Health inspection·December 29, 2025

REGULATORY VIOLATION(S): California Code of Regulations (Title 22) 72523(a) (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. California Health and Safety Code § 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. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 9/24/25, an unannounced visit was conducted at the facility to investigate a Facility Reported Incident regarding Resident/Patient/Client Abuse. The facility failed to implement their policy and procedure of abuse for Patient 1 and Patient 2 when the allegation of abuse was reported to the state agency 16 days after the alleged altercation between Patient 1 and Patient 2. This failure had the potential to affect the residents' emotional and psychosocial wellbeing. FINDINGS: Review of Patient 1's clinical record indicated she was admitted to the facility on 4/2/25 with diagnoses including idiopathic gout (sudden, severe attacks of pain, swelling, and redness in one or more joints of unknown cause), displaced fracture of lateral malleolus of right fibula (dislocated and broken ankle bone), pneumonitis (swelling of the lungs), chronic diastolic (congestive) heart failure (condition in which the heart does not pump blood as efficiently as it should), unspecified dementia (a decline in mental abilities, severe enough to interfere with daily life). Review of Patient 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/8/25, indicated her Brief Interview for Mental Status (BIMs, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14 (BIMS score of 13-15 indicates cognitively intact). Review of Patient 2's clinical record inidcated she was admitted to the facility on 2/5/25 with diagnoses including cognitive communication deficit. Review of Patient 2's Minimum Data Set, dated 2/11/25, indicated her BIMS score was 11 (BIMS score of 8 to 12 indicates moderately impaired). Review of Patient 1's Nurses' Progress Notes, dated 4/6/25, indicated Patient 2 got out of bed and stood at the foot board of Patient 1's bed and told her "You need to shut the hell up already or I'm going to make you." During an interview with Patient 2 on 10/3/25 at 1:38 p.m., Patient 2 stated she probably said "shut up" but not "make you" to Patient 1. Patient 2 stated she did not touch Patient 1. During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 10/16/25 at 2 p.m., the ADON confirmed that the incident was reported late to the state agency. During an interview with the Infection Prevention Nurse (IPN), on 10/20/25 at 1:55 p.m., the IPN stated she was the manager on duty (MOD) when the incident between Patient 1 and 2 happened. The IPN further stated she did not inform anyone of the incident on 4/6/22 between Patient 1 and 2. During a concurrent interview and record review with the Director of Nursing (DON) on 10/17/25 at 2:21 p.m., the DON stated the incident between Patient 1 and 2 was reported to the State Agency on 4/22/25. Review of the facility's SOC 341 (form used to report suspected abuse) indicated the SOC 341 was sent to the California Department of Public Health on 4/22/25, 16 days after the alleged incident between Patient 1 and Patient 2. The SOC 341 further indicated both the law enforcement and long-term care ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities) were notified on 4/22/25. The Licensed Vocational Nurse (LVN) resigned from the facility on 7/11/25. Unable to be interviewed. During a review of the facility's policy and procedures (P&P), titled "Abuse Prohibition Policy and Procedure", dated 2/23/21, indicated "6.1 Anyone who witnesses an incident of suspected abuse...report the incident to his/her supervisor immediately. 6.1.1 The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance to state law...6.1.3 All reports of suspected abuse must also be reported to the patient's family and attending physician...6.2.3 The family and physician will be notified...7.3 Report allegations involving neglect, exploitation or mistreatment...within twenty-four (24) hours...7.4 Notify local law enforcement, Ombudsman, Licensing District Office..." Review of CDPH All Facilities Letter 21-26 with subject "Mandated Reporting Requirements of Potential Abuse, Neglect, Exploitation, or Mistreatment of Elders or Dependent Adults" indicated... "File a written or electronic report to the LTC [Long Term Care] ombudsman, local law enforcement and DO within 24 hours..." The facility failed to implement their policy and procedure of abuse for Patient 1 and Patient 2 when the allegation of abuse was reported to the state agency 16 days after the alleged altercation between Patient 1 and Patient 2. The above violation had a direct or immediate relationship to the health, safety, or security of the residents.