Health inspection·September 12, 2025

§ HSC 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. F609 Freedom from Abuse, Neglect, and Exploitation 42 CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. 22 CFR § 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. On 8/6/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint allegation regarding Certified Nursing Assistant (CNA) 5 being abusive towards residents. As a result of the investigation, CDPH determined the facility failed to: 1. Report and investigate an abuse allegation that CNA 5, on an unknown date, had roughly slapped shaving cream on Resident 5’s face while shaving his face in accordance with the facility’s policy and procedure (P&P) titled, “Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigation” last revised 9/2022 and the facility’s P&P titled “Abuse Investigation and Reporting”, revised 7/2017. 2. Report and investigate an abuse allegation that CNA 5, on an unknown date, “rough housed” Resident 6 in accordance with the facility’s policy and procedure (P&P) titled, “Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigation” last revised 9/2022 and the facility’s P&P titled “Abuse Investigation and Reporting”, revised 7/2017. 3. Report and investigate an abuse allegation that CNA 5, on July 22, 2025, was “slightly rough” while shaving Resident 7’s face in accordance with the facility’s policy and procedure (P&P) titled, “Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigation” last revised 9/2022 and the facility’s P&P titled “Abuse Investigation and Reporting”, revised 7/2017. As a result of these failures, Resident 5, Resident 6, Resident 7 and other residents were placed at risk for continuous abuse and delaying in CDPH’s investigations. A review of the facility's In-Service Training titled, "Reporting Alleged Violations,” dated 6/25/2025 and 6/26/2025, presented by the Director of Staff Development (DSD), indicated the Director of Nursing (DON), the Administrator (ADM), Certified Nursing Assistant (CNA) 3, and CNA 4 were all educated to report any abuse allegations immediately and for up to two hours to the CDPH, the Ombudsman, and local law enforcement.  a. A review of Resident 5’s Admission Record indicated Resident 5 was a 64-year-old male, initially admitted to the facility on 4/17/2025 and readmitted on 7/5/2025 with diagnoses including hepatic encephalopathy and schizophrenia. A review of Resident 5’s Minimum Data Set (MDS, a resident assessment tool) dated 8/1/2025, the MDS indicated Resident 5’s cognitive skills for daily decision making were moderately impaired and required supervision with oral hygiene, toileting, bathing, dressing, and personal hygiene. A review of Resident 5’s History and Physical (H&P), dated 7/8/2025 indicated Resident 5 did not have the mental capacity to understand and make decisions. During an interview on 8/5/2025 at 2:25 p.m. and 8/6/2025 at 9:14 a.m., CNA 3 stated, on an unknown date, she overheard Resident 5 telling an unknown staff member that CNA 5 was very rough while CNA 5 shaved him and roughly slapped shaving cream on his face. CNA 3 stated upon hearing the conversation, she immediately notified Licensed Vocational Nurse (LVN) 2. CNA 3 stated she did not report the abuse allegation to the Director of Nursing (DON) nor the Administrator (ADM), who were the facility abuse coordinators. During an interview on 8/5/2025 at 2:29 p.m., CNA 4 stated Resident 5 approached him on an unknown date and Resident 5 stated to get him away from CNA 5 because CNA 5 was rough when he was shaved and was told CNA 5 was beating him. CNA 4 stated he reported the conversation to an unknown LVN who told him the allegation would be reported to the DON. During an interview on 8/5/2025 at 2:51 p.m., LVN 2 stated she was never made aware of Resident 5’s abuse allegation against CNA 5. During an interview on 8/6/2025 at 11:59 a.m., the DON stated she and the ADM were not made aware of Resident 5’s allegation against CNA 5 regarding rough handling during shaving, nor being beaten or handled roughly during shaving. b. A review of Resident 6’s Admission Record indicated Resident 6 was an 86 year old male initially admitted to the facility on 5/2/2007 and readmitted on 6/29/2025 with diagnoses including metabolic encephalopathy, depression, and schizoaffective disorder. A review of Resident 6’s H&P, dated 3/25/2025, indicated Resident 6 was unable to make healthcare decisions. A review of Resident 6’s MDS, dated 5/28/2025 indicated Resident 6’s cognition was severely impaired and was dependent on staff’s assistance with toileting, bathing, and lower body dressing. During an interview on 8/5/2025 at 2:35 p.m., CNA 4 stated Resident 6 complained he was being “rough housed” by CNA 5. CNA 4 stated Resident 6 was unable to provide details to his allegation. CNA 4 stated after being notified of Resident 6’s allegation, he notified an unknown LVN and was told the allegation would be reported to the DON. During an interview on 8/6/2025 at 10:27 a.m., the DSD stated the expectation of the staff was to report anything suspicious they see or hear. The DSD stated all staff were in-serviced on the types of abuse and how to report any abuse allegations to CDPH, the Ombudsman, and law enforcement. The DSD stated any staff member who had knowledge of an abuse allegation were expected to follow the process to the end and to ensure the line of communication was not broken. The DSD stated CNA3 and CNA4 who notified the LVNs on duty, should have also informed the DON and ADM to ensure CDPH, the Ombudsman, and law enforcement were notified of Resident 5 and 6’s abuse allegations against CNA5. The DSD stated the facility was responsible for reporting all abuse allegations to the three agencies within two hours and any staff with knowledge of an abuse allegation should not go up the chain-of-command and assume the allegations would be reported. During an interview on 8/6/2025 at 11:55 a.m., the DON stated all staff members in the facility were mandated reporters and were expected to report all allegations to the DON and the ADM to ensure CDPH, the Ombudsman, and law enforcement were notified. The DON stated reporting abuse allegations was a collaborative effort and the staff members with knowledge of the incident should ensure all parties were aware to ensure the allegation was reported within two hours. c. A review of Resident 7’s Admission Record (Face Sheet) indicated Resident 7, a 59 year-old male, was initially admitted to the facility on 5/23/2025 and readmitted on 7/3/2025 with diagnoses including encephalopathy, schizoaffective, and anxiety disorder. A review of Resident 7’s Minimum Data Set (MDS- a resident assessment tool), dated 7/25/2025, indicated Resident 7 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 7 required supervision with eating, oral hygiene, and personal hygiene. A review of the facility’s Performance Improvement Plan - Abuse Investigation and Reporting dated 7/1/2025, indicated the root cause was communication when an incident happened. The Improvement Plan indicated the goal was for staff to inform the Administrator and the DON promptly about any incidents, report any abuse allegations immediately to the three government agencies. The Improvement Plan indicated any grievances would be reported during the daily stand-up meeting for review and would be investigated and reported promptly. The Improvement Plan indicated to monitor this goal daily and monthly, to track and trend the grievances for possible abuse allegations, and to review the grievance reports. During a concurrent interview and record review on 8/6/2025 at 8:52 a.m., with the Director of Staff Development (DSD), Resident 7’s Grievance / Complaint Report Form, dated 7/22/2025 was reviewed. The Grievance Form indicated that on 7/22/2025, Resident 7 reported to Social Services (SS) 1 that CNA 5 “was slightly rough when trying to shave him.” The DSD stated that on 7/22/2025, SS 1 notified him (DSD) of Resident 7’s allegation against CNA 5 and he immediately interviewed CNA 5 who stated, Resident 7 refused to be shaved because he wanted to go to the patio for a smoke break. The DSD stated he did not suspect abuse at the time and believed the incident to be a misunderstanding. The DSD stated shaving should not be an unpleasant experience and should be tailored to the residents’ comfort. During an interview on 8/6/2025 at 9:09 a.m., SS 1 stated that on 7/22/2025, Resident 7 approached her in the hallway and informed her that CNA 5 was rough with him when CNA 5 shaved him. SS 1 stated she informed the DSD of the allegation but did not inform the Director of Nursing (DON) nor the Administrator (ADM). SS 1 stated any kind of “roughness” can be seen as a type of abuse due to shaving’s physical nature of using a razor, using their hands to apply the shaving cream, and positioning the resident. SS 1 stated as a mandated reporter (an individual who is legally required to report suspected cases of abuse or neglect to the appropriate authorities), Resident 7’s allegation should have been reported to the DON and the ADM and to CDPH, the Ombudsman, and local law enforcement. During an interview on 8/6/2025 at 10:27 a.m., the DSD stated the expectation of the staff was to report anything suspicious they see or hear. The DSD stated all staff