Other·March 3, 2026

Code of Federal Regulations, Title 42, Section §483.12 483.12(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. 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 1/27/26 at 3:21 PM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate one Facility Reported Incident regarding abuse. The facility failed to ensure that an allegation of sexual abuse involving Resident 1 was reported to the California Department of Public Health (CDPH) within two hours after the facility had knowledge of the allegation, as required by federal regulations (Pursuant to Title 42 Code of Federal Regulations section 483.12(c)(1)). This failure delayed the CDPH's review of the alleged abuse and potentially placed Resident 1 and other residents in the facility at risk for ongoing abuse. During an interview on 1/27/26 at 3:52 PM with Resident 1 at his bedside, Resident 1 stated, "...someone tried to climb on me... and it happened only once...it happened about two nights ago. It was dark but he was tall and bald..." Resident 1 further stated, "...He tried to have sex with me, he pulled down my pants, he took his thing out, he tried to climb on top of me...I pushed him away...I screamed for help, my neighbor heard it...then he went away..." Resident 1 later identified the individual as CNA 2. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 12/19/25, the MDS indicated a Brief Interview for Mental Status (BIMS, an assessment tool) score of 9 on a scale of 0-15 (BIMS scores are as follows: 13 to 15: cognition intact ; 8 to 12: moderate cognitive impairment ; 0 to 7: severe cognitive impairment). During a phone interview on 1/28/26 at 10:39 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated that on Sunday (1/25/26) at approximately 2:15 PM, Resident 1 showed her a notepad with the word "rape" written on it and stated that the male CNA on the NOC (night) shift was raping him. CNA 1 stated she reported the allegation to Licensed Nurse (LN) 3 between 2:30 PM and 3:00 PM on 1/25/26 and provided a written statement the same day. During a phone interview on 2/2/26 at 2:28 PM with Licensed Nurse (LN) 3, LN 3 stated that she was notified of the allegation involving Resident 1 at approximately 2:30 PM on 1/25/26 and immediately notified LN 2. During a review of the facility's "Progress Note" dated 1/25/26 at 5:15 PM, authored by LN 2, the note indicated the Administrator (ADM) and Director of Nursing (DON) were made aware of the allegation. During an interview on 1/28/26 at 11:37 AM with the ADM, the ADM stated she was notified of the allegation on 1/25/26 at approximately 3:17 PM. The ADM stated the CDPH was notified on 1/25/26; however, she was unable to provide evidence of the exact time of notification. During an interview on 1/28/26 at 1:20 PM with the Director of Nursing (DON), the DON stated that law enforcement was notified on 1/25/26 at approximately 4:15 PM. The DON stated that the CDPH was notified on 1/25/26; however, she was unable to provide evidence of the time of notification. During a review of the SOC 341 (a confidential report form for reporting suspected abuse or neglect of dependent adults or elders in California) submitted to CDPH by the facility, the SOC 341 for Resident 1 was received via email on 1/26/26 at 1:57 PM. During a telephone interview on 2/23/26 at 9:39 AM with the ADM, the ADM stated she was aware that the alleged abuse involving Resident 1 should have been reported to the CDPH within two hours. The ADM stated staff documented that the SOC 341 was sent to CDPH; however, she was unable to provide documentation confirming submission to CDPH within the required two-hour timeframe on 1/25/26. A review of the facility's policy titled "Abuse Prevention Program," revised 12/2016, indicated, "...residents have the right to be free from abuse...this includes...sexual abuse...Investigate and report any allegations of abuse within timeframes as required by federal requirements..." Therefore, the facility failed to ensure that an allegation of sexual abuse involving Resident 1 was reported to the California Department of Public Health (CDPH) within two hours after the facility had knowledge of the allegation, as required by federal regulations (Pursuant to Title 42 Code of Federal Regulations section 483.12(c)(1)). This failure delayed the CDPH's review of the alleged abuse and potentially placed Resident 1 and other residents in the facility at risk for ongoing abuse. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1 and is a B citation violation.