Other·May 6, 2026

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (c) 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. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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. 22 CCR § 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 (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 3/26/2026, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint indicating Resident 1 had a right shoulder fracture (broken bone) of unknown origin. The facility failed to: 1.Implement its Policy and Procedure (P&P) titled, "Unusual Occurrence" which indicated the facility will report unusual occurrences that threaten the welfare, safety, or health of residents to the CDPH within 24 hours when Resident 1 was reported to have a right shoulder fracture. 2. Implement its P&P titled, "Accidents and Incidents-Investigation and Reporting" which indicated the Nurse Supervisor, charge nurses and/or the department director or supervisor shall promptly initiate and document an investigation of all accidents or incidents involving residents, after Resident 1's Family Member (FM) notified the facility of the resident's right shoulder fracture on 3/17/2026. These failures resulted in a delay in the investigation by the CDPH and placed Resident 1 and other residents at risk for neglect and abuse. Resident 1 was a 77-year-old male, admitted to the facility on 1/26/2026 with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (tissue death in the brain due to lack of oxygen) affecting the right dominant side (right-side of the body), other symptoms and signs involving the musculoskeletal system (pain, weakness, stiffness, swelling and reduced mobility in bones, muscle or joints) and other symptoms and signs involving the nervous system (motor dysfunction, weakness, tremors, gait [manner of walking] changes). A review of Resident 1's History and Physical (H&P) dated 1/27/2026, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 1/29/2026, indicated Resident 1 had severe cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADLs) such as dressing, toilet use, transfers, bed mobility, oral hygiene, toileting hygiene, showering/bathing self and dressing. A review of Resident 1's Change of Condition (COC) dated 3/15/2026 at 2:09 a.m., indicated Resident 1 was transferred to the General Acute Care Hospital (GACH) due to hypotension (low blood pressure) and elevated heart rate. A review of Resident 1's Order Summary Report dated 3/15/2026, indicated the physician ordered to transfer Resident 1 to the GACH due to hypotension, desaturation (a drop in the oxygen [O2] level in the blood), SOB (shortness of breath), fever and for further evaluation. A review of Resident 1's GACH H&P dated 3/15/2026, indicated Resident 1 was seen for hypotension, respiratory distress (difficulty breathing) and desaturation. The H&P indicated a chest x-ray (process of taking pictures to diagnose and treat diseases) was obtained on 3/15/2026 and incidentally (discovered while looking for something else) found Resident 1 to have a subacute (recent) appearing displaced fracture of the right humerus (long bone of the upper arm, running from the shoulder to the elbow). During an interview on 3/26/2026 at 1:36 p.m., with Certified Nurse Assistant (CNA) 3, CNA 3 stated Resident 1 complained of pain by moaning and saying "ouch" every time she provided ADL care to the resident (prior to hospitalization on 3/15/2026), such as putting on his shirt and moving his right arm. CNA 3 stated Charge Nurses were made aware of the resident's pain (unable to recall the dates and names of the Charge Nurses). During an interview of 3/26/2026 at 4:10 p.m., with Resident 1's FM, the FM stated before Resident 1 was transferred to the GACH (on 3/15/2026), she noticed the resident was having pain in his right arm when his arm was touched or moved. The FM stated Resident 1's x-ray result at the GACH indicated Resident 1 had a right shoulder fracture. FM stated on 3/17/2026 she went to the facility to ask how Resident 1 sustained the fracture and the facility stated they were not aware about the fracture. During an interview on 3/27/2026 at 2:00 p.m., with the Director of Nursing (DON), the DON stated on 3/15/2026, Resident 1 was transferred to the GACH due to hypotension and elevated heart rate. The DON stated on 3/17/2026, Resident 1's FM informed the facility of Resident 1's fracture and was surprised to learn about it because there were no staff reports of falls or injuries involving Resident 1. The DON stated she investigated the incident, however, could not provide evidence of her investigation. The DON stated the facility did not report the fracture to the CDPH because the facility did not know what happened. The DON stated it was important to report Resident 1's fracture to the CDPH to ensure resident's safety during the investigation process. A review of the facility's P&P titled, "Unusual Occurrence" dated 3/2010, indicated the facility should report unusual occurrences that threaten the welfare, safety or health of patients, personnel or visitors to the CDPH within 24 hours either by telephone (with written confirmation) or by telegraph. A review of the facility's P&P titled, "Accidents and Incidents-Investigation and Reporting" dated 7/2017, indicated all accidents or incidents involving residents, occurring on the premises shall be investigated and reported to the Administrator. The Nurse Supervisor, charge nurses and/or the department director or supervisor shall promptly initiate and document investigation of the incident. The facility failed to: 1.Implement its P&P titled, "Unusual Occurrence" which indicated the facility will report unusual occurrences that threaten the welfare, safety, or health of residents to the CDPH within 24 hours when Resident 1 sustained a right shoulder fracture. 2. Implement its P&P titled, "Accidents and Incidents-Investigation and Reporting" which indicated the Nurse Supervisor, charge nurses and/or the department director or supervisor shall promptly initiate and document an investigation of all accidents or incidents involving residents. These failures resulted in a delay in the investigation by the CDPH and placed Resident 1 and other residents at risk for neglect and abuse. These violations had a direct or immediate relationship to the health, safety, or security of residents.