Health inspection·October 17, 2025

§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(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 9/2/2025, the California Department of Public Health (CDPH) received an anonymous complaint alleging two incidents, the first, a resident (unknown) smothered another resident (unknown) with a pillow. The second incident alleged that a resident’s (Resident 1) arm was grabbed really hard by another resident (Resident 2) which caused bruising to Resident 1’s arm, while Resident 2’s sitter (a caregiver whose primary role is to ensure a patient’s safety, especially for those at a higher risk of accidents or self-harm) was in the room sleeping when this occurred. On 9/4/2025, CDPH received a Facility Reported Incident (FRI), that Resident 1 feared Resident 2 would come towards him during the night. On 9/3/2025, CDPH conducted an unannounced visit at the facility to investigate the complaint allegations and FRI. Upon investigation CDPH determined the allegation of abuse had not reported to CDPH. The Facility failed to: 1. Ensure an allegation of abuse was reported to CDPH immediately but not later than two hours after the allegation was made. 2. Ensure the facility followed their Policy and Procedure (P/P), titled, “Abuse and Neglect - Clinical Protocol” revised 3/2018, that indicated management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. These deficient practices resulted in the inability of CDPH to investigate the allegation of abuse in a timely manner before information and recollection of the event(s) were possibly lost. Findings: A review of Resident 2’s Admission Record (Face Sheet) indicated Resident 2 was initially admitted to the facility on 4/21/2025 and readmitted on 6/23/2025 with diagnoses including picks disease (a gradual deterioration of nerve cells leading to changes in behavior and social appropriateness), and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 2’s Minimum Data Set ([MDS] a resident assessment tool) dated 6/30/2025, indicated Resident 2’s cognition was moderately impaired. A review of Resident 2’s untitled Care Plan dated 8/8/2025, indicated Resident 2 becomes restless easily, and wanders into other residents’ rooms. The Care Plan’s interventions included one-to-one (constant, direct, and uninterrupted observation of a single resident by a dedicated staff member for residents who are at high risk for harming themselves or others) monitoring. A review of Resident 2’s Nursing Progress Notes dated 9/1/2025 and timed at 10:22 a.m., indicated Resident 2 unintentionally touched his roommate’s (Resident 1) legs and arms. During an interview on 9/3/2024 at 9:13 a.m., Resident 1 stated Resident 2 was his roommate and on 9/1/2025 (time unknown) Resident 2 walked to his bedside, pulled his right arm, and touched his right leg multiple times. Resident 1 stated he yelled for help, but no one came. Resident 1 stated he did not like Resident 2 touching him and it made him afraid. Resident 1 stated he reported the incident to his assigned Certified Nurse Assistant (CNA) 2 during the 7 a.m. to 3 p.m. shift (9/1/2025). During a telephone interview on 9/3/2025 at 10:45 a.m., CNA 2 stated on 9/1/2025 when he started his shift (7 a.m. to 3 p.m., exact time unknown) Resident 1 reported to him that Resident 2 touched his right arm and right leg many times. CNA 2 stated he reported Resident 1’s complaint to Registered Nurse 1 (RN 1) because it was his duty to report “something like this because it could be abuse.” During an interview on 9/3/2025 at 2:30 p.m., the Social Service Designee (SSD) stated she spoke to Resident 1 about the allegation and helped the resident file a grievance. The SSD stated when there was suspected abuse a report needs to be made. During an interview on 9/4/2025 at 7:30 a.m., Registered Nurse (RN) 1 stated Resident 2 reported to her that he did not want Resident 2 to wander around because he was afraid his arm would be pulled again. RN 1 stated she reported the incident to her abuse coordinator in which there was a meeting, and a grievance was filed. During an interview on 9/4/2025 at 9:04 a.m., the Administrator (ADM), stated there was a meeting held with staff to discuss Resident 1’s complaint and determined it was not an allegation of abuse, so he treated it as a grievance. The ADM stated he did not investigate Resident 1’s complaint for possible abuse and did not report it to CDPH because he did not believe it was an allegation of abuse. During an interview on 9/4/2025 at 10:57 a.m., the Director of Nursing (DON) stated if a resident continuously touches a resident, we should report the suspected abuse to CDPH. During a review of the facility’s P&P, titled, “Abuse and Neglect - Clinical Protocol” revised 3/2018, the P&P indicated management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. The facility failed to: 1. Ensure an allegation of abuse was reported to CDPH immediately but not later than two hours after the allegation was made. 2. Ensure the facility followed their P/P, titled, “Abuse and Neglect - Clinical Protocol” revised 3/2018, that indicated management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. These deficient practices resulted in the inability of CDPH to investigate the allegation of abuse in a timely manner before information and recollection of the event(s) were possibly lost. These violations had a direct or immediate relationship to the health, safety, or security of Resident 1.