staffing requirements by not ensuring nursing staff provided 2.8 hours of direct nursing care per resident per 24 hours on five of 14 days reviewed. Review of the facility’s Staffing Policy dated 7/1/2024 showed the facility stated it would have sufficient nursing staff and that the clinical PPD would be 2.80 or greater, while also noting this minimum standard may not in itself meet the need for sufficient nursing staff. Review of the Minimum Standards for Institutions for the Aged or Infirm for Rule 45.4.1 Nursing Facility showed the minimum staffing requirement was based on a ratio of 2.80 hours of direct nursing care per resident per 24 hours. Review of the Staffing Grid dated 6/15/26 through 6/28/26 showed staffing ratios below the required 2.8 on 6/19/26 at 2.73, 6/21/26 at 2.63, 6/26/26 at 2.24, 6/27/26 at 2.4, and 6/28/26 at 2.24. During interview, the DON stated the facility scheduled direct care nursing staff to meet the state minimum staffing levels and confirmed she was notified of the nightshift shortage on 6/26/26 the morning of 6/27/26 and was notified by nursing staff on the night of 6/27/26 of the shortage. The Administrator stated the facility used the state minimum requirement ratio for daily staffing.
Failure to Meet Minimum Nursing Staffing Ratio
Penalty
Summary
The facility failed to comply with state nursing facility staffing requirements by not ensuring nursing staff provided 2.8 hours of direct nursing care per resident per 24 hours on two of 13 days reviewed in the second quarter of 2026. The facility’s policy, Nursing Services - Staffing, stated that staffing would comply with established staffing requirements by the individual state governing agencies, and the state rule required a minimum of 2.80 hours of direct nursing care per resident per 24 hours based on resident census. A review of the PBJ Payroll Based Journal Data Report for fiscal year quarter 2 of 2026 showed the facility’s metric for excessively low weekend staffing was triggered, indicating the weekend staffing data submitted by the facility was excessively low. The facility’s staffing grid showed staffing ratios of 2.63 on 2/7/26 and 2.7 on 3/21/26, both below the state requirement of 2.8. During interview, the Administrator stated the reports for those dates did not generate email notifications to alert him that the facility fell below the 2.8 staffing ratio, and he confirmed the facility did not meet its established staffing level on those dates.
Failure to Report Resident Fracture
Penalty
Summary
The facility failed to report a right wrist fracture sustained by one of three sampled residents, Resident 150, to the State Agency after the resident was sent to the emergency department for evaluation of right wrist pain. Resident 150 was admitted to the facility on an unspecified date and had an MDS dated 6/12/26 showing a BIMS score of 15 out of 15, indicating normal thinking and memory. On 3/29/26, Resident 150 reported persistent right wrist pain and requested transfer to the emergency department. Record review of the emergency department provider notes dated 3/29/26 showed closed fractures of the right radius and right ulna. During interviews, the Administrator stated that unusual occurrences such as a major injury like a fracture must be investigated and reported by fax or email according to state requirements, but was unable to provide documentation that the incident had been reported. The ADON stated that fractures must be reported so the State Agency can review the care plan, visit the facility, investigate, and help improve care areas that the facility did not identify or catch. The facility policy on unusual occurrence reporting stated that reportable events affecting resident health, safety, or welfare are to be reported to appropriate agencies within 24 hours or as otherwise required.
Unqualified Social Services Director
Penalty
Summary
The facility failed to ensure the social services department was staffed and supervised by a qualified social worker, as required by California Title 22 regulations. During interview, the Social Services Director (SSD) stated they had been in the position since December 2025 and had previously worked as a CNA. Human Resources reviewed the SSD’s resume and confirmed the highest education completed was high school, with no bachelor’s degree. HR also reviewed the job description for Social Services Director, which required a minimum of a bachelor’s degree in Social Work or Human Services and 2 years of supervised social work experience in a health care setting; HR stated the SSD did not meet those educational requirements. The facility assessment identified the need for social worker resources, including a social worker and mental health social worker. Facility policies for end-of-life care and behavioral management described social services responsibilities such as reviewing advance directives, communicating with residents, assessing outside resources, and coordinating services for resident behavior patterns. State regulations reviewed by surveyors defined social work services and stated the social work service unit shall be organized, directed, and supervised by a social worker responsible for supervision of other social work staff, including social work assistants. The deficiency affected all 20 residents for at least 3 months, and the report states all residents were receiving social services from unqualified staff.
Unqualified Social Services Director
Penalty
Summary
The facility failed to ensure the social services department was supervised and directed by a qualified social services director for all 47 residents. During interview and record review, the Operations Manager stated they were acting as the social services director for about two weeks after the previous social services director departed, and stated a replacement would be hired in 9/2025. The Operations Manager also stated they had only completed two weeks of training with the previous social services director and did not have a training record. Review of the Operations Manager’s employment file did not show two years of social work experience. The previous social services director stated they were the social services director but were not trained or licensed to be a social worker, and stated they did not have a bachelor’s degree. Review of that employee’s file did not show completion of any bachelor’s degree. The facility’s job description for Social Services Director, dated 2/24, listed a Bachelor’s Degree in Social Work or Human Services and 2 years of supervised social work experience in a health care setting working directly with individuals, with MSW preferred. The facility assessment dated 7/16/25 identified a staffing plan with a full-time social worker, and the facility policy stated the director of social services is responsible for program planning, policy development, priority setting, and supervising social services personnel.
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