Other·March 10, 2026

The following reflects the findings of the California Department of Public Health during the investigation of: Complaint #: 2721242 Event ID: 1E23CB-H1 State Citation B was written. California 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. (b) A failure to comply with the requirements of this section shall be a class "B" violation. § 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. (a) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. (2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. (3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph § 483.95. (4) Establish coordination with the QAPI program required under § 483.75. (5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual's obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. (ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. (iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act. (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. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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. On 1/27/2026 at 2 P.M., an unannounced visit was conducted at the facility to investigate complaints regarding allegations of abuse. The facility failed to report two separate incidents of alleged resident to resident abuse when: 1. Resident 11 was allegedly kicked by another Resident (Resident 1). 2. Resident 2 allegedly had water thrown on him by another Resident (Resident 4). This failure had the potential for resident-to-resident abuse to continue. Finding: A review of Resident 11's admission record indicated Resident 11 was admitted to the facility on 8/12/25. On 1/27/26 at 12:50 P.M., a concurrent interview with the Quality Nurse (QN) and record review of the EMR was conducted. The QN stated that the process for resident-to-resident abuse was to... report to the Administrator (ADM)... investigation and report to the following authorities: ...e. California Department of Public Health (CDPH). The QN stated the expectation for alleged resident-to-resident abuse was to report immediately to the Abuse coordinator. The QN stated in this facility the abuse coordinator was the ADM. The QN stated that the incident between Resident 1 and Resident 11 was brought up during the interdisciplinary team (IDT- a group of professionals from different disciplines working interdependently to achieve patient focused goals through shared decision-making) meeting, but there was no follow up on the incident. On 1/27/26 at 1:25 P.M., a concurrent interview with the Social Services Assistant (SSA) and record review of SSA's notes was conducted. The SSA stated that, "Resident 1 came to her on 1/19/26 at 9 A.M. to vent about a situation that happened with Resident 11, his roommate, the week before." The SSA stated Resident 11 asked Resident 1 to lower the TV volume, when Resident 1 barged into his side of the room and verbalized the threat "...If you don't lower the TV, I'm going to hurt you..." The SSA stated, Resident 1 said he kicked Resident 11 in the lower torso to protect himself. The SSA stated that the expectation for alleged abuse was to report the alleged abuse to the Abuse Coordinator immediately. The SSA stated the Abuse Coordinator was the ADM. The SSA stated that she reported to the DON and assumed that she had reported to the ADM. On 1/27/26 at 2 P.M., an observation and interview with Resident 11 was conducted. Resident 11 was observed in the hallway in his wheelchair. Resident 11 stated that a few weeks ago, his previous roommate, Resident 1, had kicked him with his foot and he fell back onto his wheelchair and got a bruise on his lower back from landing on the wheelchair's brake lever. On 1/27/26 at 2:15 P.M., a concurrent interview with Charge Nurse (CRN) 2 and record review of EMR for Resident 11 was conducted. CRN 2 stated that a resident kicking another resident or a resident throwing water on another resident was considered resident-to-resident abuse. CRN 2 stated that the process for resident-to-resident abuse was to separate the resident, assess, and report to the ADM. CRN 2 also stated he should have initiated the investigation and reported to California Department of Public Health (CDPH). On 1/27/26 at 2:45 P.M., an interview with the ADM (Administrator) was conducted. The ADM stated he was the abuse coordinator. The ADM stated that the incident that happened between Resident 1 and Resident 11 was not reported to him. The ADM stated if the incident was reported to him, he would have investigated and reported it to the appropriate authorities which included the State Survey Agency. The ADM stated he did not investigate, and did not report to the appropriate authorities. The ADM stated it was important to report immediately to prevent further abuse. The ADM acknowledged he did not investigate and report the incident to the appropriate authorities. On 1/28/26 at 7:43 A.M., a phone interview was conducted with the Director of Nursing (DON). The DON stated that the allegation of Resident 1 kicking Resident 11 would be considered an alleged resident-to-resident abuse. The DON stated that she did not investigate the incident between Resident 1 and Resident 11 because the SSA told her it happened a couple of weeks ago. The DON stated she thought it was a misunderstanding that happened between her and the SSA. The DON stated that she asked the SSA to strike her note dated 1/19/26 was, "...because it seemed like abuse that was not reported." The DON stated the QA (a proactive, systemic process focused on preventing defects and ensuring products or services meet quality standards) staff member was supposed to start the investigation and follow up with her but never did. The DON stated that the investigation was not on the follow up list, so it was not reported to the Abuse Coordinator which was the ADM and an investigation was not done. The DON also stated, "I am responsible as the DON." The DON stated that the incident should have been reported to the appropriate authorities per policy within 2 hours of the allegation of abuse. The DON stated that by not reporting and investigating immediately had the potential for further abuse of the victim. 