Health inspection·April 7, 2026

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (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. (c)(2) Have evidence that all alleged violations are thoroughly investigated. 22 CCR § 72315. Nursing Service-Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 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. 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. On 3/18/2026, the California Department of Public Health (CDPH) conducted unannounced visit at the facility to investigate a facility reported incident (FRI) regarding an allegation of resident-to-resident abuse that occurred on 3/11/2026. The facility failed to: 1. Report a resident-to-resident altercation in accordance with the facility's policy and procedure (P&P) titled "Abuse, Neglect, Exploitation, and Misappropriation - Reporting and Investigating." 2. Investigate a resident-to-resident altercation in accordance with the facility's P&P titled "Abuse, Neglect, Exploitation, and Misappropriation - Reporting and Investigating." As a result, there was a delay in the investigation by the CDPH and Resident 2, 4, and other residents were placed at risk for continuous abuse Resident 2, a 71-year-old male, was admitted to the facility on 10/15/2024 and readmitted 12/24/2025. Resident 2's diagnoses included anxiety disorder (mental health condition characterized by excessive, persistent, and uncontrollable worry or fear that interferes with daily life) and dementia (a progressive state of decline in mental abilities). A review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 1/8/2026, indicated Resident 2 had no cognitive impairments (when a person has trouble with memory, thinking, learning, concentration, or decision-making). The MDS indicated Resident 2 could independently perform oral hygiene and dress his upper and lower body. A review of Resident 2's Change of Condition (COC) Assessment, dated 1/31/2026, indicated that on the morning of 1/31/2026, Resident 2 displayed verbal and physical aggression and an "anger outburst". The COC assessment indicated staff observed Resident 2 initiating a physical altercation with Resident 4 without provocation and attempting to strike him for no apparent reason. The COC assessment indicated both residents were separated to minimize escalation. Resident 4, a 76-year-old male, was admitted to the facility on 11/10/2017 and readmitted on 4/30/2020. Resident 4's diagnoses included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). A review of Resident 4's MDS, dated 12/29/2025, indicated Resident 4 had no cognitive impairments. The MDS indicated Resident 4 could independently perform activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During an interview on 3/18/2026 at 12:54 PM, Registered Nurse (RN) 1 stated on 1/31/2026 she did not report the altercation between Resident 2 and 4, to the Administrator (ADM), the facility's abuse coordinator or the CDPH. RN 1 stated she was to report the altercation to the ADM and the CDPH right away. RN 1 stated the purpose of timely reporting was for the safety of the facility's residents. During an interview on 3/18/2026 at 1:36 PM, the ADM stated she was not aware of the altercation that occurred on 1/31/2026 until 3/18/2026. The ADM stated RN 1 should have reported it to her right away, and if she was unavailable, RN 1 should have reported it to the Director of Nursing (DON). The ADM stated the purpose of timely reporting to herself and the CDPH was to prevent abuse. The ADM further stated the altercation was not investigated. The ADM stated that timely reporting and investigation of the altercation was important for residents' safety. A review of the facility's P&P titled "Abuse, Neglect, Exploitation, and Misappropriation - Reporting and Investigating," revised 9/2022, indicated if resident abuse was suspected, the suspicion was to be reported to the facility ADM immediately. The P&P indicated the facility was also to report the suspicion to the state licensing/certification agency immediately or within two hours. The P&P indicated that all allegations of abuse were to be thoroughly investigated, and indicated the investigation was to be initiated by the ADM. The facility failed to: 1. Report a resident-to-resident altercation in accordance with the facility's policy and procedure (P&P) titled "Abuse, Neglect, Exploitation, and Misappropriation - Reporting and Investigating." 2. Investigate a resident-to-resident altercation in accordance with the facility's P&P titled "Abuse, Neglect, Exploitation, and Misappropriation - Reporting and Investigating." As a result, there was a delay in the investigation by the CDPH and Resident 2, 4, and other residents were placed at risk for continuous abuse Thess violations had a direct or immediate relationship to the health, safety, or security of patients or residents.