Health inspection·October 8, 2025

Code of Federal Regulations, Title 42, Section 483.12 - Freedom from abuse, neglect, and exploitation. (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. California Health and Safety Code, Section 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 9/2/25, at 1:03 PM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding abuse. The Department determined the facility failed to ensure an allegation of abuse was reported to the Department within 24 hours when Resident 1 reported to facility staff on 8/2/25 that Certified Nursing Assistant (CNA) 3 forcefully grabbed her legs on 8/2/25 and the allegation made by Resident 1 was not reported to the Department until 8/7/25. This failure resulted in a delay in the abuse investigation process and decreased the facility's potential to protect Resident 1 and other residents in the facility from physical and psychosocial harm. A review of Resident 1's "ADMISSION RECORD," indicated she was admitted to the facility with diagnoses which included need for assistance with personal care, history of falling, muscle weakness, difficulty in walking, bipolar disorder (a mental health condition that causes changes in a person mood, energy, and ability to function), and anxiety (a mental health condition characterized by excessive worry, fear, and nervousness). A review of Resident 1's minimum data set (MDS, a federally mandated resident assessment and screening tool which identifies care needs) dated 7/29/25, the MDS indicated, "...Section C-Cognitive Patterns...Brief Interview for Mental Status (BIMS) [a tool used to screen for cognitive impairment]..." indicated, a score of 14 points which suggested Resident 1's cognition/thinking/decision making was intact. A review of Resident 1's clinical document, written by the Administrator in Training (AIT), titled, "Progress Notes," dated 8/7/25, at 5 PM, indicated, "...At around 4:30pm, [Resident 1] informed writer that a CNA had hurt her legs over a week ago and was concerned why the same CNA was scheduled to work the night shift with her again...[Resident 1] explained...the saturday [sic] before (on the evening of 7/26/25)...CNA, forcefully grabbed her behind the ankles and squeezed while trying to drag her off the bed. She was very upset and crying at this time..." A review of Resident 1's clinical document, written by the AIT, titled, "Progress Notes," dated 8/7/25, at 10:41 PM, indicated, "...when [Resident 1] was interviewed by officer [police]...she added to her report that the CNA started the altercation by throwing her resident's arms around before grabbing her legs. She [Resident 1] also stated that she is starting to believe that it could have been last Saturday (8/2/25)..." During a telephone interview on 9/3/25, at 7:34 AM, Licensed Nurse (LN) 2 stated, on 8/2/25, Resident 1 reported CNA 3 grabbed her by the ankles and pulled on her. LN 2 further stated she assessed Resident 1's ankles and no redness or marks were observed. During an interview on 9/3/25, at 9:05 AM, in Resident 1's room, Resident 1 stated when she needed help to go to the bathroom, CNA 3 flung her arms over and then grabbed her by the back of the ankles and squeezed hard. Resident 1 stated CNA 3 caused her pain and made bruises like finger marks on her left ankle. During a telephone interview on 9/3/25, at 10:39 AM, LN 4 stated the incident with Resident 1 occurred on Saturday 8/2/25, at approximately 6 PM. LN 4 further stated CNA 3 had reported that Resident 1 was angry and asked LN 4 to check on her. LN 4 stated Resident 1 was agitated when they went to check on her and asked LN 4 and CNA 3 to leave her room. LN 4 further stated she had assumed the other nurse (LN 2) would document the incident. LN 4 stated after the incident happened, training on abuse reporting was conducted and now she understood the reporting process and what should have been done because it was a serious issue. During a telephone interview on 9/3/25, at 10:48 AM, LN 2 confirmed she had not documented or reported Resident 1's allegation of abuse, but she should have. LN 2 stated she should have made sure the allegation was documented and reported for the safety of Resident 1, the facility, and everyone. During an interview on 9/3/25 at 12:11 PM, the AIT confirmed LN 2, LN 4, and CNA 3 were aware of Resident 1's allegation of abuse on 8/2/25, but the incident did not come to his attention until 8/7/25. The AIT further confirmed because he did not learn about the incident until five days later, the report to the Department was delayed. During an interview on 9/3/25, at 2:54 PM, the Director of Nurses (DON) stated it was her expectation that allegations of abuse would be reported to the Department within two hours of the occurrence. The DON further stated it was important to report abuse for the safety of the residents. A review of a facility policy titled, "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating," revised 9/22, indicated, "...If resident abuse...is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law..."Immediately" is defined as...within two hours of an allegation involving abuse...or within 24 hours of an allegation that does not involve abuse..." Therefore, the Department determined the facility failed to ensure an allegation of abuse was reported to the Department within 24 hours when, Resident 1 reported to facility staff on 8/2/25 that CNA 3 forcefully grabbed her legs on 8/2/25 and the allegation made by Resident 1 was not reported to the Department until 8/7/25. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.