Health inspection·February 27, 2026

42 CFR §483.12(c) Reporting of Alleged Violations 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. (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. 22CCR §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. HSC 1418.91 (a) Abuse Reporting (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. On 1/23/2026, the California Department of Public Health (CDPH) received a complaint during the facility's annual recertification survey indicating Resident 16 informed a family member that staff members were abusive towards her (Resident 16). On 01/23/2026 at 12:30 p.m., CDPH conducted an unannounced complaint investigation during the annual recertification survey at the facility. The facility failed to: 1. Report an alleged abuse allegation to the CDPH within 2 hours for Resident 16. 2. Follow the facility's policy and procedures (P&P), titled "Abuse Prevention and Management," dated 6/12/2024, which indicated "The Administrator or designated representative will notify law enforcement, by telephone immediately, or as soon as practicably possible, but no longer than (2) hours of an initial report AND send a written SOC341 report to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within (2) hours." This failure resulted in a delay in investigation by CDPH and placed Resident 16 at risk of further abuse. Resident 16 was a 79-year-old female, admitted to the facility on 08/17/2023 with diagnoses including psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with reality), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (apprehensive uneasiness or nervousness usually over an impending or anticipated misfortune) and cerebral infarction (stroke). A review of Resident 16's Minimum Data Set (MDS- a resident assessment tool), dated 12/23/2025, indicated Resident 16's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 16 required maximum assistance (helper lifts or holds trunk or limbs and provides more than half the effort) from staff with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 16's Change of Condition (COC form), dated 11/20/2025, indicated staff noted bruising to the resident's left forearm and hand during rounds. The bruise appeared red to purplish in color with no swelling, open areas, or pain. The COC indicated when Resident 16 was asked what happened, Resident 16 stated "staff beat me" but could not provide names of specific staff members or details of the abuse allegation. The COC indicated Resident 16 frequently banged her bed remote on the bed side rails to gain attention which may contribute to bruising. During an interview on 1/23/2026 at 2:15 p.m. with the Director of Nursing, (DON), the DON stated on 11/20/2025, Resident 16 stated staff had hit her arms. The DON stated she reported the abuse allegation to the Administrator who stated he would report the allegation to CDPH. During an interview on 1/23/2026 at 2:35 p.m. with the Administrator (Admin), the Admin stated he reported Resident 16's November 2025 abuse allegation but could not provide any documentation or evidence to show that the facility reported the incident in a timely manner. The Admin stated he was responsible for reporting abuse allegations within 2 hours. The Admin stated the risk of not reporting abuse allegations in a timely manner could result in further abuse if not reported. A review of the facility's P&P, titled "Abuse Prevention and Management", dated 6/12/2024, indicated "The Administrator or designated representative will notify law enforcement, by telephone immediately, or as soon as practicably possible, but no longer than (2) hours of an initial report AND send a written SOC341 report to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within (2) hours." The facility failed to: 1. Report an alleged abuse allegation to the CDPH within 2 hours for Resident 16. 2. Follow the facility's P&P, titled "Abuse Prevention and Management," dated 6/12/2024, which indicated "The Administrator or designated representative will notify law enforcement, by telephone immediately, or as soon as practicably possible, but no longer than (2) hours of an initial report AND send a written SOC341 report to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within (2) hours." This failure resulted in a delay in investigation by CDPH and placed Resident 16 at risk of further abuse. This violation had a direct or immediate relationship to the health, safety, or security of Resident 16 and other residents in the facility.