Health inspection·November 20, 2025

The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint number: 2640320. A State Citation B was written. Regulation Violations: California Code Health and Safety Code: Section 1418.91. 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. Title 22 CCR § 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. Title 22 CCR § 72315 Nursing Service--Patient Care. (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. Title 22 CCR § 72527 Patients' Rights (a)Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. On 10/22/2025 the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding the facility's failure to accommodate Resident's needs. Upon arrival, during record review, it was noted that the Social Services notes dated 9/30/2025 at 1 pm, indicated, "SSD called up the Adult Protective Services [APS] and spoke with Social Worker [APS SW] regarding this resident [Resident 1] and the situation of suspected elderly abuse involving Family Member (FM) 1. No one reported this allegation of elderly abuse to CDPH. The facility failed to follow its policy and procedures (P&P) by failing to ensure suspicions of abuse was reported to CDPH immediately or within at two hours. As a result, Resident 1 was potentially subjected to continuous abuse by allowing the alleged perpetrator full access to Resident 1 and there was a delay in the investigation of the alleged abuse. During a review of Resident 1's admission record, the facility initially admitted Resident 1 on 3/9/2023 and readmitted her on 4/22/2025 with diagnoses including dementia chronic kidney disease (CKD), hypertension (HTN- high blood pressure), and history of urinary tract infections (UTI - an infection in the bladder/urinary tract). During a review of the General Acute Care Hospital (GACH) internal medicine progress note dated 7/7/2023, indicated Resident 1 was admitted to GACH on 7/7/2023 for a UTI. The same progress note indicated under assessment plan concern for elder abuse by Power of Attorney (FM 1). The same noted indicated there was no need for suppositories (solid medicated object shaped like a cone inserted into the rectum) at the time unless there was a clinical need. The same note indicated Resident 1 was reporting ongoing rectal pain and chronic vaginal pain. During a review of Resident 1's history and physical (H&P-a term used to describe a physician's examination of a patient) dated 4/23/2025 indicated Resident 1 had the capacity to make decisions. During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 7/3/2025 indicated Resident 1 had moderate cognitive impairment (a stage of cognitive decline that affects short-term memory and the ability to complete complex tasks). The same MDS indicated Resident 1 was required to have supervision or touching assistance for eating and partial/moderate assistance for all other Activities of Daily Living such(ADLs- routine tasks/activities such as, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a review of the GACH physician progress notes dated 7/10/2023 at 4:04 pm, the notes that Resident 1 reported loose bowel movements and agreed that she did not need more bowel regimen (medications used to relieve constipation such as suppositories). The same progress note indicated that Resident 1 tried to explain to Family Member (FM 1) but he (FM 1) was not listening to her (Resident 1). During a review of the Social Services (SS) notes dated 9/29/2025 at 5:10 pm, the notes indicated, "SSD [Social Services Director] and DSD [Director of staff Development] went to speak with resident (Resident 1) about concerns brought up by the CNAs [Certified Nursing Assistants] r/t [related to] perineal care [the cleaning and maintenance of the perineum, area between the anus and the genitals] and how they are getting specific instructions from Family Member (FM) 1 on how to do it which is in contradiction to the common practice and protocol taught from nursing school. FM 1 is instructing the CNAs insert their finger in resident's vagina and anus when cleaning her [Resident 1] this is becoming an issue that was raised to the attention of the supervisors." The same progress note indicated that Resident 1 was asked if FM 1 was cleaning her (Resident 1) the way FM 1 was directing the CNAs to clean her of which she confirmed that FM 1 was performing the same procedure in private and that she did not like it. During a review of SS notes dated 9/30/2025 at 1 pm, indicated, "SSD called up the Adult Protective Services [APS] and spoke with Social Worker [APS SW] regarding this resident [Resident 1] and the situation of suspected elderly abuse involving FM 1. Social worker is familiar with the allegation since she was the same case worker who handled the same report of suspected abuse filed by the hospital." The APS SW had asked the facility SW about the facility protocols on the matter of which the facility SW responded that reporting to APS was one of them. During a review of the nursing note entered by the RNS dated 10/13/2025 at 12:30 am, the noted indicated, "At 00:15hrs writer heard resident screaming very loudly+++ from her [Resident 1] room and immediately entered to assess the situation. Upon entering, writer observed the FM 1, wearing gloves and the resident's [Resident 1] brief [incontinence brief, are disposable absorbent garments designed to manage urinary and/or fecal incontinence] was undone. FM 1 stated he was "just changing her" and explained