Health inspection·December 24, 2025

42 CFR §483.12 - Freedom from abuse, neglect and exploitation (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 §483.12(c)(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. §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 - Report of Incidents of Alleged Abuse or Suspected Abuse (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 10/30/2025, the California Health Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) was found with a bruise on the left side of her face, her jaw, and neck and a smaller bruise was found on the resident's left arm, between her elbow and her wrist. On 11/12/2025, CDPH conducted an unannounced visit to the facility to investigate the complaint allegations. During the investigation, CDPH determined Resident 1 had an area of discoloration on the left side of her face and the facility could not identify how it occurred (an injury of unknown origin). The facility failed to ensure: 1. An injury of unknown origin to Resident 1's left jaw was reported to CDPH, when they were made aware of the injury on 10/24/2025. 2. The facility followed their Policy and Procedure (P/P) titled "Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating" that indicated all reports of resident abuse (including injuries of unknown origin) are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. This deficit practice resulted in CDPH being unaware of Resident 1's injury of unknown origin and a delay in their investigation. This deficient practice had the potential for information to be lost and/or forgotten. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, an 86-year-old female, was admitted to the facility on 7/4/2025 with a diagnosis of Alzheimer's disease. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 10/15/2025 indicated Resident 1's cognition was severely impaired, and Resident 1 required substantial/maximal assistance from staff with activities of daily living (ADL). A review of Resident 1's Change of Condition (COC) form dated 10/24/2025 indicated Resident 1 had an area of discoloration on her left jaw measuring 3.0 centimeters (cm) by 2.0 cm. The COC form indicated the Administrator (ADM) and Director of Nursing (DON) were notified. During an interview on 11/12/2025 at 9:57 a.m., Certified Nurse Assistant (CNA) 1 stated on 10/24/2025 around 1:30 p.m., she was changing Resident 1's incontinence brief, when she noticed a small discoloration on the left side of Resident 1's face, which she reported to the Registered Nurse in charge nurse (RN) 1. During an interview on 11/12/2025 at 12:30 p.m., the DON stated she was aware of the discoloration to Resident 1's face. The DON stated she investigated Resident 1's injury and believed it was related to Resident 1's agitated behavior and that was why she did not report the injury to CDPH. During an interview on 11/12/2025 at 2:30 p.m., the ADM stated the discoloration of Resident 1's face was not reported to CDPH because facility staff assumed the discoloration was due to Resident 1's behavior. A review of the facility's P/P titled "Abuse, Neglect, or Misappropriation- Reporting and Investigating," indicated all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation or resident property are reported to local, state, and federal agencies and thoroughly investigated by facility management. The facility failed to ensure: 1. An injury of unknown origin to Resident 1's left jaw was reported to CDPH, when they were made aware of the injury on 10/24/2025. 2. The facility followed their P/P titled "Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating" that indicated all reports of resident abuse (including injuries of unknown origin) are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. This deficit practice resulted in CDPH being unaware of Resident 1's injury of unknown origin and a delay in their investigation. This deficient practice had the potential for information to be lost and/or forgotten. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security and welfare of residents in the facility.