Health inspection·November 19, 2025

42 CFR § 483.12 (c) - Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. (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. California Health and Safety 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. On 9/24/2025, the California Department of Health (CDPH) received a complaint about Resident 1's left finger fracture of unknown origin. On 9/25/2025, CDPH made an unannounced visit to the facility. The facility failed to: 1. Report Resident 1's left finger fracture as an injury of unknown origin to CDPH. 2. Implement its policy and procedures (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating," dated 9/2022, which indicated "If injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury." As a result of these failures there was a delay in reporting to the CDPH and in CDPH's investigation, which posed a potential risk of ongoing abuse, neglect, and mistreatment of Resident 1 as well as other residents in the facility. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility 11/27/2024 with diagnoses including Alzheimer's disease, schizophrenia, and Parkinson's disease. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 9/11/2025, indicated Resident 1 had severely impaired cognitive skills for daily decision making and was dependent on staff with dressing, personal hygiene, and toileting. A review of Resident 1's Change of Condition (COC) dated 9/21/2025, and timed at 1:13 p.m., indicated Resident 1 had swelling and discoloration of her left hand. A review of Resident 1's Radiology Results Report dated 9/22/2025, indicated Resident 1 had an acute, transverse, non-displaced fracture (a bone that has a broken cleanly in half, straight across its length, but the broken ends remain perfectly aligned and don't move out of position) at proximal (nearer to the center) third of fifth proximal phalanx (one of the bones in the finger) of the left hand. A review of Resident 1's COC dated 9/23/2025, and timed at 12:45 a.m., indicated Resident 1's hand x-ray was received by the facility indicating that Resident 1 had a non-displaced fracture (broken bone) of Resident 1's left fifth finger. During a concurrent interview and record review on 9/25/2025, at 12:17 p.m., the Registered Nurse Supervisor (RNS) 1 stated that Licensed Vocational Nurse (LVN) 5 received Resident 1's X-ray results on 9/23/2025, at 12:45 a.m., but failed to report the results to California Department of Public Health (CDPH), local law enforcement, and the Ombudsman within two hours. RNS 1 stated that due to the absence of documentation explaining how Resident 1 sustained the fracture, it was critical to notify the appropriate agencies, including CDPH, law enforcement and Ombudsman, to ensure a proper investigation could be conducted. During an interview on 9/25/2025, at 2:31 p.m., LVN 4 stated that a fracture of unknown origin should be reported immediately, as the cause was unclear and could potentially be the result of abuse. During an interview on 9/25/2025, at 3:21 p.m., the Director of Nursing (DON) stated that LVN 5 should have reported Resident 1's fracture immediately upon receiving the information on 9/23/2025, at 12:45 a.m. The DON stated that the fracture should have been reported within two hours, but it was not, as he only became aware of the incident from RNS 1 at approximately 8:00 a.m., on 9/23/2025. The DON emphasized the importance of notifying the three required agencies CDPH, law enforcement, and Ombudsman because timely reporting is mandated by regulation to ensure appropriate investigation. A review of the facility's LVN Job Description, indicated, "Essential Responsibilities and Job Functions: Follow guidelines regarding contacting administrator and DON regarding real or potential abuse situations." A review of the facility's P&P titled, "Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating," dated 9/2022, indicated, "If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury." A review of the facility's P&P titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," dated 4/2021, indicated, "Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Investigate and report any allegations within timeframes required by federal requirements. Protect residents from any further harm during investigations." The facility failed to: 1. Report Resident 1's left finger fracture as an injury of unknown origin to CDPH. 2. Implement its P&P titled, "Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating," dated 9/2022, which indicated "If injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury." As a result of these failures there was a delay in reporting to the CDPH and in CDPH's investigation, which posed a potential risk of ongoing abuse, neglect, and mistreatment of Resident 1 as well as other residents in the facility. These failures had direct or immediate relationship to the health, safety, or security of Resident 1 as well as all other residents in the facility.