Health inspection·April 8, 2026

42 CFR §483.12 (c) Freedom from Abuse, Neglect, and Exploitation. 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 § 72315. Nursing Service-Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 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. HSC § 1418.91. Quality of Long-Term Health Facilities (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. On 2/23/2026, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint alleging a resident was sent to a General Acute Care Hospital (GACH) for evaluation of a left humerus fracture (broken upper arm bone) of unknown origin. As a result of the investigation, CDPH determined Resident 1sustained a left humerus fracture of unknown origin. The facility failed to: 1. Report an injury of unknown origin for Resident 1, when Resident 1 sustained a displaced (bone snaps into two or more pieces and shifts out of alignment) fracture through the left humeral neck (upper portion of the left arm bone just below the shoulder ball). 2. Follow its Policy and Procedure (P&P) titled “Abuse, Neglect Exploitation or Misappropriation—Reporting and Investigating” which indicated all reports of resident abuse, injuries of unknown origin, and neglect, were to be reported to the appropriate local, state, and federal agencies, within two hours of an allegation involving abuse, serious bodily injury; or within 24 hours if it did not involve abuse or result in serious bodily injury. As a result, there was a delay in the investigation by CDPH and placed Resident 1 and other residents at risk of continued abuse, neglect, or mistreatment. Resident 1 a 97-year-old female was initially admitted to the facility on 6/1/2018 and was readmitted on 12/17/2024. Resident 97’s diagnoses included polyosteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage [firm, flexible tissue]), dementia (a progressive state of decline in mental abilities), and muscle weakness. A review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool), dated 1/28/2026, indicated Resident 1 had moderate cognitive impairment. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) to complete her activities of daily living (ADL). A review of Resident 1’s change in condition (COC), dated 2/1/2026 at 11:17 p.m., indicated Resident 1 had swelling and ecchymosis (discoloration of the skin resulting from bleeding underneath caused by bruising) of the left arm, indicating an injury. A review of Resident 1’s X-Ray (a medical test that enables providers to get pictures of the inside of the body) Report, dated 2/2/2026, indicated Resident 1 had a displaced fracture at surgical neck of humerus (left). A review of Resident 1’s COC, dated 2/3/2026 at 1:13 p.m., indicated Resident 1 was transferred to a GACH for treatment of Resident 1’s left humerus fracture.  During an interview on 2/23/2026 at 4:02 p.m., Licensed Vocational Nurse (LVN) 1 stated Resident 1’s arm was discolored on the upper and lower part of the left arm. When there was a COC, she should have but did not notify the Director of Nursing (DON). During a concurrent interview and record review on 2/24/2026 at 10:52 a.m., with the DON, the facility’s P&P titled “Abuse, Neglect, Exploitation or Misappropriation—Reporting and Investigating,” dated 2001 was reviewed. The DON stated an unusual occurrence included instances of suspected abuse, such as an injury of unknown origin. Per facility’s protocol for unusual occurrences LVN 1 was to report Resident 1’s left arm fracture on 2/3/2026 to the DON, the Administrator (ADMN), notify CDPH, and the ombudsman. If needed, law enforcement, and Adult Protective Services (APS: state-mandated program that investigates reports of abuse for ages 60 and above). If a case of suspected abuse was not reported, the residents may not feel safe. During an interview on 2/24/2026 at 12:34 p.m., the ADMN stated an unusual occurrence was an occurrence that could not be explained. They did not know how Resident 1’s left arm got broken. This incident was an injury of unknown origin and was reportable. The facility should have investigated the incident to help them determine whether it was abuse or not; to protect residents from further harm and injury.   A review of the facility’s P&P titled, “Abuse, Neglect, Exploitation or Misappropriation—Reporting and Investigating,” dated 2001, indicated all reports of resident abuse, injuries of unknown origin, and neglect, were to be reported to the appropriate local, state, and federal agencies, within two hours of an allegation involving abuse, serious bodily injury; or within 24 hours if it did not involve abuse or result in serious bodily injury. The facility failed to: 1. Report an injury of unknown origin for Resident 1, when Resident 1 sustained a displaced fracture through the left humeral neck. 2. Follow its P&P titled “Abuse, Neglect Exploitation or Misappropriation—Reporting and Investigating” which indicated all reports of resident abuse, injuries of unknown origin, and neglect, were to be reported to the appropriate local, state, and federal agencies, within two hours of an allegation involving abuse, serious bodily injury; or within 24 hours if it did not involve abuse or result in serious bodily injury. As a result, there was a delay in the investigation by CDPH and placed Resident 1 and other residents at risk of continued abuse, neglect, or mistreatment. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security and welfare of Resident 1.