Health inspection·December 17, 2025

42 CFR 483.12 Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. 42 CFR 483.12 (c)(1) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 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. 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. W&I 15630 (a) A person who has assumed full or intermittent responsibility for the care or custody of an elder or dependent adult, whether or not they receive compensation, including administrators, supervisors, and any licensed 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, clergy member, or employee of a county adult protective services agency or a local law enforcement agency, is a mandated reporter. (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, suspected, or alleged 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. Title 22 72523 (a) 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 9/22/2025 to 9/23/2025 during an unannounced complaint visit conducted by the California Department of Health (CDPH). The facility failed to: 1. Report an allegation of verbal abuse which occurred between Resident 2 and Resident 1 on 8/10/2025. 2. Implement their abuse policy and procedure (P&P), titled, "Abuse Prevention and Management," revised 5/30/2024. The P&P indicated "allegations of abuse or reasonable suspicion of a crime are to be reported to the administrator or designated representative immediately. The Administrator or designated representative will notify law enforcement by telephone immediately but no longer that 2 hours of an initial report and send written reports to ombudsman and the state agency." These failures resulted in a delay in an onsite inspection by the State Agency and had the potential to place other patients at risk for unaddressed abuse and unsafe interactions. A review of Patient 1's Admission Record indicated the facility initially admitted Patient 1, a 63-year-old female, on 1/29/2025 and readmitted on 6/11/2025 with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swing that range from the lows of depression to elevated periods of emotional highs), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder (a mental illness that is characterized by disturbance in thought), and diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Patient 1's Minimum Data Set (MDS- a resident assessment tool) dated 7/16/2025, indicated Patient 1's cognition (process of thinking) was intact. Patient 1 required minimal assistance from staff with eating and dressing. Patient 1 was nicotine dependent and smoked cigarettes daily. Patient 1 used a manual wheelchair for mobility (ability to wheel at least 50 feet and make turns without assistance from staff). A review of Patient 1's History and Physical (H&P) dated 6/12/2025, indicated Patient 1 had fluctuating capacity to understand and make decisions. A review of Patient 1's change in condition evaluation note dated 8/10/2025, the note indicated Patient 1 was noted outside the patio when another patient (Patient 2) spoke to her (Patient 2) in a loud tone. The note indicated Patient 1's behavior warranted a behavioral assessment due to verbal aggression, noted as cursing and screaming. A review of Patient 1's care plan report dated 8/11/2025, indicated episode of verbal aggression (on 8/10/2025 at the patio with Patient 2) with the goal for Patient 1 to have fewer episodes of aggressive behavior. A review of Patient 2's Admission Record indicated the facility initially admitted Patient 2, a 58-year-old male, on 7/2/2025 and readmitted on 8/21/2025 with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder, restlessness and agitation. A review of Patient 2's MDS dated 7/9/2025, indicated Patient 2's cognition was intact. Patient 2 required minimal assistance from staff for eating, dressing and bathing. Patient 2 was able to walk with minimal staff supervision. Patient 2 was nicotine dependent and smoked cigarettes daily. A review of Patient 2's H&P dated 8/23/2025 indicated Patient 2 had the capacity to understand and make decisions. A review of Patient 2's change in condition (COC) evaluation note dated 8/10/2025, indicated Patient 2 was observed smoking outside on the patio (on 8/10/2025) and began making inappropriate comments towards another patient (Patient 1). A review of Patient 2's Psychiatric note dated 8/10/2025, indicated Patient 2 had exhibited increased aggression towards another patient (Patient 1). During an interview on 9/22/2025 at 11:30 a.m., with Patient 1, Patient 1 stated, Patient 2 called her (Patient 1) a fat white bitch after she (Patient 1) refused him (Patient 2) cigarettes. Patient 1 stated, Licensed Vocational Nurse (LVN) 1 and a Certified Nursing Assistant (CNA) "witnessed everything". Patient 1 stated the incident happened sometime in early August. Patient 1 stated Patient 3 also had an incident with Patient 2 because Patient 2 begs for cigarettes and gets angry when other patients do not give him (Patient 2) cigarettes. During an interview on 9/22/2025 at 12:30 p.m., Patient 3 stated Patient 2 "bugs patients for cigarettes and gets mad if he does not get one". Patient 3 stated filing a grievance with the social worker. During an interview on 9/22/2025 at 12:45 p.m., with the Social Service Assistant (SSA), the SSA stated, hearing about an incident of verbally aggressive behavior (on 8/10/2025 at the patio) between 2 patients (Patient 1 and Patient 2) but knew nothing else. The SSA stated all abuse, verbal and physical, must be reported to the administrator (ADM) or supervisor immediately. The SSA stated, Patient 3 filed a grievance regarding Patient 2 bugging her for cigarettes and getting upset when cigarettes were not given. During an interview on 9/22/2025 at 1:35 p.m., with LVN 1, LVN 1 stated, Patient 1 and Patient 2 were observed being verbally aggressive towards each other while out on the smoking patio (on 8/10/2025). LVN 1 stated, Patient 1 and Patient 2 were getting very close to each other, angry and aggressive over cigarettes, so he (LVN 1) had to separate them. LVN 1 stated, all abuse allegations are reportable, both verbal and physical. LVN 1 stated she reported the verbally aggressive behavior between the two patients (Patient 1 and Patient 2) to the nursing supervisor. During an interview on 9/22/2025 at 2:45 p.m., with Registered Nurse (RN) 1, RN 1 stated she was the supervisor on the day of the incident (on 8/10/2025) and stated she was aware both patients (Patient 1 and Patient 2) were inappropriate with each other shouting back and forth over cigarettes. During an interview on 9/22/2025 at 3:30 p.m., with the Director of Nurses (DON), the DON stated she did not report the incident (8/10/2025) of verbal aggression between Patient 1 and Patient 2 to the Department. The DON stated allegations of abuse, verbal, and physical are investigated and reported (to the Department). During an interview on 9/23/2025 at 3 p.m., with the Administrator (ADM), the ADM stated he was notified of the verbal aggressive incident (on 8/10/2025) involving Patient 1 and Patient 2. The ADM stated the report was "verbally aggressive behavior" and no physical or verbal abuse was reported to him. The ADM stated that he was aware that allegations including verbal and physical abuse, must be reported to all appropriate agencies. A review of the facility's policy and procedure (P&P) titled, "Abuse Prevention and Management," revised 5/30/2024, indicated, "Abuse includes verbal and physical". allegations of abuse or reasonable suspicion of a crime are to be reported to the administrator or designated representative immediately. The Administrator or designated representative will notify law enforcement by telephone immediately but no longer that 2 hours of an initial report and send written reports to ombudsman and the state agency." The facility failed to: 1. Report an allegation of verbal abuse which occurred between Resident 2 and Resident 1 on 8/10/2025. 2. Implement their abuse policy and procedure (P&P), titled, "Abuse Prevention and Management," revised 5/30/2024. The P&P indicated "allegations of abuse or reasonable suspicion of a crime are to be reported to the administrator or designated representative immediately. The Administrator or designated representative will notify law enforcement by telephone immediately but no longer that 2 hours of an initial report and send written reports to ombudsman and the state agency." These failures resulted in a delay in an onsite inspection by the State Agency and had the potential to place other patients at risk for unaddressed abuse and unsafe interactions. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health safety or security of Patient 1 and Patient 2 and other patients in the facility