Health inspection·March 25, 2026

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) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 42 CFR 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. CCR 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. 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. On 2/9/2026, CDPH conducted an unannounced visit at the facility to investigate a facility reported incident. The facility failed to: 1. Report an alleged physical abuse between Resident 1 and Resident 2 to CDPH within two hours of the occurrence. 2. Implement it Policy and Procedure (P&P) titled, "Abuse Prevention and Management," dated 1/1/2026, which indicated the facility will report to CDPH the allegation of abuse within regulated two hours. 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 Resident 1's Admission Record indicated the facility admitted Patient 1, a 82-year-old male, on 6/6/2025 with diagnoses that included type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar-control and poor wound healing), chronic obstructive pulmonary disease (chronic lung disease causing difficulty in breathing), osteoarthritis (progressive disorder of the joints, caused by a gradual loss of cartilage), and schizophrenia (mental illness that is characterized by disturbances in thought). A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 1/7/2026, indicated Resident 1 had severe cognitive impairment (ability to think and understand) and required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). A review of Resident 2's Admission Record indicated the facility admitted Resident 2, a 62-year-old male, on 10/29/2025 with diagnoses that included chronic kidney disease (kidneys lose the ability to clean blood and remove waste), type 2 diabetes mellitus, heart disease (blood vessels around the heart are damaged and harder for the heart to pump blood), gout (uric acid builds up and forms crystals in joints causing painful swelling). A review of Resident 2's MDS, dated 1/30/2026, indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 required moderate assistance (Helper does less than half the effort) from one staff for bed mobility and transfer. A review of Resident 2's History and Physical (H&P), dated 10/31/2025, indicated Resident 2 had the capacity to understand and make decisions. During an interview on 2/9/2026 at 1:45 p.m. with Resident 2, Resident 2 stated Resident 1 was lying on his left side and was coughing with particulates on his (Resident 1's) face. Resident 2 stated he used the rubber handle of his cane to lift Resident 1's pillow. Resident 2 stated he retracted his cane when Occupational Therapist Technician (COTA) 1 was standing in doorway and alleged he hit Resident 1 on the head with his cane. During a concurrent interview and record review on 2/9/2026 at 11:15 a.m. with Registered Nurse Supervisor (RNS), the RNS stated Licensed Vocational Nurse (LVN) 1 informed her of the physical abuse allegation where Resident 2 hit Resident 1 on the head with a cane. The RNS stated she transferred Resident 1 to another room, removed Resident 2's cane, and notified Resident 1's the physician. During an interview on 2/9/2026 at 1:00 p.m. with LVN 1, LVN 1 stated COTA 1 reported the alleged abuse of Resident 2 hitting Resident 1 on the head with a cane. LVN 1 stated he assessed both residents and informed the RN Supervisor. LVN 1 stated RN Supervisor relocated Resident 1 to another room and removed Resident 2's cane. During an interview on 2/9/2026 at 1:30 p.m. with the Administrator, the Administrator stated reporting to CDPH, law enforcement, and the Ombudsman must occur immediately, within two hours. The Administrator acknowledged administration conducted their own investigation and then the RNS faxed the SOC341 report on 1/26/2026 at 4:34 p.m. to CDPH and the Ombudsman seven hours after Resident 2 hit Resident 1 on the head with a cane on 1/26/2026 at approximately 9:30 a.m. During a record review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Management, dated 1/1/2026, indicated "The Administrator or designated representative will notify law enforcement, by telephone immediately, or as soon as practicably possible, and send a written SOC341 report to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification: i. Immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury" The facility failed to: 1. Report an alleged physical abuse between Resident 1 and Resident 2 to CDPH within two hours of the occurrence. 2. Implement it Policy and Procedure (P&P) titled, "Abuse Prevention and Management," dated 1/1/2026, which indicated the facility will report to CDPH the allegation of abuse within regulated two hours. 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 Resident 1 and Resident 2.