Health inspection·April 22, 2026

§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. §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) Abuse Reporting (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 3/11/2026, the California Health Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) experienced a hip displacement([dislocation] a traumatic injury where the ends of two connected bones are forced out of their normal positions) while at the facility. On 3/12/2026, the CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. During the investigation, the CDPH determined Resident 1 complained of right hip pain on 11/21/2025 and an X-ray (a medical test that takes pictures of the inside of the body) dated 11/22/2025 confirmed Resident 1's right hip was dislocated but the facility did not report Resident 1's injury to the CDPH. The facility failed to: 1. Report an injury of unknown origin, to the CDPH when they were made aware after an Xray taken on 11/22/2025 indicated Resident 1's right hip was dislocated. 2. Follow its Policy and Procedure (P/P) titled "Abuse: Prevention of and Prohibition Against" dated 4/2025 that indicated allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported to the appropriate State or Federal agencies. The facility's P/P did not include reporting an injury of unknown origin, per the CDPH's regulation. As a result, there was a delay in the investigation by CDPH. Resident 1, a 79-year-old female, was admitted to the facility on 11/6/2025. Resident 1 had a diagnosis of joint replacement surgery aftercare (specialized care, rehabilitation, and lifestyle adjustments needed immediately after surgery to ensure the new joint heal correctly). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/19/2026 indicated Resident 1's cognition (the mental process of acquiring knowledge and understanding through thought, experience and the senses) was intact and she required substantial/maximal assistance (helper does more than half the effort) from 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 1's Change of Condition (COC) form dated 11/21/2025 indicated Resident 1 complained of right hip pain. The COC indicated Resident 1's skin was intact with slight swelling. A review of Resident 1's Radiology (a branch of medicine that uses imaging technology, including Xray, to diagnose and treat diseases) report dated 11/22/2025 indicated Resident 1 had a femoral head arthroplasty (a prior surgical procedure that replaces only the damaged ball of the hip joint with a implant while preserving the natural socket) with a superior lateral dislocation (when the artificial joint becomes unstable and pops out of the socket toward the top and side) of the right hip. During an interview on 3/12/2026 at 9:53 a.m., the Assistant Director of Nursing (ADON) stated, she investigated Resident 1's injury, initially there was no explanation for Resident 1's hip pain until X-ray results indicated her hip was dislocated. The ADON stated she reported the injury of unknown origin to the Administrator (ADM), who was the facility's abuse coordinator, but she did not report this to the CDPH. During an interview on 3/13/2026 at 3:56 p.m., the Director of Nursing (DON) stated she thought Resident 1 reported hearing a "pop" while being transferred to her bed, that was why she did not report it as an injury of unknown injury to CDPH, but she was wrong, there was no report of how the injury occurred. A review of the facility's P/P titled "Abuse: Prevention of and Prohibition Against" dated 4/2025, indicated "allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported to the appropriate State or Federal agencies in the applicable time frame, as per this policy and applicable regulations. The facility failed to: 1. Report an injury of unknown origin, to the CDPH when they were made aware after an Xray taken on 11/22/2025 indicated Resident 1's right hip was dislocated. 2. Follow its P/P titled "Abuse: Prevention of and Prohibition Against" dated 4/2025 that indicated allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported to the appropriate State or Federal agencies. The facility's P/P did not include reporting an injury of unknown origin, per the CDPH's regulation. As a result, there was a delay in the investigation by the CDPH These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1.