Health inspection·February 20, 2026

42 CFR §483.12(c) Reporting of Alleged Violations §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. 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, poisonings, fires, major accidents, death from unnatural causes or other catastrophes 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 shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. H&S 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. (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. (d) This section shall not change any reporting requirements under Section 15630 of the Welfare and Institutions Code, or as otherwise specified in the Elder Abuse and Dependent Adult Civil Protection Act, Chapter 11 (commencing with Section 15600) of Part 3 of Division 9 of the Welfare and Institutions Code. CCWIC § 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, suspected, or alleged 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. On 1/20/2026 to 1/23/2026 the California Department of Public Health (CDPH) conducted an unannounced annual recertification survey and determined the facility failed to implement its abuse reporting and prevention policy (P&P) titled, "Unusual Occurrence Reporting," by failing to report an injury of unknown origin for Resident 9 to the CDPH. As a result, there was a delay in the investigation by the CDPH. Resident 9 an 82-year-old female, was initially admitted to the facility on 3/8/2020 and readmitted on 2/17/2023. Resident 9's diagnoses included cerebral infarction (stroke - loss of blood flow to a part of the brain), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), anemia (a condition where the body does not have enough healthy red blood cells), and dementia (a progressive state of decline in mental abilities). A review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 11/22/2025, indicated Resident 9 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment. The MDS indicated Resident 9 required setup assistance with eating, oral hygiene, and required moderate assistance (helper does less than half the effort) for toileting hygiene, and bathing. A review of Resident 9's Physician Order dated 12/29/2025, indicated to transfer Resident 9 to the general acute care hospital (GACH) due to a right distal femur (lower thigh bone) fracture (break). During a concurrent interview and record review on 1/7/2026 at 11:44 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 9's change of condition (COC) dated 12/29/2025 and progress note dated 12/29/2025 were reviewed. Resident 9's COC dated 12/29/2025 at 2:21 p.m., indicated Resident 9 had swelling of the lower right thigh, and the physician ordered an x-ray (a diagnostic procedure that shows image of bones). A review of Resident 9's progress note dated 12/29/2025 at 10:44 p.m., indicated Resident 9's x-ray results revealed a fracture of the distal femur. RNS 1 stated there was no indication that Resident 9 had a fall to cause the fracture. RNS 1 stated Resident 9's fracture should have been reported to the CDPH because it was not normal to have a bone fracture. During an interview on 1/8/2026 at 2:12 p.m., the Director of Nursing (DON) stated it was the facility's policy to report Resident 9's fracture to the CDPH within 24 hours because it was an injury of unknown origin. The DON stated it was not reported to the CDPH. During a concurrent interview and record review on 1/8/2025 at 3:11 p.m., with the Administrator (ADM), the facility's P&P titled Abuse: Prevention of and Prohibition Against, dated 12/2023, was reviewed. The ADM stated unusual occurrences should be reported to CPDH within 24 hours. A review of the facility P&P indicated an "injury of unknown source" was used to classify an injury when all of the following were met: The source of the injury was not observed by any person; and The source of the injury could not be explained by the resident; and The injury was suspicious because of the extent of the injury of the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma), or the number of injuries observed at one particular point in time or the incidence of injuries over time. A review of the facility's P&P, titled Unusual Occurrence Reporting, dated 4/2023, the P&P indicated unusual occurrences shall be reported by the facility within twenty-four hours either by telephone (and confirmed in writing) or facsimile to the CDPH. The facility failed to implement its abuse reporting and prevention P&P titled, "Unusual Occurrence Reporting," by failing to report an injury of unknown origin for Resident 9 to the CDPH. As a result, there was a delay in the investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of Resident 9.