Health inspection·January 22, 2026

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. It was determined that the facility failed to ensure an allegation of physical abuse involving Patient 2 and Patient 3 was reported to the California Department of Public Health (CDPH) immediately or within 24 hours of the incident. The facility was made aware of the alleged physical abuse on November 23, 2025, and was reported to CDPH on December 1, 2025, (eight days after the facility was made aware). This failure had the potential to result in delayed investigation of abuse, delayed implementation of appropriate actions and delayed provision of protection for Patient 2 and had the potential to place the patients at the facility at risk for further abuse. A review of Patient 2’s (alleged victim) “Admission Record,” indicated the patient was admitted on September 19, 2025, with diagnoses of pneumonia (lung infection), lung cancer, and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of Patient 2’s “History and Physical,” dated September 22, 2025, indicated Patient 2 was not capable of understanding and making decisions. A review of Patient 2’s “eINTERACT SBAR (Situation, Background, Action, Recommendation) Summary for Providers,” dated December 1, 2025, at 12:06 p.m., indicated, “The Change In Condition/s (CIC) reported on this CIC Evaluation are/were… Patient's room mate (sic) allegedly flicked his (Patient 2's) head on 11/23/2025. He is safe with no injuries. No concerns or worries. room mate's (sic) bed moved to another room. MD (Medical Doctor) and family aware. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: - Continue with POC (plan of care)…” A review of Patient 3’s (alleged perpetrator) “Admission Record,” indicated the patient was admitted on November 6, 2025, with diagnoses of chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Patient 3’s “History and Physical,” dated November 8, 2025, indicated the patient had the capacity to make decisions. A review of Patient 3’s “Progress Notes,” dated November 23, 2025, at 8 a.m., indicated, “Patient (Patient 3) hit another Patient (Patient 2) on the head for being 'too noisy'. Client educated on the importance of hitting or coming into contact with another resident. Patient reported ‘he (referring to Patient 2) is lucky I didn't kick his ass’. Patient (Patient 3) again educated. Patient reported he ‘flick the other Patient (Patient 2) on the head to quiet him’…” A review of Patient 3’s “eINTERACT SBAR Summary for Providers,” dated December 1, 2025, at 12:45 p.m., indicated, “Situation: The Change In Condition/s reported on this CIC Evaluation are/were… Alleged physical aggression, flicking roommates head with his fingers one time. This happened on 11/23/25 and was documented but not reported. Patient room changed for his safety and that of room mates (sic) on 12/1/2025. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: - Continue monitoring- Psych consult…” On December 9, 2025, at 11:52 a.m., An attempt was made to interview Patient 2; however, the patient (Patient 2) did not respond to verbal questions. On December 9, 2025, at 12:18 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1, and she stated an allegation of abuse would be reported to the Administrator and the Director of Nursing (DON) within two hours. LVN 1 stated that an allegation of abuse would require a room change to separate the patients involved, documentation of a change in condition, notification to the physician, and an update to the care plan. On December 9, 2025, at 12:32 p.m., an interview was conducted with Patient 3. Patient 3 stated that back in November 2025, a patient (referring to Patient 2) was reaching for the television remote and was reaching towards his bed, so he flicked him (Patient 2) in the head. Patient 3 stated that he did not hurt him (Patient 2) and felt it was ridiculous that the facility reported the incident. Patient 3 stated there were no witnesses to the event. On December 9, 2025, at 3:01 p.m., an interview was conducted with the DON. The DON stated that on December 1, 2025, the Social Service Director (SSD) reported an incident involving Patient 2 and Patient 3 which was documented on November 23, 2025, in Patient 3’s progress notes. The DON confirmed that the incident (referring to the alleged physical abuse involving Patient 2 and Patient 3) should have been reported within two hours to the state survey agency, to the Ombudsman, and to the police department. The DON stated that they did not report the alleged physical abuse timely. On December 18, 2025, at 12:38 p.m., a phone interview was conducted with the SSD. She said that on December 1, 2025, while reviewing Patient 3’s notes, she discovered an incident of alleged physical abuse involving Patient 2 on November 23, 2025, at 8 a.m., and reported it to the DON. The SSD stated the incident involving Patient 2 and Patient 3 was reported to the state agency on December 1, 2025. On December 18, 2025, at 12:51 p.m., an interview was conducted with LVN 3. She reported that on November 23, 2025, at 8 a.m., a CNA informed her of an incident between Patient 3 and Patient 2. Patient 3 admitted to flicking Patient 2 in the head, but Patient 2 had no injuries. LVN 3 was unaware that abuse allegations must be reported within two hours. A review of the facility’s policy and procedure titled, “Compliance with Reporting Allegations of Abuse/Neglect/Exploitation,” revised December 19, 2022, indicated “…Reporting/Response: The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation…When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated… a. Respond to the needs of the patient and protect him/her from further incidents; b. Remove the accused employee from patient care areas; c. Notify the Administrator or designee... The Administrator or designee will: a. Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery or forming the suspicion…” Based on interview and record review, it was determined that the facility failed to ensure an allegation of physical abuse involving Patient 2 and Patient 3 was reported to the CDPH immediately or within 24 hours of the incident. The facility was made aware of the alleged physical abuse on November 23, 2025, and was reported to CDPH on December 1, 2025, (eight days after the facility was made aware). This failure had the potential to result in delayed investigation of abuse, delayed implementation of appropriate actions and delayed provision of protection for Patient 2 and had the potential to place the patients at the facility at risk for further abuse. The violation of the above regulations had a direct relationship to the health, safety, or security of Patient 2.