Health inspection·December 31, 2025

Citation B was written REGULATORY VIOLATIONS: 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. On 10/29/25 an unannounced visit was conducted at the facility to investigate a complaint regarding resident/patient/client abuse. The facility failed to implement their abuse policy and procedure for one of three sampled patients (Patient 1) when the facility did not report Patient 1's allegation of abuse to required agencies (California Department of Public Health [CDPH], law enforcement agency, and Long-Term Care Ombudsman) timely. This failure resulted in Patient 1's allegation of abuse not being reported timely to the required agencies California Department of Public Health (CDPH), law enforcement agency, and Long-Term Care Ombudsman. This failure had the potential to compromise the safety of the patients in the facility. Findings: Review of Patient 1's clinical record titled, "Face sheet (document that summarizes a person's information such as medical history) indicated Patient 1 was admitted to the facility on 10/1/25 with diagnoses including Idiopathic Progressive Neuropathy (rare condition characterized by progressive damage to the peripheral nerves, the nerves outside the brain and spinal cord) and Depression (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities once enjoyed), unspecified. Review of Patient 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) assessment dated 10/4/2025, indicated Patient 1's brief interview for mental status (BIMS, an assessment to test a person's cognition level) score was 15 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). A review of Patient 1's progress note dated 10/16/25 indicated, "...Resident [Patient 1] calls CNA (Certified Nursing Assistant) stupid 3x, fabricating stories that she did not receive her dinner and fabricating stories that CNA hit her... resident fabricating stories that CNA said "[F*** ***]" and spat on resident and states front desk told resident "[F*** ***]" a well... Resident consistently refusing help from CNA, CNA went to clean resident's dirty brief to keep her clean and sitter was walking by doing her rounds, sitter walked into room and saw CNA cleaning resident nicely and speaking to her with a helpful tone, resident was shouting and screaming that she was hit. Sitter witnessed and confirmed resident was not hurt in any way and fabricating stories. Notified DON (Director of Nursing) and DSD (Director of Staff Development), desk nurse is aware and called sister to speak to resident to come visit tomorrow and talk to resident about behavior..." During an interview on 10/29/25 at 12:59 p.m., with Patient 1, Patient 1 stated that on 10/16/25 this Lady Certified Nursing Assistant (CNA) A was changing her diaper around 9:00 p.m., she told CNA A she is dry, CNA A changed her anyway, Patient 1 stated CNA A pushed her, hit her stomach and grabbed her left leg and foot. Patient 1 stated she screamed too loud for help no one came. Patient 1 stated CNA A showed middle finger and said "F" word to her. Patient 1 further stated she told the supervisor and told everyone about the CNA A name. During an interview on 10/29/25 at 2:35 p.m., with Licensed Nurse (LN) B, LN B stated it was her first time hearing Patient 1 to accuse the CNA. LN B stated Patient 1 was saying the CNA punched her in the stomach that time and was being rude to her. LN B stated Patient 1 accused the assigned CNA to her which was CNA A. LN B stated it happened on 10/16/25 after dinner, LN B further stated she didn't hear if it was reported. During a review of Patient 1's progress notes dated 10/16/25 to 10/25/25 indicated no documentation "that CNA hit her" was reported to CDPH and Ombudsman. During a concurrent interview and record review on 10/29/25 at 3:03 p.m., with the Director of Nursing (DON), the DON reviewed Patient 1's progress note dated 10/16/25, she stated she received a text message from LN B claiming Patient 1 was hit by CNA A. The DON stated there was another staff member inside the room and CNA A did not hit Patient 1. The DON stated it was not reported to CDPH and Ombudsman. The DON further stated Patient 1 makes fabrications about not getting food, medication, and staff not changing her. The DON also stated 10/16/25 she believes is the first time Patient 1 made an allegation about somebody hitting her. During a Review of Nursing Staffing Assignment/Room Assignment indicated CNA A worked from 10/15/25 to 10/18/25 and on 10/16/25 at 3 p.m. to 11 p.m. CNA A was assigned to Patient 1. During a phone interview on 10/31/25 at 12:47 p.m. with the DON, the DON stated the abuse allegation from Patient 1 was reported only on 10/29/25 to the State Department (CDPH, California Department of Public Health) after surveyor started the investigation. The DON confirmed CNA A worked from 10/15/25 to 10/18/25 and on 10/16/25 CNA A was assigned to Patient 1. The DON further stated CNA A was not suspended. During a review of facility's policy and procedure (P&P) titled, " Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating " Revision date April 2021, the P&P indicated, "Policy Statement: 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. Reporting Allegations to the Administrator and Authorities: 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... 3."Immediately" is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Investigating Allegations: 1. All allegations are thoroughly investigated. The administrator initiates investigations... 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete...." This failure had the potential to compromise the safety of the residents in the facility. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.