Health inspection·November 6, 2025

The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint Number: CA00964661 (IQIES 2344008) Representing the Department, HFEN 44583 Citation B was written. REGULATORY VIOLATIONS: CA 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 6/6/2025, an unannounced complaint survey was conducted at the facility. The facility failed to report and investigate an abuse allegation for one of two patients (Patient 1). This failure resulted in an incident of alleged abuse not being investigated and had the potential to compromise the safety of the patients in the facility. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents. FINDINGS: Review of Patient 1's clinical records titled, "Admission Record," dated 6/6/2025, Patient 1 was admitted to the facility with diagnoses including spondylosis (a degenerative condition of the spine that occurs when the discs and vertebrae [bones] in the spine wear down over time) with myelopathy (a condition affecting the spinal cord which could lead to impaired function), cervical region (area of the neck), heart failure (occurs when the heart muscle cannot pump blood effectively enough to meet the body's needs) and asthma (a lung condition that causes inflammation and narrowing of the airways which could lead to shortness of breath, chest tightness and cough). Review of Patient 1's admission and 5-day minimum data set (MDS - a federally mandated resident assessment tool) assessment dated 3/19/2025, indicated Patient 1's brief interview for mental status (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 15 (a score of 13-15, patient is cognitively intact). Review of Patient 1's social services (SS) progress notes dated 4/14/2025, indicated, "...SSM (social services manager) acknowledged and validated resident's concerns as resident reported feeling anxious about some of the nursing staff..." Another review of Patient 1's social services progress notes dated 4/21/2025, indicated, "...Resident reported feeling more sad and uncomfortable over the weekend as a result of the incident that had occurred with one of the CNAs [certified nursing assistant] ...Resident informed SSM that she still feels uncomfortable about the CNA that she was having issues with..." Further review, it indicated the director of nursing (DON) was aware of Patient 1's concern. Review of Patient 1's list of care plans, one care plan indicated, "The resident has a psychosocial well-being problem (Potential) r/t [related to] ...Ineffective coping after resident reported potential instance of abuse from staff," date initiated 4/18/2025. During a concurrent interview with social services manager (SSM) and record review of Patient 1's SS progress notes dated 4/14 and 4/21/2025 on 6/6/2025 at 2:08 p.m., SSM confirmed Patient 1 reported on 4/14/2025 that one of the CNAs helped her with toileting and stated CNA A made Patient 1 uncomfortable when CNA A touched Patient 1's "bottom." The SSM further stated he went to the DON to report Patient 1's allegation and asked the DON how to address the situation. The SSM confirmed the DON decided to remove Patient 1 from CNA A's assignment. The SSM confirmed on 4/21/2025, Patient 1 reported to him again that she felt stress whenever she sees CNA A. The SSM stated he reported Patient 1's concerns to the DON and they have decided to move Patient 1 from the third floor to the fourth floor. The SSM confirmed there was no other follow up or investigation after the alleged abuse report and stated he was not sure if they have to report it to the department (CDPH - California Department of Public Health) or to the Long Term Care Ombudsman (LTC Ombudsman - (an advocate for residents of nursing homes, board and care centers, and assisted living facilities). During an interview with the assistant director of nursing (ADON) on 6/6/2025 at 2:43 p.m., the ADON confirmed Patient 1 reported that a male CNA grabbed her buttocks and they identified the CNA was CNA A. ADON further confirmed they did not report because it was not an abuse, but they reported it to their executive director (ED). ADON stated she was aware that Patient 1 felt uncomfortable when she was touched by CNA A. ADON confirmed they did not suspend CNA A. During an interview with CNA A on 6/6/2025 at 2:59 p.m., CNA A confirmed he did not know that Patient 1 complained about him and stated their DON or ADON did not tell him about it. CNA A confirmed Patient 1 was at risk of falling and needed to be assisted in the bathroom. CNA A stated he helped Patient 1 pulled down her pants in the bathroom and he stated the allegation of abuse did not happen. During an interview with the executive director (ED) on 6/6/2025 at 3:23 p.m., the ED confirmed they did not report the complaint and stated, "I don't think it met the criteria that it should be reported." The ED further stated Patient 1 had a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought) and that was the reason why they did not report the complaint. The ED stated, "our DON should know what to report to your department." The ED confirmed he did not complete an investigation summary related to the complaint. During an interview with the DON on 10/2/2025 at 12:36 p.m., the DON confirmed one of her nurses reported that Patient 1 complained that she was not comfortable with male nurses. The DON stated the CNA only assisted Patient 1 with her activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and held her right hip "only." The DON further stated after she talked to Patient 1, Patient 1 told another nurse and to their physician that a "CNA man" touched her. The DON confirmed they did not report the complaint because Patient 1 couldn't recall when it happened and who did it. The DON stated, "I cannot suspend everybody, and this happened during ADL care." During a phone interview with Santa Clara Ombudsman on 10/2/2025 at 1:49 p.m., the Ombudsman confirmed Patient 1's abuse allegation was not reported to them, and he stated this was concerning. During a review of the facility's policy and procedure titled, "Elder and Dependent Adult Abuse - Skilled Nursing," date revised 5/2025, indicated, " All employees including administrators, supervisors, licensed staff, support and maintenance staff are mandated reporters...The executive director, administrator, director of nursing or designee is responsible for assuring that when there is an allegation of abuse...the allegation is thoroughly investigated. The investigation will include:...Within five working days of the alleged incident the Executive Director, Administrator, or Director of Nursing will give the resident, the resident's representative, the ombudsman, CDPH, accused individuals, etc., a written report of the findings of the investigation and a summary of corrective action taken to prevent such incident from recurring...Reporting shall include immediately notifying the administrator and local law enforcement by telephone, and following up with a completed SOC 341 form to law enforcement, the long term care ombudsman and California Department of Public Health Licensing and Certification Division (CDPH L&C) within 24 hours." This failure resulted in an incident of alleged abuse not being investigated and had the potential to compromise the safety of the patients in the facility. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.