Health inspection·February 26, 2026

Code of Federal Regulations, Title 42, Section 483.12(c)(1). 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. Code of Federal Regulations, Title 42, Section 483.12(c)(2). 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. California Code, Welfare and Institutions Code – WIC, Section 15630(b)(1) 15630(b) (1) A mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that they have experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known, suspected, or alleged instance of abuse by telephone or through a confidential internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an internet report shall be made through the confidential internet reporting tool established in Section 15658, within two working days. California Code of Regulations, Title 22, Section 72523(a) Patient Care Policies. 72523(a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 1/7/2026, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care. The facility failed to report to the Department and investigate an injury of unknown origin for Resident 2 on 12/21/2025, in accordance with the facility’s policy and procedure (P&P) titled, “Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating,” revised September 2022. As a result, these deficient practices violated Resident 2’s right, and placed Resident 2 at risk for further injury and or harm from abuse and or other sources. A review of Resident 2’s Admission Record (AR) indicated Resident 2, an 82-year-old male, was admitted [DH1]to the facility on 4/16/2024 with diagnoses which included diabetes mellitus, and hemiplegia and hemiparesis following cerebral infarction. A review of Resident 2’s History and Physical, dated 4/19/2026, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2’s Minimum Data Set (MDS), dated 10/9/2025, indicated Resident 2 was dependent on others for activities of daily living and chair/bed-to-chair transfers. A review of Resident 2’s bilateral hip X-ray results, dated 12/21/2025 and timed at 9:14 am, indicated Resident 2 had a suspected acute right femur fracture. A review of Resident 2’s Change In Condition Evaluation (CIC), dated 12/21/2025 and timed at 1:56 pm, indicated Resident 2’s bilateral hip X-ray results indicated Resident 2 had a suspected right femur fracture and Resident 2’s primary physician recommended Resident 2 to be transferred to General Acute Care (GACH) 1 for further evaluation. A review of Resident 2’s Nurses Note (NN), dated 12/21/2025 and timed at 4:30 pm, indicated Resident 2 was picked up by an ambulance and transferred out to GACH 1 at 4:20 pm. A review of Resident 2’s GACH 1 right hip X-ray, dated 12/22/2025 and timed at 9:11 am, indicated Resident 2 had an acute right femur fracture. During an interview on 1/9/2026 at 3:30 pm with the Director of Nursing (DON), the DON stated the facility did not start an investigation to determine how Resident 2 sustained the right femur fracture and did not report Resident 2’s injury of unknown origin (right femur fracture) to the local Ombudsman (an official appointed to investigate individuals’ complaints against facility administration), to the Police, and to the Department within two (2) hours of obtaining Resident 2’s right hip X-ray results. The DON stated the facility did not follow their policy on investigating injuries of unknown origin. A review of the facility’s P&P titled, “Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating,” revised September 2022, 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. Findings of all investigations are documented and reported.” The facility failed to report to the Department and investigate an injury of unknown origin for Resident 2 on 12/21/2025, in accordance with the facility’s P&P titled, “Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating,” revised September 2022. As a result, these deficient practices violated Resident 2’s right, and placed Resident 2 at risk for further injury and or harm from abuse and or other sources. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 2. [DH1]Please add gender and age.