Health inspection·April 2, 2026

REGULATION VIOLATIONS: 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. HSC § 1418.91 (b) A failure to comply with the requirements of this section shall be a class "B" violation. FINDINGS: On 2/12/2026 through 3/7/2026, an unannounced visit was conducted at the facility to investigate three intake investigations of physical abuse and alleged sexual abuse involving Patient 1, 2, 3, 4, 5, 6. Patient 2 punched Patient 1 in the face, alleging that Patient 1 attempted to engage in unwanted sexual activity with Patient 2. Patient 3 kicked Patient 4 in the buttocks and in retaliation Patient 4 punched Patient 3 in the face three times. Patient 6 alleged that Patient 5 punched him in the chin. The facility failed to report multiple abuse allegations within the mandated 24-hour timeframe. Patient 1 reported physical abuse and Patient 2 reported an allegation of sexual abuse on 2/7/2026 to the facility staff, but the facility did not notify California Department of Public Health (CDPH) until 2/10/2026, two days late. Additionally, the facility staff witnessed physical abuse between Patient 3 and Patient 4 on 2/28/2026, and this incident was not reported to CDPH until 3/2/2026, exceeding the required reporting timeframe by one day. Similarly, Patient 6 reported physical abuse by Patient 5 on 2/28/2026, which was also reported on 3/2/2026 to CDPH, one day late. 1. During a review of Patient 1's "Quarterly Minimum Data Set (MDS- federally required assessment tool used to guide patient care)," dated 11/28/2025, the MDS indicated Patient 1 was admitted to the facility on 5/22/2024, with diagnoses that included absence of the left eye and tracheostomy (a surgical hole in the throat to help with breathing). During a review of Patient 2's "Treatment Plan," dated 1/29/2026 the "Treatment Plan" indicated Patient 2 was admitted to the facility on 7/25/2025 with a diagnosis that included schizophrenia (Mental disorder). During a review of the facility's "Report of Unusual Occurrence," dated 2/10/2026, the report indicated on 2/7/2026, Patient 2 punched Patient 1 in the face, which resulted in a laceration above Patient 1's right eyebrow. Patient 2 alleged Patient 1 attempted to engage in sexual activity with him. During an interview on 2/12/2026 at 10 a.m. with Standards Compliance Supervising Registered Nurse (SCSRN), SCSRN confirmed Patient 2 punched Patient 1 on 2/7/2026 and Patient 2 reported a sexual assault allegation against Patient 1. SCSRN stated the Department of Standards Compliance was not open over the weekend, therefore they would not be able to report abuse within 24 hours. SCSRN further stated she does not consider patient-on-patient physical and/or sexual assault as abuse; therefore, it was not mandated to be reported to CDPH within 24 hours of incident. 2. During a review of Patient 3's Treatment Plan, the Treatment plan indicated Patient 3 was admitted to the facility on 8/9/2022 with diagnoses that included gastrostomy status (a surgical opening into the intestines to administer nutrition and medications via a tube) and pulmonary fibrosis (chronic lung disease). During a review of Patient 4's "Treatment Plan," the Treatment Plan indicated Patient 4 was admitted to the facility on 8/1/2024 with diagnoses that included unsteadiness on feet, blindness of left eye and fracture of left femur (broken left thigh bone). During a review of the facility's "Report of Unusual Occurrence," dated 3/2/2026, the report indicated on 2/28/2026, Patient 3 kicked Patient 4 in the buttocks unprovoked and in retaliation, Patient 4 punched Patient 3 in the face three times. During an interview on 3/4/2026 at 4:30 p.m. with Standards Compliance Director (SCD), SCD confirmed the physical altercations between Patient 3 and Patient 4 were not reported to CDPH until 2 days after the incident on 2/28/2026, because patient-to-patient abuse was not considered abuse per facility's policy. 3. During a review of Patient 5's "Treatment Plan," the "Treatment Plan" indicated Patient 5 was admitted to the facility on 4/29/2025 with diagnoses that included back fracture and epilepsy (recurrent, unprovoked seizures). During a review of Patient 6's "Treatment Plan," the "Treatment Plan" indicated Patient 6 was admitted to the facility on 5/31/2024 with diagnosis that included schizophrenia. During a review of the facility's "Report of Unusual Occurrence," dated 3/2/2026, the report indicated on 2/28/2026, Patient 5 allegedly punched Patient 6 in the chin after a verbal altercation. During an interview on 3/4/2026 at 4:30 p.m. with SCD, SCD confirmed the alleged physical altercation between Patient 5 and Patient 6 was not reported to CDPH until 2 days after the incident on 2/28/2026 because patient-to-patient abuse was not considered abuse per facility's policy and definition. During a review of the facility's policy and procedure (P&P) titled, "Reporting Patient Abuse and Neglect," dated 5/7/2025, the P&P indicated, "Abuse of Dependent Adult/Elder: Includes physical... as defined as... Physical abuse: Any of the following: (a) Assault, as defined in Section 240 of the Penal Code... (e) Sexual assault...Standards compliance responsibilities... all alleged violations involving abuse... which occurred in Skilled Nursing units shall be reported by SCD/Designee to CDPH IMMEDIATELY but not later than 2 HOURS after allegation is made..." During a review of the facility's P&P attachment titled, "Appendix A- Definitions," undated, the document indicated, "Alleged Patient abuse- physical: any intentional interaction or physical contact, motion, or action that is directed toward a patient by someone other than another patient... Alleged Sexual Abuse: An employee engages in sexual contact with a patient. An employee encourages or allows sexual contact between patients..." The facility failed to report multiple abuse allegations within the mandated 24- hour timeframe. Patient 1 reported physical abuse and Patient 2 reported an allegation of sexual abuse on 2/7/2026 to the facility staff, but the facility did not notify the California Department of Public Health (CDPH) until 2/10/2026, two days late. Additionally, the facility staff witnessed physical abuse between Patient 3 and Patient 4 on 2/28/2026, and this incident was not reported to CDPH until 3/2/2026, exceeding the required reporting timeframe by one day. Similarly, Patient 6's report of physical abuse by Patient 5 on 2/28/2026, was also reported on 3/2/2026 to CDPH, one day late. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients.