Health inspection·October 24, 2025

F609 42 CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. 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. H&S § 1418.91 (a)A long-term health care facility shall report all incidents of alleged 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 9/5/2025, the California Department of Public Health (CDPH) received a complaint indicating facility staff were not providing proper care for Resident 1. On 9/9/2025 at 11:40 a.m., the CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: 1. Report the Ombudsman's (OMB 1) allegation of the facility's neglect (failure to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress) of Resident 1 to the CDPH. This failure resulted in delayed investigation by the CDPH and placed Resident 1 and other residents in the facility at risk for further neglect. Resident 1 was a 56-year-old male, who was admitted to the facility on 8/11/2025 with diagnoses including hypertension (HTN- high blood pressure), flaccid hemiplegia (condition where one side of the body experiences weakness and loss of muscle tone) and anxiety disorder (mental health condition characterized by excessive worry, fear and nervousness that can interfere with daily life). A review of Residents 1's Minimum Data Set (MDS - a resident assessment tool) dated 8/17/2025, indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 was dependent (staff does all the effort. resident does none of the effort to complete the activity. Or the assistance of two or more staff is required for the resident to complete the activity) for Activities of Daily Living (ADLs) such as toileting hygiene, showering/bathing self, lower body dressing and transfers (the ability to transfer to and from bed to chair). The MDS indicated Resident 1 was always incontinent of urine and bowel and had an unhealed pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence). During an interview on 9/9/2025 at 10:01 a.m. with OMB 1, OMB 1 stated, on 9/8/2025 between 11 a.m. and 12 p.m., Resident 1 reported to her that the facility had not provided him (Resident 1) a shower since he was admitted to the facility on 8/11/2025. OMB 1 stated Resident 1 reported staff had not shaved him, took away his urinal and had not provided him with a urinal for several days (number of days not specified). OMB 1 stated she did not observe a urinal at the bedside, and no one answered the call light when the resident pressed his call light in her presence. OMB 1 also stated she observed Certified Nurse Assistant (CNA) 1 at the nurse's station while the call light was on and did not answer it. OMB 1 stated, she notified CNA 1, Resident 1 needed to be showered, shaved and given a urinal, and CNA 1 told OMB 1, it was not her job, and she was on her way to lunch. OMB 1 stated, CNA 1 dismissed Resident 1's needs stating Resident 1 had dementia (a progressive state of decline in mental abilities) and did not know what he wanted. OMB 1 stated, she reported an allegation of neglect to the Assistant Administrator (AADM) and the AADM notified her (OMB 1), he (AADM) would suspend CNA 1 and complete a report of suspected dependent adult/elder abuse (SOC 341- documentation of information given by the reporting party on the suspected incident of abuse or neglect of an elder or dependent adult). During an interview on 9/9/2025 at 1:22 p.m., with Resident 1, Resident 1 stated CNA 1 told him he did not need a urinal, he could urinate in his diaper and staff would change him. Resident 1 stated CNA 1 also told him she (CNA 1) was the sergeant (military official), and he was supposed to do whatever she told him after he (Resident 1) shared he had been in the military. Resident 1 stated staff did not respond to his call light when he needed assistance (date/time unspecified). Resident 1 stated he wanted to be treated like a human being. Resident 1 stated he notified OMB 1 (of his allegations) and OMB 1 asked CNA 1 to assist him, however, CNA 1 did not want to help. During an interview on 9/9/2025 at 4:00 p.m., with the AADM, the AADM stated OMB 1 reported to him (date unspecified) that OMB 1 pressed the call light in Resident 1's room while CNA 1 was about to go on her break. The AADM stated OMB 1 requested a wheelchair and medication for Resident 1 and CNA told OMB 1 the Social Services could provide the wheelchair and a Licensed Vocational Nurse could provide the medication. The AADM stated OMB 1 told him CNA 1 was neglectful towards her (OMB 1). The AADM stated he suspended CNA 1 because of unprofessionalism. The AADM stated he did not report an allegation of neglect to the CDPH because OMB 1 did not tell him about an allegation of neglect (towards the resident). The AADM also stated, if OMB 1 had informed him Resident 1 was neglected and was not provided with basic needs, he would have reported it (to the CDPH) as indicated in the facility's (Abuse and Neglect Prohibition) policy. During an interview on 9/10/2025 at 3:06 p.m., with CNA 1, CNA 1 stated (on 9/8/2025), OMB 1 stated Resident 1 was being neglected. CNA 1 stated the AADM told her OMB 1 reported her (CNA 1) for neglect. CNA 1 stated the AADM told her (CNA 1) the AADM did not think CNA 1 did any neglect and she was suspended for customer service and not neglect. A review of the facility's P&P titled, "Abuse and Neglect Prohibition Policy," dated 6/2022 indicated upon receiving information concerning a report of suspected neglect, the Administrator or designee should report all alleged violations of immediately, but not later than two hours if the alleged violation involves abuse or within 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury using the SOC 341, to the Licensing and Certification Program District Office. The facility failed to: 1. Report OMB 1's allegation of neglect towards Resident 1 to the CDPH. This failure resulted in delayed investigation by the CDPH and placed Resident 1 and other residents in the facility at risk for further neglect This violation had a direct or immediate relationship to the health, safety, or security of residents.