Other·May 4, 2026

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (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. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. 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. 22 CFR § 72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be implemented to ensure that patient related goals and facility objectives are achieved. §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. (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. HSC 1418.91 (a) A long-term health care facility shall report all incident of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) Failure to comply with the requirements of this section shall be a class "B" violation. On 3/19/2026, the California Department of Public Health (CDPH) conducted an unannounced visit to investigate verbal altercation (clash, refers to shouting or angry words) between the Social Services Director (SSD) and Resident 1. The facility failed to: 1). Investigate and report to the CDPH the verbal altercation between the SSD and Resident 1 on 2/3/2026. This failure delayed the investigation by the CDPH and placed Resident 1 and other residents at risk for verbal abuse. Resident 1 was a 60-year-old female, admitted to the facility on 8/20/2025. Resident 1's diagnoses included morbid (severe) obesity due to excess calories (chronic disease characterized by having excessive body fat that poses an immediate, serious risk to health, resulting from consistently consuming more energy than the body burns) and hypertension (high blood pressure). A review of Resident 1's History and Physical (H&P) dated 8/20/2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/2/2025, indicated Resident 1 was able to understand and be understood by others. Resident 1 required setup or clean-up assistance for eating and oral hygiene. Resident 1 was dependent (Helper does all of the effort) with toileting hygiene, lower body dressing and in putting on/taking off footwear. Resident 1 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/ bathing self. Resident 1 required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with upper body dressing and personal hygiene. A review of Resident 1's Progress Notes dated 2/3/2026 at 4:16 p.m., indicated the SSD asked Resident 1's Family Member (FM) 1 to put on a face mask before entering Resident 1's room. Resident 1 asked the SSD if there was an outbreak, but SSD stated she could not disclose that information. Resident 1 became very upset and started yelling at the SSD for not disclosing the information. While the SSD was exiting Resident 1's room, and overheard Resident 1 call her a bitch, the SSD walked back to Resident 1's room and asked Resident 1 why she called her a bitch. A review of Resident 1's progress notes did not indicate documentation that an investigation was conducted regarding the SSD and Resident 1's verbal altercation on 2/3/2026. During an interview on 3/19/2026 at 12:23 p.m., Resident 1 stated on 2/3/2026, FM 1 visited and entered the resident's room without a face mask. Resident 1 stated, the SSD entered her (Resident 1) room and told FM1 to wear a mask because of an outbreak. Resident 1 stated she asked the SSD the type of outbreak and the SSD responded, "not to worry about it because she (Resident 1) was going to leave anyway." Resident 1 stated she had had multiple incidents with the SSD before (not specified) and the SSD was not supposed to enter her room. Resident 1 stated she called the SSD a bitch and the SSD did not like that. Resident 1 stated the SSD tried to come back inside her room. The SSD waved her arms, yelling and asking why she (Resident 1) called her a bitch. Resident 1 stated she felt threatened when the SSD seemed like she wanted to fight her. The SSD had no professionalism and no sense of respect to someone who was bedridden. During an interview on 3/19/2026 at 9:11 a.m., with Registered Nurse (RN) 1, RN 1 stated Resident 1 reported the SSD's behavior was threatening and unprofessional towards her (Resident 1). RN 1 stated she got in between Resident 1 and SSD to calm the situation. During an interview on 3/20/2026 at 10:10 a.m., with RN 2, RN 2 stated she reported the altercation between the SSD and Resident 1 to the Administrator (ADM) but did not report the incident to the CDPH. During an interview on 3/24/2026 at 3:10 p.m., the ADM stated on 2/3/2026 she did not conduct an investigation regarding the verbal altercation between SSD and Resident 1 because she discussed the incident with Resident 1 and agreed to put it as a grievance. The ADM stated if there was a report regarding Resident 1 fearful or threatened, she (ADM) would have reported the incident to the CDPH. The ADM stated if an abuse allegation was not reported, it could affect the resident's wellbeing, mental state and cause a repetitive abuse if exposed to abuser. A review of the facility's undated policy and procedure (P&P) titled, "Abuse, Neglect & Exploitation Prohibition," indicated the facility will conduct an investigation of any alleged abuse, all patterns, trends or incidents that suggest the possible presence of abuse, in accordance with state law. The P&P indicated the facility should report all abuse allegations to the State agency as designated by state law. The facility failed to: 1). Investigate and report to the CDPH the verbal altercation between the SSD and Resident 1 on 2/3/2026. This failure delayed the investigation by the CDPH and placed Resident 1 and other residents at risk for verbal abuse. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to the resident.