Health inspection·October 17, 2025

Title 42 § 483.12 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. 22 CCR § 72315 Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 22 CCR § 72523 - Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be implemented to ensure that patient-related goals and facility objectives are achieved. 22CCR §72541 - Unusual Occurrences Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility should furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs on or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. California Code, Health and Safety Code - HSC § 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. On 8/28/2025, the California Department of Public Health (CDPH) received a complaint indicating Resident 7 sustained a broken finger of unknown cause at the facility. On 9/8/2025, the CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: 1. Report Resident 7’s right thumb fracture (broken bone) to the CDPH, as indicated in the facility’s policy and procedure (P&P) titled “Unusual Occurrence Reporting,” which indicated to report unusual occurrences affecting the health, safety or welfare of the residents to the state agency via telephone within 24-hours of the incident. This failure delayed the investigation by the CDPH and subjected Resident 1 to further injuries and potential abuse. Resident 7 was a 95-year-old male, originally admitted to the facility on 5/2/2025 and readmitted on 8/30/2025. Resident 7’s diagnoses included a tracheostomy (a surgical opening in the neck, fitted with a device to allow air and oxygen to be administered directly to the airway), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), ventilator (a medical device to help support or replace breathing) dependence, and dementia (a progressive state of decline in mental abilities). A review of Resident 7’s Situation, Background, Assessment, and Recommendations Form (SBAR- tool used by healthcare workers when there is a change of condition among the residents), dated 6/24/2025 at 4 p.m., indicated on 6/24/2025, Registered Nurse (RN) 7 identified redness and swelling on Resident 7’s right thumb and notified the Medical Doctor (MD) 7 on 6/24/2025. The SBAR indicated MD 7 ordered a radiology (X-ray- process of taking pictures inside the body to diagnose and treat diseases) of the right fingers. A review of Resident 7’s right finger X-ray report, dated 6/24/2025, indicated an acute (short-term) nondisplaced inter-articular (in or near the joint) fracture at the proximal radial aspect of first proximal (next to) phalanx (finger bone). A review of Resident 7's Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) conference, dated 6/25/2025 at 5:09 p.m., indicated the IDT conference was conducted secondary to Resident 7’s recent non-displaced intra-articular fracture at the proximal radial aspect of the first proximal phalanx. The IDT notes indicated the facility would continue to monitor Resident 7’s right splinted thumb, re-educate staff on proper positioning and safe handling of the resident. A review of Resident 7’s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 7/3/25, indicated Resident 7 had no speech, was rarely or never able to understand others, and was rarely or never able to express ideas and wants. The MDS indicated Resident 7 was dependent (helper does all the effort, the assistance of 2 or more helpers is required to complete the activity) to roll left and right side and in maintaining personal hygiene (combing hair, shaving, washing/drying face and hands). A review of Resident 7’s History and Physical (H&P), dated 9/1/2025, indicated Resident 7 did not have the capacity to understand and make decisions. During an interview on 9/9/2025 at 11:30 a.m. with the Administrator, the Administrator stated she was the abuse coordinator and did not report Resident 7’s right thumb fracture on 6/24/2025 because Resident 7 did not require hospitalization or surgical intervention. The Administrator stated she did not send the results of the abuse investigation to the State Survey Agency. During a concurrent interview and record review on 9/9/2025 at 1:45 p.m. with Registered Nurse (RN) 7, Resident 7’s SBAR, dated 6/24/2025, and the facility’s undated P&P titled “Abuse & Mistreatment of Residents” were reviewed. RN 7 stated Resident 7’s right thumb bone fracture sustained on 6/24/ could be a result of abuse because no staff witnessed how the fracture happened, the resident could not explain how the fracture happened, and a severe injury (fracture) was sustained. RN 7 stated the P&P indicated an unusual occurrence like Resident 7’s right thumb fracture must be reported to the CDPH immediately because there was a possibility of abuse. During an interview on 9/22/2025 at 2:57 p.m. with MD 7, MD 7 stated Resident 7’s right thumb fracture could be because of accidents, mishandling, and abuse. MD 7 stated staff should consider mishandling and abusing any time a resident sustained a fracture in the facility. A review of the facility’s P&P titled “Unusual Occurrence Reporting,” dated 12/2007, indicated, as required by the federal or state regulations, the facility should report unusual occurrences or other reportable events which affect the health, safety or welfare of the residents to the state agency via telephone as required by the current law and/or regulations within 24-hours of such incident. A review of the facility’s undated P&P titled “Abuse & Mistreatment of Residents,” indicated it was the facility’s policy for any mandated reporter working in a facility to report abuse to their supervisor as well as the CDPH. The P&P indicated the facility shall report all alleged violations of abuse to the CDPH within two hours of the knowledge of the incident, followed by a letter explaining the circumstances surrounding the incident. The facility failed to: 1). Report Resident 7’s right thumb fracture to the CDPH as indicated in the facility’s P&P titled “Abuse & Mistreatment of Residents”, which indicated the facility should report suspected or known instances of abuse to the CDPH within two hours of the knowledge of the incident. This failure delayed the investigation by the CDPH and subjected Resident 1 to further injuries and potential abuse. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.