Health inspection·April 3, 2026

42 CFR §483.12(c) Reporting of Alleged Violations 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. (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. 22 CCR §72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 22CCR §72541 - Unusual Occurrences Occurrences such as epidemic outbreaks 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 should furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. HSC §1418.91 Abuse Reporting (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 2/27/2026, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint allegation indicating Resident 1 had a left black eye (an area of bruised skin around the eye). This facility failed to: 1. Follow its policy and procedure (P&P) titled, “Unusual Occurrence Reporting,” which indicated it will notify the CDPH of all unusual occurrences, within twenty-four hours, when Resident 1 was observed with a dark bruise (skin discoloration) around the left eye. This failure resulted in a delay in investigation by the CDPH. Resident 1 was a 74-year-old female, admitted to the facility on 9/14/2024 and readmitted on 12/19/2025. Resident 1’s diagnoses included metabolic encephalopathy (an acute or chronic alteration in brain function), epilepsy (a chronica neurological disorder characterized by recurrent, unprovoked seizures), dementia (a progressive state of decline in mental abilities), and muscle weakness. A review of Resident 1’s History and Physical (H&P), dated 12/20/2025, indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1’s Minimum Data Sheet ([MDS]- a resident assessment tool), dated 1/21/2026 indicated Resident 1’s cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 1 required partial/moderate assistance (helper does more than half the effort. Helper lifts or holds trunks or limbs and provides more than half the effort) from staff for toileting hygiene, showers, and dressing. A review of Resident 1’s Change of Condition (COC), dated 2/25/2026, indicated Resident 1 had dark purplish discoloration and swelling under her left eye. During an observation on 2/27/2026 at 3:36 p.m., in Resident 1’s room, Resident 1 had a large dark bruise around her left eye. During a concurrent interview and record review on 2/27/2026 at 3:44 p.m., with the Director of Nursing (DON), the facility’s P&P titled, “Unusual Occurrence Reporting,” dated 3/2024, was reviewed. The P&P indicated the facility was to notify the Department of Health Services of all unusual occurrences, within twenty-four hours. The DON stated Resident 1 had a large bruise on the left eye. The DON stated the incident was not witnessed by staff and therefore the injury was considered an injury of an unknown source. The DON stated the facility’s process for reporting an injury of unknown origin was to report within two hours to the federal and 24 hours to the state. A review of the facility’s P&P titled, “Unusual Occurrence Reporting,” dated 3/2024, indicated the facility was to notify the Department of Health Services of all unusual occurrences, within twenty-four hours. The P&P indicated the facility would report any facility related injury of any resident which required medical treatment within one working day. The P&P indicated unusual occurrences included occurrences that constitute an interference with facility operations affecting the welfare, safety or health of residents and other injuries that affect health and safety as identified by the facility and DHS as required reporting. This facility failed to: 1. Follow its policy and procedure (P&P) titled, “Unusual Occurrence Reporting,” which indicated it will notify the CDPH of all unusual occurrences, within twenty-four hours, when Resident 1 was observed with a dark bruise (skin discoloration) around the left eye. This failure resulted in a delay in investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1 and other residents in the facility.