Health inspection·March 4, 2026

§483.12 Freedom from Abuse, Neglect, and Exploitation §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 Procedure (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 1/23/2026 the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) was found at the facility cool, pale and diaphoretic (sweating heavily), with a blood pressure of 84/64 (normal range 120/80) and the facility staff did not perform ventilatory interventions or use an Automated External Defibrillator ([AED] a portable, medical device that analyses heart rhythms and delivers an electric shock to restore a normal heartbeat during a sudden cardiac arrest), they only performed chest compressions. On 1/23/2026, the CDPH conducted an unannounced visit at the facility to investigate the allegation. During the investigation, the CDPH determined, on 1/9/2026 Resident 1 was found on the floor, face down, unresponsive and required cardiopulmonary resuscitation ([CPR] an emergency lifesaving procedure that is done when someone's breathing or heartbeat has stopped). The paramedics were called to the facility and Resident 1 was pronounced dead. The facility failed to: 1. Report an injury of unknown origin to the CDPH, when Resident 1 was found on the floor in his room, face down and unresponsive requiring CPR. 2. Follow its Policy and Procedure (P/P), titled, "Abuse Investigation and Reporting " revised 7/2017, that indicated "all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ("abuse") shall be promptly reported to local, state and federal agencies (as defined by current regulations)". These failures resulted in a delay in the investigation by the CDPH and placed other residents at risk for neglect. Resident 1 was a 62 year-old-male, originally admitted to the facility on 10/14/2024 and readmitted on 7/11/2025. Resident 1's diagnoses included schizophrenia (mental illness that is characterized by disturbances in thought), glaucoma (a group of eye conditions that damages the nerve in the eye often leading to blindness) and hypertension ([HTN] high blood pressure). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 10/27/2025 indicated Resident 1 had severe cognitive (ability to think and reason) impairment and was sometimes able to understand and be understood by others. The MDS indicated Resident 1 required supervision or touch assistance (helper provides verbal cues and touching/steadying guard as resident completes activity, may be provided throughout the activity or intermittently) to transfer to and from a bed to a chair or wheelchair. A review of Resident 1's Progress Note, dated 1/9/2026, and timed at 8:20 p.m., indicated on 1/9/2026 at approximately 7:20 p.m., Certified Nursing Assistant (CNA) 1 was walking past Resident 1's room when she found him face down on the floor. The Progress Note indicated Licensed Vocational Nurse (LVN) 1 arrived to Resident 1's room, assessed Resident 1 and determined he was unresponsive, without a pulse, not breathing and blood was coming out from his nose. A review of Resident 1's Progress Note, dated 1/9/2026, and timed at 8:40 p.m., indicated on 1/9/2026 at approximately 7:45 p.m., paramedics arrived to Resident 1's room and took over resuscitation efforts. The Progress Note indicated at 7:57 p.m., per paramedic's report, Resident 1 was pronounced dead. During an interview on 1/23/2026, at 4 p.m., the Director of Nursing (DON) stated, she was made aware of Resident 1's injury and death by a nurse (unknown) at the facility but she did not report the incident to the CDPH because she did not consider it an unusual occurrence. The DON stated, based on her investigation, Resident 1 may have become unresponsive in bed and fallen to the floor, injuring his nose. The DON stated the incident was unwitnessed, so she could not determine with certainty why Resident 1 was found face down and unresponsive, and in hindsight, she should have reported it to the CDPH. A review the facility's P/P, titled, "Abuse Investigation and Reporting" revised 7/2017 indicated all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ("abuse") shall be promptly reported to local, state and federal agencies (as defined by current regulations). All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility...... An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: Two hours if the alleged violation involves abuse or has resulted in serious bodily injury, or 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. The facility failed to: 1. Report an injury of unknown origin to the CDPH, when Resident 1 was found on the floor in his room, face down and unresponsive requiring CPR. 2. Follow its Policy and Procedure (P/P), titled, "Abuse Investigation and Reporting " revised 7/2017, that indicated "all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ("abuse") shall be promptly reported to local, state and federal agencies (as defined by current regulations)". These failures resulted in a delay in the investigation by the CDPH and placed other residents at risk for neglect. These failures had direct or immediate relationship to the health, safety, or security of Resident 1.