Other·April 10, 2026

B Citation Code of Federal regulations, Title 42, Section 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. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. California Health and Safety Code, 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. On 3/11/26, at 9:35 AM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to conduct a Federal Recertification Survey and to investigate a Facility Reported Incident regarding abuse. The facility failed to ensure allegations of abuse were reported within two hours for one of four sampled residents (Resident 1) when an injury of unknown origin (or allegation of possible staff to resident abuse) on 2/20/26 was reported to the Department on 2/25/26. This failure had the potential for Resident 1 to experience continued abuse and not having an advocate available to protect Resident 1 rights. A review of Resident 1's "ADMISSION RECORD," indicated Resident 1 was admitted to the facility with diagnoses which included muscle weakness and osteoporosis (a common disease that makes bones weak, brittle, and porous, significantly increasing the risk of fractures). A review of the facility document titled, "REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE [SOC 341]," dated 2/20/26, indicated "Primary nurse notified by CNA of discoloration of resident's right forearm. Resident [1] states it may have happen while being repositioned by CNA..." The date of incident was "2/20/26." The document also indicated it was not faxed to the department until 2/25/26 at 4:42 PM (Transmittal date and time). During an interview on 3/11/26, at 9:57 AM, with the Director of Nurses (DON), the DON stated the facility did not have a fax confirmation indicating the SOC 341 was faxed to The Department and the Ombudsman (a state-certified, trained advocate who protects the rights, dignity, and quality of life of people living in skilled nursing facilities) within two hours of allegations of abuse. During an interview on 3/11/26, at 10:25 AM, with the Ombudsman, the Ombudsman stated they did not receive the SOC 341 dated 2/20/26, from the facility until 2/26/26. During a follow-up interview on 3/11/26, at 10:28 AM, with the DON, the DON stated the SOC 341 form was supposed to be filled out and faxed to the Department and the Ombudsman within two hours as per their policy. The DON explained waiting six days was too long to wait to fax the SOC 341. The DON further explained the importance of ensuring the SOC 341 was faxed to The Department and the Ombudsman was to protect the residents' rights and alerts residents' advocates of the alleged abuse. A review of the facility policy titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," revised September 2022, indicated, "... All reports of resident abuse (including injuries of unknown origins) ...are reported to local, state and federal agencies...are documented and reported...Reporting Allegations to the Administrator and Authorities...Within two hours of an allegation involving abuse ..." A review of the facility policy titled, "Abuse Investigation and Reporting," revised July 2017, indicated, "... Reporting ... All alleged violations involving abuse ..will be reported by the facility Administrator, or his/her designee, to the following persons or agencies...The State licensing/certification agency responsible for surveying/licensing the facility [The Department]...The local/State Ombudsman...An alleged violation of abuse...will be reported immediately, but not later than...Two (2) hours if the alleged violation involves abuse..." The Department determined the facility failed to report an allegation of abuse to the Department within two hours after the suspicion of abuse was recognized on 2/20/26 by facility staff for Resident 1. This failure had the potential for Resident 1 to experience continued abuse and not having an advocate available to protect Resident 1 rights. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents and is a B citation.