were in-serviced on the types of abuse and how to report any abuse allegations to CDPH, the Ombudsman, and local law enforcement. The DSD stated any staff member who had knowledge of an abuse allegation were expected to follow the process to the end to ensure the line of communication was not broken. The DSD stated the CNAs who notified the LVNs on duty should have informed the DON and ADM to ensure CDPH, the Ombudsman, and local law enforcement were notified of abuse allegations. The DSD stated the facility was responsible for reporting all abuse allegations to the three agencies within two hours and any staff with knowledge of an abuse allegation should not go up the chain-of-command and assume the allegations would be reported. During an interview on 8/6/2025 at 10:40 a.m., the DSD stated even though he interviewed CNA 5, who stated the allegation was a misunderstanding, Resident 7’s allegation should not have been discredited and should have been reported to the DON, the ADM, CDPH, the ombudsman, and law enforcement to allow investigations to be initiated. The DSD stated he did not implement his In-Service Lesson Plan into his own practice. The DSD stated he conducted a preliminary investigation on 7/22/2025 and based on his investigation, he felt the allegation was untrue. The DSD stated prior to an investigation, all abuse allegations should be reported to ensure a separate investigation from CDPH was done. The DSD stated on 7/22/2025, CNA 5 was in-serviced on the proper way of shaving. During an interview on 8/6/2025 at 11:55 a.m., the DON stated all staff members in the facility were mandated reporters and were expected to report all allegations to the DON and the ADM to ensure CDPH, the ombudsman, and law enforcement were notified. The DON stated reporting abuse allegations was a collaborative effort and the staff members with knowledge should ensure all parties were aware to ensure the allegation was reported. During an interview on 8/6/2025 at 12:04 p.m., the DON stated she was not made aware of Resident 7’s allegation, on 7/22/2025, until 8/5/2025. The DON stated when SS 1 and DSD were made aware of Resident 7’s allegation, the allegation should have been immediately reported to CDPH, the Ombudsman, and local law enforcement prior to the investigation taking place. The DON stated on 7/22/2025, CNA 5 should have been suspended while the investigation was ongoing. The DON stated other residents should have been interviewed to determine if there were other allegations of rough shaving. The DON stated allowing CNA 5 to continue to work after Resident 7’s allegation not only placed Resident 7 at risk for further potential abuse but all residents in the facility at risk for potential abuse. The DON stated a thorough investigation was necessary to determine whether the allegation was true and if disciplinary action was needed. During a review of the facility’s policy and procedure (P&P) titled, “Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating,” revised 9/2022, the P&P indicated, “All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management.” The P&P indicated if resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown origin was suspected, the administrator or the individual making the allegation was to report immediately, but not later than two hours if the alleged violation involved abuse or resulted in serious bodily injury; or twenty-four hours if the alleged violation did not involve abuse and had not resulted in serious bodily injury. A review of the facility’s policy and procedure (P&P) titled, “Abuse Investigation and Reporting”, revised 7/2017, indicated all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (“abuse”) would be thoroughly investigated by the facility management and that “All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency (CDPH) responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident’s Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident’s Attending Physician; and g. the facility Medical Director. An alleged violation of abuse, neglect, exploitation (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two hours if the alleged violation involves abuse or has resulted in serious bodily injury; or b. Twenty-four hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury.” As a result of the investigation, CDPH determined the facility failed to: 1. Report and investigate an abuse allegation that CNA 5, on an unknown date, had roughly slapped shaving cream on Resident 5’s face while shaving his face in accordance with the facility’s policy and procedure (P&P) titled, “Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigation” last