Other·August 26, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint number 965020. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. A deficiency was written for complaint number 965020 at F-tag 607/D. Health & 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. F607 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(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. §483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. §483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act. On 6/11/2025, an unannounced visit was conducted at the facility to investigate a complaint regarding an alleged abuse towards a resident. Resident 1 was a 78 year old female who was admitted on 8/24/18 with diagnoses of metabolic encephalopathy (brain dysfunction due to metabolic [chemical changes that take place in a cell or an organism] disorder), dementia (impairment of at least two brain functions, such as memory loss and judgement), hemiplegia (paralysis on one side of the body) and hemiparesis ( muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (blood flow to the brain is blocked, causing brain tissue to die) affecting right dominant side. Based on interview and record review, the facility failed to implement its own policy on abuse when an allegation of abuse for one of three sampled residents (Resident 1) was not reported to Ombudsman (an independent advocate who helps residents navigate concerns, ensuring their rights are protected and their voices are heard), law enforcement (police), and the California Department of Public Health (CDPH). This failure had the potential to place Resident 1 at risk of abuse. Findings: During a review of Resident 1's "Admission Record" (AR) dated 6/12/25, the AR indicated, Resident 1 was admitted on 8/24/18 with the following diagnoses: metabolic encephalopathy (brain dysfunction due to metabolic [chemical changes that take place in a cell or an organism] disorder). . .dementia (impairment of at least two brain functions, such as memory loss and judgement). . .hemiplegia (paralysis on one side of the body) and hemiparesis ( muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (blood flow to the brain is blocked, causing brain tissue to die) affecting right dominant side." During a review of Resident 1's "Cognitive Patterns" (CP) dated 3/24/25, the CP indicated Brief Interview for Mental Status (BIMS assesses cognitive status with scores ranging from 0 - 15, with higher scores reflecting more intact cognitive status) score of 8 (score of 8-12 means moderate cognitive [mental process involved in knowing, learning, and understanding things] impairment). During a review of Resident 1's "Progress Notes (PN)," dated 5/21/25 at 9:50 a.m., the PN indicated, "Writer [DSD/Director of Staff Development] received complaint from staff member in regards to a possible altercation between CNA [Certified Nursing Assistant] and resident [1]. Resident [1] was interviewed by ADON [Assistant Director of Nursing] and DSD in regards [sic] the altercation." During an interview on 6/11/25 at 12:24 p.m. with Resident 1, Resident 1 stated approximately two to three weeks ago, CNA 1 was assigned to her. Resident 1 stated when she was on the phone with Family Member (FM) 1, CNA 1 was in the room and CNA 1 said something (unable to recall what was said) to her, and she (Resident 1) said something back and stuck her tongue out at CNA 1. CNA 1 then bopped (to hit someone) her with the back of her hand in the head and her head hit the side rail of the bed. During an interview on 6/11/25 at 1:15 p.m. with DSD, DSD stated on 5/21/25 the IP (Infection Preventionist) reported that FM 1 had made an allegation of abuse towards CNA 1 saying she had bopped Resident 1 over the head while she was on the phone with her. DSD stated CNA 1 was suspended and the allegation was reported to the Administrator, Human Resources (HR) and Director of Nursing (DON). DSD stated an investigation was initiated by the ADON and HR. DSD stated she did not report the allegation to any outside entity (Ombudsman, law enforcement, state licensing agency/CDPH). During an interview on 6/11/25 at 1:28 p.m. with IP, IP stated on 5/21/25 FM 1 reported that when she was on the phone with Resident 1, CNA 1 went into Resident 1's room and Resident 1 offered her some food. CNA 1 declined the food and Resident 1 said oh you are going to be a diabetic today and CNA 1 said yes, she did not want her sugar to go up. CNA 1 then walked over to do something, and Resident 1 said 'ow' and when FM 1 asked what happened Resident 1 said CNA 1 bopped her over the head. IP stated she reported the incident to the Administrator who immediately removed CNA 1 from resident care. IP stated the allegation was not reported to any outside agencies and the alleged incident should have been reported within two hours. During an interview on 6/11/25 at 1:54 p.m. with DON, DON stated on 5/21/25 it (allegation of abuse) was reported to her that Resident 1 had stated CNA 1 had bopped her in the head. DON stated the allegation was not reported to any outside agencies and it should have been. During an interview on 6/11/25 at 4:08 p.m. with Family Member (FM) 1, FM 1 stated during a phone call with Resident 1 on approximately 5/17/25 or 5/18/25 she heard Resident 1 offer CNA 1 some cinnamon balls from Taco Bell and then say you're going to be diabetic and then Resident 1 said 'ow'. FM 1 asked Resident 1 what happened, and Resident 1 said CNA 1 bopped her over the head with her hand. FM 1 stated she reported the allegation to the IP. FM 1 stated she had a meeting with the Administrator, DSD and another staff on 6/5/25 regarding the incident. FM 1 stated "I think it could be abuse, think she was very unprofessional and crossed the line." During an interview on 6/19/25 at 11:43 a.m. with Administrator, Administrator stated on 5/21/25 the IP informed him that FM 1 reported that CNA 1 had bopped Resident 1 on her head. Administrator stated he was aware of the allegation but was not reported to any outside agencies. During a review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" dated 2021, the P&P indicated, "All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. . .The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies. . .the state licensing/certification agency responsible for surveying/licensing the facility. . .the local/state ombudsman. . .law enforcement officials. . .Immediately is defined as. . .within two hours of an allegation involving abuse or result in serious bodily injury or. . .within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. . ." In violation of the above cited, the facility failed to report an allegation of abuse to the Ombudsman, law enforcement, and CDPH. This failure had the potential to put residents at risk for abuse. This violation had a direct or immediate relationship to the health, safety, or security of residents and constitutes a Class "B" citation.