Health inspection·December 18, 2025

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. CCR §72523 – Patient Care Policies and Procedures (a) 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. On 10/21/2025 the California Department of Public Health (CDPH) received a complaint regarding resident (Resident 1) abuse. On 10/22/2025 CDPH conducted an unannounced complaint investigation at the facility to investigate the abuse allegation. CDPH determined the facility failed to implement its policy and procedure (P/P) titled, “Abuse Policy – Prevention, Reporting and Correction of Inappropriate Conduct including Abuse, Neglect and Mistreatment, including injuries of unknown origin” revised October 2024, by not immediately reporting an abuse allegation about certified nursing assistant (CNA) 1 rough handled Resident 1 while providing care, to CDPH, the State Long Term Care Ombudsman (a resident advocate) and local authorities within the regulated time frame of two hours. This deficient practice resulted in CDPH’s inability to investigate the allegations of abuse timely and placed facility residents, including Resident 1, at risk for potential continued abuse, injuries, and psychosocial harm.   A review of Resident 1's Admission Record indicated Resident 1 an 88-year-old female was admitted to the facility on 9/11/2025 with diagnoses including kidney failure and chronic heart failure. A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 9/17/2025, indicated Resident 1 had moderate cognitive impairment, was independent when eating, required moderate assistance from staff with oral hygiene and upper body dressing, required maximal assistance form staff with toileting and bathing, and was dependent on staff with lower body dressing. During an interview on 10/22/2025 at 8:26 a.m., Resident 1’s responsible party (RP) stated that on 10/19/2025 at approximately 11:30 a.m., she (RP) reported to Licensed Vocational Nurse (LVN) 1 that on 10/18/2025 at approximately 1 a.m., CNA 1 roughly pinned and forcefully turned Resident 1, while providing care. The RP stated no one followed up with her regarding her allegation of abuse. The RP stated she again reported the allegation to Registered Nurse (RN) 1 and the Administrator on 10/20/2025 at approximately 11 a.m. During an interview on 10/22/2025 at 1:07 p.m., LVN 1 stated on 10/19/2025 at approximately 1 p.m., Resident 1’s RP told her about CNA 1 rough handling Resident 1 on 10/18/2025. LVN 1 stated she did not report this abuse to the Administrator (ADM) or Director of Nursing (DON) “because at that time of the night, they would not have picked up the phone.” During an interview on 10/22/2025 at 3:45 p.m., the ADM stated allegations of rough handling should be investigated as abuse. The administrator stated abuse allegations should be reported immediately, but no later than two hours to CDPH, the Ombudsman, and the police department. The Administrator stated he was the abuse coordinator, and the staff were instructed to report all abuse allegations immediately. The Administrator stated the RP informed him of the abuse allegation that occurred on 10/19/2025 during the 11 p.m. to 7 a.m. shift on 10/20/2025 at approximately 11 a.m. and he faxed the report to CDPH on 10/20/2025 at 5:15 p.m. (approximately 18 hours after the allegation occurred). The Administrator stated it was important to report alleged abuse within two hours to protect the resident and investigate timely.   During an interview the Chief Clinical Officer (CCO), stated LVN 1 was aware of the allegation of rough handling on 10/19/2025, and did not report the alleged abuse on 10/19/2025. The CCO stated the alleged abuse should have been reported within two hours on 10/19/2025. The CCO stated it was important to report alleged abuse within two hours to ensure the facility takes proper precautions to maintain an abuse free environment for all residents.    During a review of the facility’s P&P, titled Abuse Policy – Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown origin, revised October 2024, the P&P indicated It is the policy of this facility that “abuse,” allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property) are reported per federal and state law (including to the state Survey Agency, Long Term Ombudsman and Adult Protective Services if applicable). The facility will ensure that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknow origin and misappropriation of resident property, are reported immediately, but not later than two (2) hours after the allegation is made. In addition, local law enforcement will be notified of any suspicion of a crime against a resident in the facility. The facility failed to implement its P/P titled, “Abuse Policy – Prevention, Reporting and Correction of Inappropriate Conduct including Abuse, Neglect and Mistreatment, including injuries of unknown origin” revised October 2024, by not immediately reporting an abuse allegation about CNA 1 rough handled Resident 1 while providing care, to CDPH, the State Long Term Care Ombudsman and local authorities within the regulated time frame of two hours. This deficient practice resulted in CDPH’s inability to investigate the allegations of abuse timely and placed facility residents including Resident 1 at risk for potential continued abuse, injuries, and psychosocial harm. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1.