Other·May 27, 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 CFR § 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. HSC § 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. On 4/2/2026, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate an allegation indicating Resident 2 scratched Resident 1's face. The facility failed to: Follow its Policy and Procedure (P&P) titled, "Abuse Investigation and Reporting" which indicated all alleged violations involving abuse or mistreatment, including injuries of unknown source will be reported by the Administrator (ADM) or his/her designee to the state licensing/certification agency immediately, but no later than two hours when: 1. On 3/10/2026, Resident 3 slapped Resident 2 who was sitting in a chair in the hallway. 2. On 3/14/2026, Resident 3 swung her purse and hit Resident 1. 3. On 3/25/2026, Resident 3 hit Resident 1. 4. On 3/31/2026, Resident 2 scratched Resident 1's face while Resident 1 was entering the dining room. This failure resulted in a delay in the investigation by the CDPH and placed Resident 1, Resident 2 and Resident 3 at risk for continued abuse and injuries. Resident 1 was a 90-year-old female, originally admitted to the facility on 3/14/2024 and readmitted on 2/11/2026. Resident 1's diagnoses included pneumonia (an infection/inflammation in the lungs), presence of cardiac pacemaker (a small, implanted device that regulates the heart rate) and a displaced intertrochanteric fracture (broken bone) of the right femur (hip bone). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/17/2026, indicated Resident 1 had moderate cognitive (ability to think and reason) impairment, had clear speech and was able to understand others. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with oral hygiene, dressing, showering/bathing self, bed mobility (the ability to roll on back to left and right side, and return to lying on back on the bed) and transfers (the ability to transfer to and from a bed to a chair. A review of Resident 1's Situation, Background, Assessment, Recommendation Communication Form (SBAR- a communication tool used by healthcare workers when there is a resident change in condition) dated 3/14/2026, indicated Resident 1 reported to the facility that a resident with dementia (a progressive state of decline in mental abilities [Resident 3]) hit her (Resident 1) with a purse. The SBAR indicated Resident 1 did not have any injuries. The SBAR did not indicate the incident was reported to the CDPH. A review of Resident 1's SBAR dated 3/25/2026, indicated Resident 1 had an altercation with another resident (Resident 3). The SBAR indicated Resident 3 was noted hitting Resident 1. The SBAR did not indicate the incident was reported to the CDPH. A review of Resident 1's SBAR dated 3/31/2026, indicated another resident (Resident 2) scratched Resident 1's face while Resident 1 was entering the dining room. The SBAR indicated Resident 1 sustained superficial (located on the surface) wounds to the chin and lip. The SBAR did not indicate the incident was reported to the CDPH. During a concurrent observation and interview on 4/13/2026 at 11:30 a.m., with Resident 1, Resident 1 was observed with a red scratch on her chin. Resident 1 stated Resident 2, who had long fingernails scratched her (Resident 1's) face. Resident 1 stated the incident occurred on 3/31/2026 while she (Resident 1) was trying to go into the activities room and Resident 2 was leaving the activities room. Resident 2 was a 79-year-old female, admitted to the facility on 1/21/2024 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), dementia and hypertension (high blood pressure) A review of Resident 2's MDS dated 1/28/2026, indicated Resident 2 had severe cognitive impairment, had clear speech and was able to understand others. The MDS indicated resident 2 required partial/moderate assistance from staff with personal hygiene, lower body dressing, showering/bathing self, and bed mobility. A review of Resident 2's SBAR dated 3/10/2026, indicated Resident 3 passed by Resident 2 in her wheelchair and slapped Resident 2 on the right shoulder while the resident was sitting in a chair in the hallway. The SBAR indicated Resident 2 did not have any visible injuries. The SBAR did not indicate the incident was reported to the CDPH. A review of Resident 2's SBAR dated 3/31/2026, indicated Resident 3 had aggressive behavior and scratched another resident (Resident 2) while exiting the activities room. The SBAR indicated staff immediately separated the residents and the physician was made aware. The SBAR did not indicate the incident was reported to the CDPH. Resident 3 was a 91-year-old female, originally admitted to the facility on 5/26/2025 