Health inspection·December 18, 2025

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §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. §72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 10/8/2025 the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) was being verbally and physically attacked by another resident (Resident 2) on the same day CDPH received a Facility Reported Incident (FRI) reporting that the Director of Nursing (DON) received a report from Resident 1 that Resident 2 tried to throw water on her. On 10/8/2025, CDPH conducted an unannounced visit to the facility to investigate the Complaint allegations and FRI. During the investigation, CDPH determined on 10/7/2025 at approximately 9:30 p.m., Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1, were informed by Resident 1 that Resident 2, who had a history of delusions (unrealistic false or unrealistic beliefs) and wandering, wandered into her roommates (Resident 1) living space, yelled at her, threw water on her and hit her with a water bottle. The facility failed to: 1. Ensure they reported an allegation of abuse to CDPH within two hours of CNA 2 and LVN 1 being made aware of the allegation that Resident 2 wandered into Resident 1's living space, yelled at her, threw water on her and hit her with a water bottle on 10/7/2025. 2. Follow their Policy and Procedure (P/P), titled "Abuse Prohibition" dated 2/23/2021, that indicated upon receiving information concerning a report of suspected or alleged abuse, mistreatment or neglect, the designee will..... report allegations involving abuse (physical, verbal, sexual mental) not later than two hours after the allegation is made, notify local law enforcement, ombudsman, licensing district office, licensing boards, registries and other agencies as required. These deficient practices resulted in CDPH's being unaware of the abuse allegation and the inability to conduct a timely investigation. These deficient practices had the potential for information to be lost and/or forgotten. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on 9/30/2024 and readmitted on 11/5/2024 with diagnoses that included atrial fibrillation ([a-Fib] a heart rhythm disorder), muscle weakness and fractures of the left femur (thigh bone), left tibia (inner bone in lower leg, commonly known as the shinbone) and right arm humerus (upper arm bone). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 10/3/2025, indicated Resident 1 had no cognitive (ability to think and reason) impairment and was understood and could be understood by others. A review of Resident 2's Admission Record (Face Sheet) indicated Resident 2 was admitted to the facility on 9/11/2025, with diagnoses that included dementia (a progressive state of decline in mental abilities), and major depressive disorder ([MDD] a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 10/6/2025, indicated Resident 2 had severe cognitive (ability to think and reason) impairment and was rarely or never understood. The MDS indicated Resident 2 had a history of delusions (unrealistic false or unrealistic beliefs) and physical behaviors (ex: hitting) directed toward others, verbal behaviors (threatening and screaming) directed toward others, and other behavioral symptoms which put others at significant risk for physical injury and other behaviors not directed toward others (ex: pacing and rummaging, verbal/vocal sounds like screaming, disruptive sounds). A review of the Police Department's General Case Report dated 10/9/2025, indicated Resident 1 reported on approximately on 10/6/2025 or 10/7/2025 in the evening, she was lying in bed when she was approached by her roommate (Resident 2), who stood directly in front of her face. The General Case Report indicated Resident 2 grabbed a plastic water bottle and struck Resident 1 on her feet and shin approximately five to ten times. The General Case Report indicated Resident 1 told Resident 2 to stop and yelled to get someone's attention. During an interview on 10/9/2025, at 12:20 p.m., Resident 1 stated on approximately 10/7/2025 sometime in the evening, Resident 2 approached her while she (Resident 1) was lying in bed and hit her on the leg with a water bottle. Resident 1 stated she told Resident 2 to stop but Resident 2 would not listen. Resident 1 stated she yelled for help and pressed the call light, but no one arrived. During telephone interview on 10/10/2025, at 2:30 p.m., CNA 2 stated on 10/7/2025 at approximately 9:45 p.m., she heard a loud noise, and yelling coming from Resident 1 and Resident 2's shared room. CNA 2 stated when she entered the resident's room she observed Resident 2 standing very close to Resident 1. CNA 2 stated Resident 1 appeared very agitated/upset and was saying that Resident 2 was in her space, throwing and hitting her with a water bottle. CNA 2 stated she observed a water pitcher on the ground near Resident 1's bed. CNA 1 stated she did not report the incident to anyone because no one was hurt, and she thought the Administrator (ADM) already knew what was going on between Resident 1 and Resident 2. During an interview on 10/14/2025, at 4 p.m., the Director of Nursing (DON) stated he overheard about the incident between Resident 1 and Resident 2 on 10/8/2025 during a staff huddle. The DON stated LVN 1 should have reported the allegation of abuse to the ADM on 10/7/2025 when she was made aware by Resident 1 that Resident 2 hit her with a water bottle. The DON stated all allegations, and suspected abuse should be reported to the ADM, the police, Ombudsman and CDPH immediately and within two hours. The DON stated failure to report abuse placed Resident 1 at risk for continued abuse, caused a delay and or lack of needed services to Resident 1 and Resident 2, led to a delay in CDPH's investigation, and was a violation of the Federal regulations. During an interview on 10/14/2025 at 4:15 p.m., the ADM stated she was in the building on 10/7/2025 until almost 11 p.m. but was not informed of the incident between Resident 1 and Resident 2 until it was reported to her by the DON on 10/8/2025. The ADM stated the facility was in violation of their policy and Federal regulations for not reporting the alleged incident of abuse between Resident 1 and Resident 2 within two hours of being made aware of it. During a review of the facility's Policy and Procedure (P/P) titled, "Abuse Prohibition Policy and Procedure" dated 2/23/2021, the P/P indicated upon receiving information concerning a report of suspected or alleged abuse, mistreatment or neglect, the designee will perform the following, report allegations involving abuse (physical, verbal, sexual mental) not later than two hours after the allegation is made, notify local law enforcement , ombudsman, licensing district office, licensing boards, registries and other agencies as required. These failures had direct or immediate relationship to the health, safety, or security of Resident 2.