Other·June 4, 2026

§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. §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(a)(b) (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" citation. On 4/27/2026, the California Health Department of Public Health (CDPH) received a complaint alleging a resident (Resident 2) was transferred to a General Acute Care hospital (GACH 2) and an Xray (a procedure that takes pictures of the inside of the body to diagnose broken bones and other injuries) confirmed Resident 2 had a femur fracture (a complete or partial break in the thighbone). The skilled nursing facility transferred Resident 2 to GACH 2 and denied that Resident 2 had fallen. On 4/29/2026, the CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. As a result of the investigation, the CDPH determined Resident 2 was handled roughly by two staff at GACH 1 before admission to the facility on 4/9/2026 and Resident 2 sustained an unexplained displaced fracture (when a broken bone snaps into two or more pieces and moves, causing the ends to become misaligned) of the right femur (largest bone extending from the hip to the knee [hip fracture]). Neither incident was reported to the CDPH. The facility failed to: 1. Report an allegation of mistreatment when Resident 2 reported to facility staff that she was handled roughly by two hospital staff at GACH 1 prior to her admission to the facility on 4/9/2026. 2. Report an injury of unknown origin when an Xray taken on 4/24/2026 confirmed Resident 2 had a displaced fracture and there was no determination how the fracture occurred. 3. Follow its Policy and Procedure (P/P) titled "Compliance with Reporting Allegations of Abuse/Neglect/Exploitation" dated 12/19/2022 that indicated "it is the policy of the facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources." These deficient practices resulted in the CDPH not being aware of Resident 2's allegation of abuse and her injury of unknown origin causing a delay the CDPH's investigation and the potential for pertinent information to be lost and/or forgotten. Resident 2's Admission Record (Face Sheet) indicated Resident 2, a 68 year old female, was admitted to the facility on 4/9/2026 with the diagnosis of osteogenesis imperfecta (a rare genetic disorder characterized by extremely fragile bones that break easily, often with little or no trauma). A review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 4/13/2026 indicated Resident 2's cognition was intact and Resident 2 was dependent (helper does all of the effort) on facility staff to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). A review of Resident 2's SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers dated 4/23/2026 and timed at 3:22 p.m. indicated Resident 2's right hip had a prominent protrusion (something that sticks out or bulges out from a surface or its surroundings), redness and warmth. The SBAR Summary for Providers indicated the physician ordered an Xray of Resident 2's right hip. A review of Resident 2's Nurses Progress Notes dated 4/23/2026 and timed at 4:07 p.m., indicated Resident 2's Family Member (FM) reported that Resident 2 was not handled properly at GACH 1 where she was previously admitted. The FM stated Resident 2's hip was not like that (with a protrusion, red and warm) before getting admitted to GACH 1. A review of Resident 2's Physician's Order dated 4/23/2026 indicated to obtain a right hip Xray due to a prominent protrusion, redness, and warmth. A review of Resident 2's Radiology Results Report dated 4/23/2026 indicated Resident 2 had an acute displaced fracture of the proximal shaft of the right femur. A review of Resident 2's SBAR Summary for Providers dated 4/24/2026, indicated Resident 2's Xray results showed an acute displaced right hip fracture. Resident 2 was transferred to GACH 2 for further evaluation and treatment. During an interview on 4/29/2026 at 11:37 a.m., Resident 2's FM stated Resident 2's right hip was injured at GACH 1, she (FM) was concerned about Resident 2's hip pain and she was upset about how Resident 2 was treated at GACH 1. During an interview on 4/29/2026 at 3:28 p.m., the Physical Therapist (PT) stated when he completed Resident 2's PT Evaluation (4/10/2026), Resident 2 reported she had pain in her right hip and when she was at GACH 1 she was handled roughly by the nurses there. He (PT) did not report what Resident 2 told him because he thought her complaint of pain was related to her diagnosis of osteogenesis imperfecta. He (PT) should have reported it to the supervisory staff at the facility. During an interview on 4/30/2026 at 12:14 p.m., Registered Nurse (RN ) 1 stated on 4/23/2026 when she assessed Resident 2, her right hip was protruding more than it had been on admission (4/9/2026). There was more redness in the resident's inner thigh, and it was a little warm to touch. Resident 2 reported she had been rough handled by nurses at GACH 1 and that was what caused her injury. Resident 2 reported she had not fallen and there was no other explanation for what might have caused her injury. During an interview on 4/29/2026 at 1:01 p.m., the Director of Nursing (DON) stated the Department was not notified of Resident 2's hip fracture because Resident 2 was able to explain that she did not fall or have any incident that would cause the fracture and the facility's Consultant told her (DON) Resident 2's fracture did not need to be reported. Resident 2's allegation of being rough handled by nurses at GACH 1 should have been reported but she (DON) was concerned with Resident 2's fracture and missed reporting Resident 2's allegation. A review of the facility's P/P titled "Compliance with Reporting Allegations of Abuse/Neglect/Exploitation" dated 12/19/2022, indicated "it is the policy of the facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property immediately to the Administrator of the facility and to other appropriate agencies in accordance with current State and Federal regulations with prescribed timeframes." The facility failed to: 1. Report an allegation of mistreatment when Resident 2 reported to facility staff that she was handled roughly by two hospital staff at GACH 1 prior to her admission to the facility on 4/9/2026. 2. Report an injury of unknown origin when an Xray taken on 4/24/2026 confirmed Resident 2 had a displaced fracture and there was no determination how the fracture occurred. 3. Follow its P/P titled "Compliance with Reporting Allegations of Abuse/Neglect/Exploitation" dated 12/19/2022 that indicated "it is the policy of the facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources." These deficient practices resulted in the CDPH not being aware of Resident 2's allegation of abuse and her injury of unknown origin causing a delay the CDPH's investigation and the potential for pertinent information to be lost and/or forgotten. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.