and readmitted on 4/3/2026. Resident 3 diagnoses included dementia, metabolic encephalopathy (occurs when the brain has trouble working because of a chemical or metabolic problem in the body), and urinary tract infection (UTI- an infection in the bladder/urinary tract). A review of Resident 3's MDS dated 3/5/2026, indicated Resident 3 had severe cognitive impairment, and was sometimes able to understand others. The MDS indicated Resident 3 required partial/moderate assistance from staff with personal hygiene, dressing, transfers and walking. A review of Resident 3's SBAR dated 3/10/2026, indicated Resident 3 hit Residents (Resident 2) and staff. The SBAR did not indicate the incident was reported to the CDPH. A review of Resident 3's SBAR dated 3/14/2026, indicated another resident (Resident 1) reported to the facility that Resident 3 hit Resident 1 with her purse. The SBAR indicated the physician, police and Resident 3's responsible party were notified. The SBAR did not indicate the incident was reported to the CDPH. A review of Resident 3's SBAR dated 3/25/2026, indicated staff witnessed Resident 3 strike/hit another resident (Resident 1). The SBAR indicated the physician was contacted. The SBAR did not indicate the incident was reported to the CDPH. During a concurrent interview and record review on 4/13/2026 at 12:49 p.m., with Registered Nurse (RN) 1, All Facilities Letter (AFL- a letter from the Center for Health Care Quality [CHCQ], Licensing and Certification [L&C] Program to health facilities that are licensed or certified by L&C with information that include changes in requirements in healthcare, enforcement or general information that affects the health facility) 24-09 titled, "Assembly Bill (AB) 1417- Elder and Dependent Adult Abuse Mandated Reporting" dated 2/28/2024 was reviewed. AFL 24-09 indicated facilities are required to provide written notice to the appropriate state agency for incidents resulting in physical harm immediately or as soon as possible, but not later than two hours after the incident occurred. RN 1 stated on 3/31/2026, Resident 1 and Resident 2 had an altercation and Resident 2 scratched Resident 1's face. RN 1 stated she reported the incident to the police and Ombudsman. She did not report the incident to the CDPH. RN 1 stated the (abuse) incident involving Resident 1 and Resident 2 should have been reported to the CDPH within two hours because Resident 1 sustained a scratch to her face. During an interview on 4/15/2026 at 9:35 a.m., with the ADM, the ADM stated the incidents (on 3/10/2026, when Resident 3 slapped Resident 2, on 3/14/2026 when Resident 3 hit Resident 1 with a purse, on 3/25/2026 when Resident 3 hit Resident 1) were not reported to the CDPH because Resident 3 had dementia and according to AFL 24-09, it was her understanding, that the incidents did not need to be reported. A review of AFL 24-09 titled, "Assembly Bill (AB) 1417- elder and Dependent Adult Abuse Mandated Reporting" dated 2/28/2024, indicated Certified facilities must continue to report incidents of abuse pursuant to title 42 of the code of Federal Regulations section 483.12(c)(1). The AFL indicated the facilities are responsible for following all applicable laws. The CDPHs failure to expressly notify facilities of statutory or regulatory requirements do not relieve facilities of their responsibility to comply with all laws and regulations. A review of the facility's undated P&P titled, "Abuse Investigation and Reporting," indicated all allegations of resident abuse, neglect, mistreatment and/or injuries of unknown source ("Abuse") shall be promptly reported to the appropriate local, state and/or federal agencies (as defined by current regulations). All alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source will be reported by the ADM. or his/her designee, to the state licensing/certification agency responsible for surveying/licensing the facility immediately but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury. The facility failed to: Follow its P&P titled, "Abuse Investigation and Reporting" which indicated all alleged violations involving abuse or mistreatment, including injuries of unknown source will be reported by the ADM or his/her designee to the state licensing/certification agency immediately, but no later than two hours when: 1. On 3/10/2026, Resident 3 slapped Resident 2 who was sitting in a chair in the hallway. 2. On 3/14/2026, Resident 3 swung her purse and hit Resident 1. 3. On 3/25/2026, Resident 3 hit Resident 1. 4. On 3/31/2026, Resident 2 scratched Resident 1's face while Resident 1 was entering the dining room. This violation had a direct or immediate relationship to the health, safety, or security of residents.