Other·May 8, 2026

§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. §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)(b) (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" citation. On 4/8/2026, the California Health Department of Public Health (CDPH) received a Facility Reported Incident (FRI) indicating a Family Member (FM) of a resident (Resident 2) overheard via a telephone conversation, a Certified Nursing Assistant (CNA) use a demanding tone and referred to Resident 2 as "stupid." On 4/7/2026, the CDPH conducted an unannounced visit to the facility to investigate the allegation. During the investigation, the CDPH determined CNA 1 was accused of verbal abuse towards Resident 2 and the facility failed to report the allegation to the CDPH. The facility failed to: 1. Report an allegation of verbal abuse when a FM reported to Licensed Vocational Nurse (LVN 1) that CNA 1 used inappropriate words in an aggressive and frustrated tone when providing care to Resident 2. 2. Follow its Policy and Procedure (P/P) titled "Abuse Prevention and Prohibition Program" dated 2/9/2024 that indicated "facility employees are obligated by the Elder Justice Act and the California Elder Abuse and Dependent Adult Civil Protection Act to report known or suspected instances of abuse of elder or dependent adult." This resulted in the inability of the CDPH to conduct a timely investigation and had the potential for information pertinent to the investigation to be lost and/or forgotten. Resident 2, a 92 year old female, was admitted to the facility on 11/28/2025 with a diagnosis of hepatic encephalopathy (a reversible, serious neurological condition causing brain dysfunction including confusion, personality changes, and coma due to advanced liver disease). A review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 1/16/2026 indicated Resident 2's cognition was intact and she required partial/moderate assistance (helper does less than half the effort) to complete her activities of daily living ([ADLs) activities such as bathing, dressing and toileting a person performs daily). A review of Resident 2's Licensed Nurses Notes dated 3/27/2026 and timed at 11:41 p.m., indicated LVN 1 received a telephone call (3/27/2026 time unknown) from a FM reporting the FM overheard inappropriate words from CNA 1 when CNA 1 was talking to Resident 2. LVN 1 reported the allegation to the Director of Staff Development (DSD) and the Director of Nursing (DON). A review of the DSD's Statement (Investigation) dated 3/27/2026 and timed at 7:14 p.m., indicated the DSD received a telephone call (3/27/2026) from the Administrator (ADM) reporting Resident 2 was crying alleging CNA 1 called her stupid. A review of a Text Message sent to the DSD from CNA 2 dated 3/30/2026 and timed at 11:24 a.m., indicated CNA 2 heard CNA 1 tell Resident 2 "you f*ckin bug so much and sh*t what the f*ck do you want now. I'm so f*ckin tired of your sh*t." During an interview on 4/7/2026 at 3:04 p.m., the DON stated the incident was not reported to the CDPH because the FM could not hear what was said by CNA 1 and CNA 1 denied saying inappropriate words to Resident 2. During an interview on 4/7/2026 at 3:21 p.m., the ADM stated the incident was not reported to the CDPH because Resident 2 reported she felt rushed during care so there was no need for the incident to be reported. The ADM stated they could not prove what actually happened, the FM could not make out the actual words said by CNA 1, and CNA 1 denied saying anything wrong. During an interview on 4/7/2026 at 3:45 p.m., the FM stated on 3/27/2026 (time unknown) while staff (unknown) was providing care to Resident 2 she (FM) was on the telephone with Resident 2 and overheard staff (unknown) speak to Resident 2 in a frustrated and aggressive voice. The FM stated she could not hear what was said to Resident 2, but Resident 2 was crying and said, "I'm not stupid." The FM stated Resident 2 told her this was not the first time that staff treated her that way. A review of the facility's P&P titled "Abuse Prevention and Prohibition Program" dated 2/9/2024, indicated "facility employees are obligated by the Elder Justice Act and the California Elder Abuse and Dependent Adult Civil Protection Act to report known or suspected instances of abuse of elder or dependent adult. The facility will report allegations of abuse, neglect, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime.' The facility failed to: 1. Report an allegation of verbal abuse for when Resident 2's FM reported to LVN 1 that CNA 1 used inappropriate words in an aggressive and frustrated tone when providing care to Resident 2. 2. Follow the facility's P/P titled "Abuse Prevention and Prohibition Program" dated 2/9/2024 that indicated "facility employees are obligated by the Elder Justice Act and the California Elder Abuse and Dependent Adult Civil Protection Act to report known or suspected instances of abuse of elder or dependent adult." This resulted in the inability of the CDPH to conduct a timely investigation and had the potential for information pertinent to the investigation to be lost and/or forgotten. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of residents in the facility.