that the resident was screaming due to leg pain. Writer asked the resident [Resident 1] if she was okay and what was happening, but the resident did not respond. To prevent further discomfort or pain to the resident, writer offered to have nursing staff assist with the brief change. Both FM 1 and the resident [Resident 1] agreed. Two CNAs entered the room and proceeded to change the resident's brief. Writer remained present throughout the entire process, including repositioning. During the care, FM 1 repeatedly made inappropriate comments, demanding that the CNAs insert their fingers into the resident's vagina. Both CNAs and writer firmly responded that such actions were inappropriate and outside the scope of practice. Despite being told no, FM 1 continued to make the demand and attempted to physically intervene during the care process. Writer informed FM 1 that if he could not follow facility protocols and continued to interfere with the CNAs' care, he would be asked to leave. Before writer and CNAs exited the room, FM 1 began to undo the sheets and attempted to change the resident's brief again. When asked why, FM 1 states it is because the CNAs did not insert their fingers into the resident's vagina. Will continue to monitor resident for safety." During an interview with CNA 1 on 10/22/2025 at 10:08 am, CNA 1 stated that FM 1 was very involved in Resident 1's care such as he (FM 1) demanded that staff changed Resident 1's incontinence briefs even when she complained that she did not wish to be changed at the time. During an interview with the Medical Director (MD) on 10/22/2025 at 1:40 pm, the MD confirmed that FM 1 displayed strange behaviors and requests such as requesting staff to insert fingers in Resident 1's vagina and rectum which is considered abuse, which is why the facility had reported it to the ombudsman. During an interview with the Registered Nurse Supervisor (RNS) on 10/22/25 at 2:16 pm, RNS confirmed that on 10/13/2025 at 12:15 pm, he (RNS) heard screaming coming from her (Resident 1) room. RNS found FM 1 wearing gloves with briefs undone and Resident 1's incontinence briefs open. FM 1 quickly stated that Resident 1 was screaming because her (Resident 1) legs hurt. RNS stated that Resident 1 did not scream when the CNAs were changing her. RNS stated that FM 1 usually came to the facility with his suppositories and inserts them without informing the nursing staff and had been overheard telling Resident 1 her (FM 1) that if she (Resident 1) did not allow him (Resident 1) to insert the suppository, then FM 1 would stop taking care of her. RNS stated that the incident should have been reported to administration. The RNS was unable to state if this was an abuse or not. During an interview with the SSD on 10/22/2025 at 2:51 pm, the SSD stated that there had been some concerns from the CNAs that the son was giving specific instructions which were not in accordance with professional nursing standards such as directing them to insert fingers with towel in the anus and vagina. The CNAs had not been complying with the instructions because of infection concerns. FM 1 had been yelling at the staff and ended up doing it himself. The SSD stated that she had reported it to the APS SW as well as to the Ombudsman. During an interview and a concurrent record review with the Director of Nursing (DON), on 10/22/2025 at 3:14 pm, the SS noted was reviewed. The DON stated there were no concerns about the way FM 1 was requesting to have the perineal care to be completed. The DON stated that FM 1 preferred to be present when staff were performing care. The DON stated that she (DON) considered the requests to have staff or FM 1 insert fingers in Resident 1's private parts to be part of their relationship and was ok with it. The SS Note dated 9/29/2025 at 5:10, the Note indicated that Resident 1 did not like to have fingers inserted in her private parts. The DON was unable to define abuse and/or if the incidents needed to be reported to the State licensing/certification agency as indicated in the facility's policy regarding abuse. The DON further stated that the importance of reporting abuse to the State Licensing and Certification agency was to ensure that it was investigated and prevent further exposure of the affected resident from the perpetrator. During a review of the facility's P&P titled, "Abuse Investigation and Reporting," revised 1/29/2025, the P&P indicated, "All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ("abuse") shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported." The same P&P indicated reporting the following: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: • The State licensing/certification agency responsible for surveying/licensing the facility. • The local/State Ombudsman. • The Resident's Representative (Sponsor) of Record. • Adult Protective Services (where state law provides jurisdiction in long-term care); • Law enforcement officials. • The residents' Attending Physician; and • The facility Medical Director. The facility failed to follow its P&P by failing to ensure suspicions of abuse was reported to CDPH immediately or within at two hours. As a result, Resident 1 was potentially subjected to continuous abuse by allowing the alleged perpetrator full access to Resident 1 and there was a delay in the investigation of the alleged abuse. The above violation had a direct relationship to the health, safety, and security of Resident 1.