Health inspection·March 2, 2026

California Health & Safety Code, Section 1418.91 (a) A long term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately or within twenty-four hours. (b) Failure to comply with the requirements of the section shall be a Class B Citation. California Code, Welfare and Institutions Code - WIC, Section 15630 (b)(1) A mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that they have experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an internet report shall be made through the confidential internet reporting tool established in Section 15658, within two working days. California Code of Regulations Title 42, Section 483.12 (c)(1) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. On 2/5/26 at [time], an unannounced visit was made to the facility to investigate a complaint of alleged falsification of records and non-reporting of an injury of unknown origin. The Department determined that the facility failed to report and investigate an injury of unknown origin that occurred involving facility staff and Patient 1. One facility staff member, who was a mandated reporter, had knowledge of an injury of unknown origin on 11/5/25 and failed to report to the administrator of the facility. Therefore, the department determined the facility failed to report immediately, not later than 24 hours all incidents of alleged violation involving abuse and injuries of unknown origin when Patient 1 was allegedly injured while receiving care from family staff. This failure decreased the facility's potential to protect and provide residents with a safe environment. During a review of Patient 1's face sheet (a document containing patient information), Patient 1 was admitted to the facility October 2025 with multiple diagnoses which included muscle weakness and abnormalities of gait (manner of walking and limb movement) and mobility. A review of Patient 1's Minimum Data Set (MDS, an assessment tool) dated 11/5/25, indicated Patient 1 had moderate memory impairment. During an interview on 2/5/26, at 1:28 p.m., with Licensed Nurse (LN) 1, LN 1 confirmed Patient 1 had informed him that Patient 1 had gotten injured while receiving care by facility staff and that Patient 1 had felt unsafe. LN 1 stated he had not reported the allegation to facility management. During an interview on 2/5/26, at 2:52 p.m., with the Director of Staff Development (DSD), the DSD stated that her expectation from staff is that if they see a new injury they need to report immediately to the nurse. The DSD further stated that if a resident reports they got injured during care with another staff member the CNA is to report it as potential abuse. During an interview on 2/5/26, at 3:10 p.m., with the Director of Nursing (DON), the DON stated the expectations were for staff to report to management any injury of unknown source or allegation of abuse. DON further stated if injuries or allegations of abuse were not reported, residents could potentially experience further abuse and be injured. During a review of Patient 1's "Progress Note" (PN), dated 11/5/25, the PN indicated, "...patient [Patient 1] reported recent trauma to bilateral [both sides] legs/feet from dangling off of bed. Noted with large area of bruising to left lower leg... with 0.2cm [centimeter, unit of measurement] linear [straight] break in skin to lateral [side] aspect of L [left] lower leg... Patients preferences (using multiple staff members, gently moving legs)..." During a review of Patient 1's hospital record titled, "Inpatient Wound Care CAPI," date of service 11/6/25, the hospital record indicated, "Pt [patient] reports she was rolled by a CNA [Certified Nursing Assistant] at SNF [skilled nursing facility] and nearly fell OOB [out of bed] sustaining injuries to her left leg and right foot... Plantar [sole of foot] surface of L foot with circular red/maroon discoloration of unknown etiology [cause] possibly related to trauma..." During a review of Patient 1's care plan initiated on 11/6/25, the care plan indicated, "Resident has impaired skin integrity as evidenced by skin tear... related to trauma and is at risk for infection..." During a review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating", revised 9/22, the P&P indicated, "All reports of resident abuse (including injuries of unknown origin... are reported to local, state and federal agencies and thoroughly investigated by facility management... if resident abuse... injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law... within two hours of an allegation involving abuse or result in serious bodily injury; or... within 24 hours of an allegation that does not involve abuse or result in serious bodily injury." Therefore, the department determined the facility failed to report immediately, not later than 24 hours all incidents of an alleged violation involving physical and verbal abuse and injuries of unknown origin when Patient 1 reported her injuries were caused by facility staff during care. This failure decreased the facility's potential to protect and provide residents with a safe environment. This violation had a direct or immediate relationship to the health, safety, or security of Patient 1.