Health inspection·April 2, 2026

California Code, Welfare and Institutions Code - WIC § 15630  (b)(1) A mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that they have experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an internet report shall be made through the confidential internet reporting tool established in Section 15658, within two working days.  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.  (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 patient 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.        On 2/26/2026 at 9:30 AM, an unannounced visit was made to the facility by the California Department of Public Health (CDPH) to conduct a complaint and facility reported incident (FRI) to investigate staff to resident abuse. The facility failed to immediately report an allegation of physical abuse involving Physical Therapist (PT) 1 toward Resident 1 to the Administrator (ADM), as required by the facility’s Abuse Prevention Program policy and procedure.    On 2/23/2026, while Resident 1 was beginning a physical therapy session, Resident 1 entered the rehabilitation room and touched PT 1 on the back of the head. In response, PT 1 slapped Resident 1 on the right thigh. PT 2 was present in the room during the incident. Neither PT 1 nor PT 2 reported the incident to the Administrator (ADM) on 2/23/2026 as required.  This failure resulted in the facility not immediately reporting a witnessed incident of physical abuse to the Administrator, which delayed the initiation of an investigation and the implementation of protective measures to prevent further potential abuse of Resident 1. Findings: A review of Resident 1’s Admission Record (AR) indicated the facility admitted Resident 1, a 79 year old male to the facility on 12/12/2023, with a diagnosis including Hemiplegia (complete paralysis on one side of the body) and hemiparesis ( weakness on one side of the body) following a cerebral infarction (a blood clot or blocked blood vessel stops oxygen from reaching part of the brain , causing brain cells to die)  affecting left side of his body.         A review of Resident 1’s History and Physical (H&P) dated 02/05/2026, indicated Resident 1 has the capacity to understand and make decisions.     During an interview on 02/26/2026 at 9:35 AM with the ADM, ADM stated that PT 2 reported the incident of PT 1 slapping Resident 1 on the right thigh that occurred on 2/23/26 on 2/24/2026 between Resident 1 and PT 1 one day later 2/24/26. ADM stated PT 2 reported the incident to the Director of Rehabilitation (DOR).     During an interview on 02/26/2026 at 10:26 AM with PT 2, PT 2, stated Resident 1 entered the therapy room and approached PT 1 who was seated at a computer with his back to the room.  Resident 1 “flicked” [to move, hit, or remove something with a quick, light, and sudden jerk] PT 1 once on the back of the head to get his attention.  PT 1 then rotated his chair approximately 180 degrees towards Resident 1 and struck Resident 1 once on the right thigh with an open hand.  PT 2 stated the slap was very loud and sounded like someone slamming their hands down on a desk. PT 2 stated as the therapist struck the resident, Resident 1 yelled “no, you can’t do that.” Resident 1 appeared shocked and upset and said, “you beat me.” PT 2 stated it appeared that PT 1 was often annoyed with Resident 1 and, on multiple occasions, she had heard PT 1 speaking loudly to the resident stating you need to be quiet, you talk too much, which was directed toward Resident 1. PT 2 stated Resident 1 did not appear to have visible injury and therapy continued with both therapists remaining in the room.  PT 2 stated she did not immediately report the incident of PT 1 slapping Resident 1’s right thigh on 2/23/2026 because she believed there was a 24hour window for reporting and wanted to give PT 1 an opportunity to report the incident himself. PT 2 stated she reported the incident the following day, on 2/24/2026, to the Director of Rehabilitation (DOR) after learning that PT 1 had not reported the incident.           During an interview on 2/26/2026 at 11:55AM with Resident 1, Resident 1 stated on 2/23/2026, Resident 1 entered the therapy room and approached PT 1 to get his attention and touched the back of PT 1’s head.  Resident 1 stated PT 1 quickly turned around and slapped Resident 1 on the right leg.  Resident 1 stated PT 1 appeared very angry and mean, and that the slap inflicted by PT 1 stung Resident 1’s leg. Resident 1 stated he felt angry and felt “assaulted” and went on to say he had previously considered PT 1 a friend and someone he could talk to and did not expect this kind of behavior. Resident 1 stated he continued with physical therapy with PT 2 afterward while PT 1 remained in the room. Resident 1 further stated no one asked him how he was or whether he was okay following the incident.    During an interview on 02/26/2026 at 1:10 PM with the Director of Nursing (DON), DON stated the incident between Resident 1 and PT 1 was considered physical abuse and should have been reported immediately to facility administration in accordance with facility policy and abuse reporting requirements.     During an interview on 02/26/2026 at 1:40 PM with PT 1, PT 1 stated he did not notify the ADM or DOR because in his experience when he reports concerns, no action was taken.     During a review of the facility’s policy and procedure ( P&P)  titled “ Abuse investigation & Reporting,” undated, the P&P indicated All allegation or resident abuse, neglect, exploitation, misappropriation or resident property, mistreatment and/ or injuries of unknown source ( “Abuse”) shall be promptly reported to appropriate local, state and  / or federal agencies ( as defined by current regulation ) and thoroughly investigated by Company management.  Findings of abuse investigations will also be reported to local law enforcement and the Office of Ombudsman. The P&P further indicated an alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately.         During a review of the facility’s P&P titled Abuse Prevention Program, undated, the P&P indicated the facility would investigate and report any allegations of abuse within timeframes as required by federal requirements.     During a review of the facility’s P&P titled, Abuse and Neglect Clinical Protocol, undated, indicated the facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The P&P indicated management and staff will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations.   The facility failed to immediately report an allegation of physical abuse involving Physical Therapist (PT) 1 toward Resident 1 to the Administrator (ADM), as required by the facility’s Abuse Prevention Program policy and procedure.    On 2/23/2026 while Resident 1 was beginning physical therapy, Resident 1 entered the rehabilitation (rehab) room and touched PT 1 on the back of the head. PT 1 reacted by slapping Resident 1 on the right thigh. PT 2 was also in the room. Neither PT 1 or PT 2 reported this incident on 2/23/2026 to the ADM.     This failure resulted in the facility not immediately reporting a witnessed incident of physical abuse to the Administrator, which delayed the initiation of an investigation and the implementation of protective measures to prevent further potential abuse of Resident 1. These violations had a direct or immediate relationship to the health and safety, or security of Resident 1 and all other residents of the facility.