Other·April 17, 2026

The following reflects the findings of the California Department of Public Health during the investigation of the complaint intake number 2699073. Event ID: 1F23C8-H1 Exit Date: 3/16/2026 State Citation B was written for the following violation. F 609 Regulatory violations: Title 22 CCR §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. (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. §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. On 1/6/2026 at 9:40 a.m., 2/6/2026 at 10:30 a.m., 2/25/2026 at 9:35 a.m., and 3/3/2026 at 9:30 a.m., an unannounced visits were conducted at the facility to investigate a complaint intake (2699073) during an abbreviated standard survey regarding "Quality of Care and Treatment." The facility failed to ensure to notify local police, Ombudsman (independent official, who advocates residents), and state agency in a timely manner following an allegation of abuse reported by facility's staff member for one resident (Resident 1). This failure had the potential for further abuse and delay implementation of appropriate corrective actions for sampled Resident 1. Review of Resident 1's face sheet (FS, a document that provides resident's information at a quick glance) indicated Resident 1 was admitted in facility on 4/11/2025. Review of Resident 1's admission diagnoses included dementia (a decline in mental ability such as memory, reasoning, and communication, severe enough to interfere with daily life) and anxiety (persistent and excessive worry and fear of danger). Review of Resident 1's minimum data set (MDS, clinical and functional assessment tool) assessment dated 1/5/2026 indicated Resident 1 had short-term (time period, typically 15-30 seconds) and long-term (time period ranging from hours to a lifetime) memory problem. Review of Resident 1's change of condition (COC, any significant physical, mental or functional condition change from a resident's baseline status) document dated 12/21/2025 indicated, "Incident regarding husband, resident, and CNA (certified nursing assistant)". Further review of this COC indicated Resident 1's medical doctor (MD) recommended to monitor signs and symptoms for emotional distress for Resident 1 when licensed nursing staff reported above allegation to MD. Review of Resident 1's nurse's notes dated 12/21/2025 indicated, morning shift CNA A reported to licensed vocational nurse C (LVN C) a witnessed an alleged incident of Resident 1's husband made a gestured motion towards the Resident 1's face. Resident 1's husband being rough/upset at the Resident 1 for not sitting in a wheel chair to go to dining hall. This notes also indicated CNA A reported Resident 1 was appeared to be shaken and somewhat fidgeting after the alleged event. Review of Resident 1's all documented person- centered care plans (an individualized, collaborative document that focuses on a resident specific needs, goals, interventions, and preferences) indicated there was a care plan for "alleged hand gesture to resident's face," dated 12/21/2025 with interventions. During an interview over the telephone with LVN/supervisor B (LVN/S B) on 2/25/2026 at 2:15 p.m., LVN/S B confirmed above documentation for Resident 1's COC dated 12/21/2025. LVN/S B stated investigation following the abuse allegation indicated no abuse happened to Resident 1, he did not report to necessary entities. LVN/S B also stated not sure facility reported this abuse allegation. During an interview with LVN C on 2/25/2026 at 2:39 p.m., LVN C stated CNA A reported to her of above abuse allegation for Resident 1. LVN C reported this allegation to LVN/S B after separated husband from Resident 1. LVN C stated LVN/S B started the investigation and discussed with facility's administrator (ADMN) and director of nursing (DON) right away. LVN C also stated she was not aware if facility reported this allegation of abuse or not. During an interview with CNA A over the telephone on 2/26/2026 at 10;07 a.m., CNA A stated he witnessed Resident 1's husband pushed Resident 1 to sit in wheelchair (w/c, a mobility device designed for who cannot walk to enabling independence with mobility and transportation) and punched on Resident 1's face near chin area while CNA A was passing by in hallway. CNA A also stated he could see above abuse clearly from hallway. CNA further stated Resident 1's body was shaken and appeared fearful after this incident when CNA A walked in to Resident 1's room to separate husband from Resident 1. CNA A stated what husband did to Resident 1 was an abuse, it should be reportable. During an interview with facility's DON on 3/3/2026 at 2:02 p.m., DON stated based on facility's investigation for abuse allegation indicated there was no abuse happened to Resident 1 and did not report this allegation to necessary entities. During a concurrent record review of Resident 1's COC of an allegation on 12/21/2025 and interview with facility's regional administrator (R ADMN) on 3/3/20026 at 3:20 p.m., R ADMN stated he was ADMN for this facility when above allegation happened. R ADMN confirmed he was aware of staff reported an allegation for Resident 1and her husband. R ADMN stated based on the discretion of allegation's investigation, facility's management considered the allegation was not an abuse and not reported to necessary entities. R ADMN also stated Resident 1's husband was denied the allegation. Review of facility's policy and procedures (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating," revised September 2024, the P&P indicated, "1. If resident abuse, neglect, exploitation, misappropriation of resident's property or injury of unknown source 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 following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman (an independent, neutral, and resident's advocate); e. Law enforcement officials (government officials including police, responsible for public safety);" In violation of the above cited standards, the facility failed to ensure to notify local police, Ombudsman, and state agency in a timely manner following an allegation of abuse reported by facility's staff member for Resident1. This violation had a direct or immediate relationship to the health, safety or security of patients or residents.