Health inspection·November 20, 2025

The following reflects the findings of the California Department of Public Health (CDPH) during the investigation of Facility Reported Incident (FRI) number: 2645362. A Class B Citation was written. 22 CR §72523: §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. W&I-15630 (b)(1) A mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that they have experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known, suspected, or alleged instance of abuse by telephone or through a confidential internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an internet report shall be made through the confidential internet reporting tool established in Section 15658, within two working days. (A) If the known, suspected, or alleged abuse occurred in a long-term care facility, except a state mental health hospital or a state developmental center, the following shall occur: (i) If the abuse was allegedly caused by another resident of the facility with dementia diagnosed by a licensed physician and there was no serious bodily injury, the reporter shall submit a written report of the known, suspected, or alleged instance of abuse to both of the following agencies within 24 hours: (I) The long-term care ombudsman. (II) The local law enforcement agency. (ii) In all other instances, immediately or as soon as practically possible, but no longer than two hours, the reporter shall submit a verbal report of the known, suspected, or alleged instance of abuse to the local law enforcement agency, and shall submit a written report to all of the following agencies within 24 hours: On 10/23/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident related to allegation regarding resident to resident abuse. The facility failed to report allegations of physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for Resident 2 to CDPH, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the facility's policy and procedures (P&P) titled, "Abuse Reporting and Prevention" reviewed 7/11/2025, by failing to report the unusual occurrence of a resident-to-resident altercation to the State Survey Agency (SSA) within 2 hours. On 10/15/2025 at approximately 5:30 P.M., Resident 2 reported to the Facility Administrator (FM) that Resident 1 spilled coffee on Resident 2. This deficient practice placed Resident 2 at increased risk for further elder abuse by Resident 1 and delayed onsite inspection by the California Department of Public Health (CDPH) to ensure the resident-to-resident abuse allegation was investigated timely. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on 1/12/2024 with medical diagnoses that included post-traumatic stress disorder (PTSD - a mental health condition that develops after experiencing or witnessing a traumatic event, such as a natural disaster, war, or violent crime), unspecified dementia (a progressive state of decline in mental abilities), and hypertension (HTN - high blood pressure). A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 7/15/2025, indicated Resident 1 had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), was independent with eating, oral hygiene, and required substantial/maximal assistance from staff with activities of daily living (ADL - activities such as bathing, dressing and toileting a person performs daily). A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility on 5/23/2025 with medical diagnoses that included PTSD, bipolar (a mental health condition that causes extreme shifts in mood, energy, and behavior), and diabetes (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 2's MDS dated 9/1/2025, indicated Resident 2 had intact cognition (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), was independent with eating, oral hygiene, and required supervision to partial/moderate assistance from staff with ADL (bathing, dressing and toileting a person performs daily). During a review of the facility's final investigation report dated 10/17/2025, the final investigation report indicated that on 10/15/2025, at approximately 5:30 P.M., Resident 2 reported that Resident 1 became upset during a social interaction during dinner and that Resident 1 spilled coffee onto Resident 2. The final investigation report indicated that the Facility Administrator (FA) and the Assistant Director of Nursing (ADON) both observed that a small area on Resident 2's left jacket sleeve appeared slightly damp (wet). Resident 2 stated he did not feel any pain, burn, or noticeable wetness due to the thickness of his coat (jacket). During an interview on 10/23/2025, at 8:50 A.M., Resident 2 stated that on Wednesday, 10/15/2025, he was in the dining room for dinner when Resident 1 "threw" coffee on him. Resident 2 stated there was a lot of staff (unable to recall names) in the dining room and that one female staff member was present. Resident 2 described the female staff member as in charge of the dining room. Resident 2 stated the female staff member was "black and has straight hair." During an interview on 10/23/2024, at 11:27 A.M., the Activities Director (AD), stated that on Wednesday, 10/15/2025 around 5:30 P.M., during dinner, Resident 2 told her (AD) that Resident 1 threw coffee at him. AD stated that she and the nurses (unable to recall names) went over to the dining table where Resident 2 was seated and that Resident 2 had a wet spot on the resident's left jacket sleeve. The AD stated the charge nurse (unable to recall the name) then took Resident 2 to the resident's room to assess the resident. The AD stated the FA was still in the building at the time and was aware that Resident 1 threw coffee onto Resident 2. During an interview on 10/23/2024, at 1:10 P.M., the FA stated that he was in the building when Resident 2 reported to FA that Resident 1 spilled coffee on Resident 2. FA stated that it was on 10/15/2025, during dinner time, he was making rounds when he saw Resident 2 together with the ADON by the double doors by the front lobby that led into the dining room. The FA stated Resident 2 seemed upset, so he (FA) went to speak with Resident 2. The FA stated he saw a bit of a wet area on Resident 2's jacket sleeve. The FA stated the facility nursing staff assessed Resident 2 and that Resident 2 denied any pain. The FA stated he should have reported the incident between Resident 1 and Resident 2 to the SSA but did not report the incident "because there were no witnesses." A review of the facility's P&P titled, "Abuse Reporting and Prevention" reviewed 7/11/2025, indicated, "The purpose of the policy is to ensure that resident rights are protected by providing a method of investigation and reporting of alleged violations involving mistreatment, neglect, abuse including injuries of unknown sources, unusual occurrences, unauthorized photographs, unauthorized video recordings, unauthorized postings on social media of nursing home residents and misappropriation of resident property. This also includes any physical or chemical restraint not required to treat a resident's symptoms. • A resident-to-resident altercation should be reviewed as a potential situation of abuse. When either or both residents have a cognitive impairment or mental disorder it does not automatically mean that an abuse did not occur. • In accordance with the interpretive guidelines, because all reasonable suspicions of crimes must be reported, regardless of whether it is perpetrated by facility staff, residents, or visitors, it would be especially beneficial for the facility to work with local law enforcement in determining what would not be reported. All alleged violations-Immediately hut not later than 2 hours- If the alleged violation involves abuse or results in serious bodily injury." The facility failed to report allegations of physical abuse for Resident 2 to the Department of Public Health, Ombudsman and to the local law enforcement in accordance with the facility P&P titled, "Abuse Reporting and Prevention" reviewed 7/11/2025, by failing to report the unusual occurrence of a resident-to-resident altercation to the State Survey Agency (SSA) within 2 hours. On 10/15/2025 at approximately 5:30 P.M., Resident 2 reported to the FM that Resident 1 spilled coffee on Resident 2. This deficient practice placed Resident 2 at increased risk for further elder abuse by Resident 1 and delayed onsite inspection by the CDPH to ensure the resident-to-resident abuse allegation was investigated timely. These above violations had a direct relationship to the health, safety, and security of Resident 1.