2. A review of Resident 2's admission record indicated Resident 2 was admitted on 12/11/25. A review of Resident 2's nursing note, dated 1/15/26 at 3:22 P.M., indicated "Resident [2] claims that someone threw water on him but cannot recall the face upon assessment resident gown is wet." On 1/27/26 at 10:15 A.M., a concurrent observation and interview was conducted with Resident 2. Resident 2 was observed in therapy in his wheelchair doing arm exercises. Resident 2 stated that about a week ago, someone threw water at him while he was resting in bed. Resident 2 stated that the alleged abuser said, "You snore too much..." after he threw water on him. On 1/27/26 at 10:40 A.M., an interview with Certified Nursing Assistant 1(CNA) was conducted. CNA 1 stated that on 1/15/26 Resident 2 told him that "the man in the wheelchair threw water on me..." CNA 1 stated that throwing water on another resident was considered resident-to-resident abuse. CNA 1 stated the process for resident-to-resident abuse was to separate the residents, make sure they are safe, and report it to the Charge Nurse (CRN), the Director of Nursing (DON), and the Administrator (ADM). CNA 1 stated that the ADM was the abuse coordinator. CNA 1 stated he immediately reported to CRN 1, the DON and the ADM. On 1/27/26 at 11:50 A.M. an interview with CNA 2 was conducted. CNA 2 stated she was working with Resident 2, the day he complained about getting water thrown at him. CNA 2 stated that Resident 2 stated "the guy in the wheelchair threw water on me". CNA 2 stated she thought the person who threw the water on him was Resident 4, Resident 2's roommate. CNA 2 stated the process for an incident of resident-to-resident abuse was to separate the residents, make sure they are safe, and to report it to the CRN, the DON, and the ADM. CNA 2 stated that the ADM was the abuse coordinator. CNA 2 stated that throwing water on another resident or kicking another resident would be considered resident-to-resident abuse and it should be reported and investigated to prevent further abuse. On 1/27/26 at 12: 35 P.M., a concurrent interview and record review was conducted with CRN 1. CRN 1 stated that she was the charge nurse the day that Resident 2 had water thrown on him. CRN 1 stated that the incident was reported to her at 11 A.M. CRN 1 stated that she considered the incident to be resident to resident abuse and it should be reported to the abuse coordinator which was the ADM. CRN 1 stated that she wrote a note that Resident 2 had water thrown on him by another resident, and that it was reported to the DON and the ADM. CRN 1 presented a copy of the text she made to the interdisciplinary team( IDT- a group of professionals from different disciplines working interdependently to achieve patient focused goals through shared decision-making), which included the ADM, DON, Social Services Director (SSD), and Quality (QN) Nurse, notifying them that Resident 2 had water thrown on him by another resident. CRN 1 reviewed Resident 2's EMR and was not able to find any documentation of IDT report on the incident or any follow up made by the SSD or ADM. On 1/27/26 at 12:50 P.M., a concurrent interview and record review was conducted with the Quality Nurse (QN). The QN stated that she found out about Resident 2 getting water thrown on him during the IDT team meeting. The QN stated she spoke to the DON who stated she was going to talk to Social Services about investigating the alleged abuse on 1/26/26. The QN stated the ADM was the abuse coordinator. The QN stated that typical process for resident-to-resident abuse was to separate the residents, do an assessment and report it to the ADM. The QN stated the ADM should have initiated the investigation and report it to the California Department of Public Health (CDPH). The QN stated it was important to report the incident immediately to prevent further abuse and ensures patient safety. On 1/27/26 at 2:45 P.M., an interview with the ADM was conducted. The ADM stated he was the abuse coordinator. The ADM stated he investigated the alleged abuse involving Resident 2 and Resident 4 but didn't report it because Resident 2 did not complain about water being thrown on him during the interview. The ADM stated that Resident 2 and Resident 4 were offered room changes but both refused so they did not pursue the incident as alleged abuse and did not further investigate. The ADM stated that the investigation was not documented in the electronic medical record and was unsure why. The ADM stated he was not sure if the abuse had occurred and was unsure if he should have reported it. The ADM stated by not reporting and properly investigate the alleged abuse, it could result in "...the abuse repeated, escalated, and put the victims at further risk." On 1/28/26 at 7:43 A.M., a phone interview was conducted with the DON. The DON stated that Resident 2 getting a cup of water thrown on him by another resident would be considered a resident-to-resident abuse. The DON stated that QA nurse was supposed to be the one starting the investigation, and she (the DON) would follow up. The DON stated for alleged abuse, they should have reported to the appropriate authorities per policy and procedure within 2 hours of the allegation of abuse. The DON stated the facility did not report this alleged abuse to the appropriate authorities because, "She believed that the incident did not happen." The DON stated by not reporting and investigating alleged abuse in a timely manner could put the residents at risk for more abuse. A record review of the facility policy titled "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating", dated 2001, indicated "Reporting Allegations to the Administrator and Authorities...1. If the resident abuse...is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law, 2. The Administrator or the individual making the allegation immediately reports his or her suspicion to the f