Health inspection·March 20, 2026

F609 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual’s obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(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. §483.12(c)(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 §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 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 2/2/2026, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint and a facility-reported incident regarding an allegation of employee-to-resident physical abuse. The facility failed to report an allegation of employee-to-resident abuse involving Resident 2 within two hours to the State Survey Agency (SSA- the agency that inspects long-term care facilities for the purposes of survey and certification), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement (LLE) agency in accordance with its abuse policy. On 1/6/2026, following a shower, Student 1 reported to Certified Nursing Assistant 2 (CNA 2) that Certified Nursing Assistant 1 (CNA 1) had slapped Resident 2 in the face. As a result, Resident 2 was placed at an increased risk for further abuse, which could have led to additional unreported incidents and a failure to protect residents from potential harm. A review of Resident 2‘s Admission Record indicated the facility admitted Resident 2, an 84-year old female, on 9/12/2025, with diagnoses that included unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities), Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities), and generalized weakness. A review of Resident 2’s History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 9/13/2025, indicated Resident 2 did not have the capacity to understand and make decisions. A review of Resident 2’s Minimum Data Set (MDS- a resident assessment tool), dated 12/15/2025, indicated Resident 2 had the ability to sometimes understand others and make self-understood. The MDS indicated Resident 2 required supervision from staff with toileting and showering. A review of Resident 2’s Progress Notes, dated 1/6/2026, indicated that on 1/6/2026, prior to the shower, Resident 2 exhibited verbal and physical restlessness (a state of heightened inner tension or unease that manifests as excessive, involuntary, and often purposeless movements and speech) and anger outburst (a sudden, intense, and often disproportionate burst of rage, yelling, or aggression). The Progress Note further indicated that although Resident 2 initially calmed down and agreed to the shower, Resident 2 became physically aggressive during the shower, yelled and spat at CNA 1. During an interview on 2/2/2026, at 11:06 a.m., with CNA 2, CNA 2 stated that on 1/6/2026, CNA 1 was providing a shower to Resident 2, while CNA 2 and Student 1 were simultaneously assisting Resident 3 in the same shower room, separated by a shower curtain when Resident 2 became agitated and was yelling during the shower. CNA 2 further stated that after the shower, Student 1 reported to her (CNA 2) that CNA 1 had slapped Resident 2 in the face. CNA 2 stated she (CNA 2) instructed Student 1 to report the incident, and Student 1 stated that she (student) had already done so (it was later determined that the report had been made to Student 1’s Clinical Instructor but was not reported to the Administrator [Adm]). CNA 2 stated she (CNA 2) should have reported the incident directly to the ADM. During an interview on 2/2/2026, at 11:22 a.m., with the Director of Staff Development (DSD), the DSD stated that on 1/6/2026, CNA 1 reported that during Resident 2’s shower, Resident 2 became combative (being eager or ready to fight), agitated (to feel very worried, upset, or nervous, showing this state through restlessness, irritability) and spat at CNA 1 inside the shower room. The DSD stated that CNA 1 reported she (CNA 1) tried to cover herself by blocking Resident 2’s spit with CNA 1’s both hands. During a concurrent interview and record review on 2/3/2026, at 12:21 p.m., with the ADM, the facility’s policy and procedure (P&P), titled, “Abuse and Mistreatment of Residents”, last reviewed on 1/14/2026 indicated, “Reporting: Facility shall ensure reporting of all alleged and substantiated (something is proven true) violations to the state agency and all other agencies as required, and take all necessary corrective action based on the results of the investigation. A mandated reporter is any person who has assumed full or intermittent responsibility for care or custody of an elder or dependent adult, whether or not that caretaker receives compensation. This includes administrators, supervisors, and any staff of a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care custodian, health practitioner, or employee of a county adult protective services agency or a local law enforcement agency. It is the facility's policy for any mandated reporter working in a facility to report abuse to their supervisor as well as the California Department of Public Health (CDPH/SSA). When an incident has been determined to have satisfied the definition of an abuse: a) Facility Administrator shall be responsible for reporting of all alleged and substantiated violations to the state agency and all other agencies as required. b) Facility shall report the incident by notifying the CDPH within two hours of the knowledge of such incident; followed by a letter explaining the circumstances surrounding the incident. This letter shall be maintained in a separate file and made available to the CDPH upon request.” The ADM stated that allegations of abuse should be reported within two hours to the SSA, the Ombudsman and the police. The ADM stated that CNA 2 did not report the allegation on 1/6/2026. The ADM stated that on 2/2/2026, she (ADM) spoke with CNA 2, who reported that on 1/6/2026, Student 1 had stated that CNA 1 slapped Resident 2. The ADM stated that CNA 2 should have reported this information to her (ADM) immediately on 1/6/2026. The ADM stated that failure to report allegations of abuse could cause psychological (related to the mental and emotional state of a person) distress to Resident 2 and may lead to further abuse. The facility failed to report an allegation of employee-to-resident abuse involving Resident 2 within two hours to the SSA, the Ombudsman, and LLE agency in accordance with its abuse policy. On 1/6/2026, following a shower, Student 1 reported to CNA 2 that CNA 1 had slapped Resident 2 in the face. As a result, Resident 2 was placed at an increased risk for further abuse, which could have led to additional unreported incidents and a failure to protect residents from potential harm. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 2.