Health inspection·December 18, 2025

The following reflects the findings of the California Department of Public Health during the investigation of: Complaint #: 2639496 Event ID: 1D9568-H1. Representing the Department, Nurse Surveyor #49330. State Citation B was written. §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(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. HSC 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 24 hours. (b)  A failure to comply with the requirements of this section shall be a class “B” violation. (c)  For purposes of this section, “abuse” shall mean any of the conduct described in subdivisions (a) and (b) of Section 15610.07 of the Welfare and Institutions Code. On 10/15/25 at 8:58 A.M., an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Resident 1’s right leg fracture. The facility failed to report an injury of unknown origin within 24 hours for one of three sampled residents (Resident 1). As a result of this failure, investigation into Resident 1’s injury was delayed and placed Resident 1 at risk for further mishandling and/or abuse. During a record review on 10/15/25, the facility’s Face Sheet indicated Resident 1 was admitted to the facility on 6/27/25 with diagnoses which included dementia (a progressive state of decline in mental abilities), muscle weakness, and need for assistance with personal care. During a record review on 10/15/25, the Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 8/26/25, the MDS indicated Resident 1’s Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident) of 3, which indicated severe cognitive impairment. During a joint observation and interview on 10/15/25 at 9:33 A.M., Resident 1 was observed in her bedroom, lying in bed. While pointing to her right leg, Resident 1 stated, “My leg got broken!” Resident 1 stated she did not remember what happened or how she broke her leg. During a telephone interview on 10/15/25 at 10:04 A.M. with Resident 1’s Responsible Party (RP), the RP stated on 9/30/25 at around 11:30 P.M., he was informed by the facility that Resident 1 was being sent to the hospital for right leg pain and swelling. The RP stated Resident 1 was diagnosed at the hospital with a fracture (broken bone) to her right leg. Resident 1’s RP stated, “…we don’t really know what happened, how she got the fracture…” The RP stated Resident 1 was confused and did not remember how she fractured her leg. During an interview with the Director of Nursing (DON) on 10/15/25 at 10:56 A.M., the DON stated Resident 1 was sent to the hospital on 10/1/25 for right leg pain and edema (swelling). The DON stated Resident 1 was readmitted to the facility on 10/5/25 with a confirmed diagnosis of fracture to the right femur (a bone in the upper leg). The DON stated Resident 1’s injury was considered an injury of unknown origin because the facility was not certain how Resident 1 sustained the fracture. The DON stated the facility’s investigation was not yet completed because she had not spoken to or received statements from staff who worked with Resident 1 on 9/30/25. The DON stated a corporate nurse consultant was covering for her when Resident 1 returned from the hospital with the fracture. During a telephone interview with the Corporate Nurse Consultant (CNC) 1, CNC 1 stated, “I was filling in for the DON [when Resident 1 returned from the hospital]. The ED [Emergency Department] indicated that [Resident 1] had a fracture, and they indicated that the fracture was approximately 24 hours old. I’m not sure how they indicated that…in any event, they said she had a fracture 24 hours prior to arriving there. I’m not sure why we didn’t report it right away…” CNC 1 stated, “Every time we have an injury of unknown origin, we have to report it, per regulations. The rationale behind it is we want to make sure people aren’t being abused, being neglected. Reporting protects them…” During a review of the facility’s undated policy titled Unusual Occurrence Reporting, the policy indicated, “As required by federal regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors…” In violation of the above cited standards, the facility failed to report an injury of unknown origin to the state licensing/certification office within 24 hours, which delayed the abuse investigation.