Health inspection·April 22, 2026

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §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 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)(b) Abuse Reporting (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. On 3/2/2026, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) indicating a resident (Resident 2) alleged a Certified Nursing Assistant (CNA 1) grabbed her arm aggressively and twisted it. On 3/5/2026, the CDPH received a complaint alleging a resident (Resident 1) was fearful of two female nurses and had a bruise. On 3/5/2026 an FRI was received indicating a Licensed Vocational Nurse (LVN 1) looked under Resident 1's blanket and touched the resident's diaper inappropriately.. On 3/6/2026, the CDPH conducted an unannounced visit to the facility to investigate the complaint allegation and FRIs. Upon investigation, the CDPH determined allegations of abuse were made against CNA 1 by Resident 2 and against LVN 1 by Resident 1's Family Member (FM) and the facility did not report the allegations of abuse to the CDPH. The facility failed to: Report allegations of abuse to the Administrator (ADM) and/or the CDPH when: 1. CNA 1 reported to LVN 3 that Resident 2 accused her of abuse on 3/1/2026 and when Resident 2 reported to LVN 3 that CNA 1 twisted her (Resident 2) arm on 3/2/2026. 2. Registered Nurse (RN) 1 was made aware of an allegation that LVN 1 inappropriately touched Resident 1 on 3/4/2026. As a result, the ADM, who was the facility's abuse coordinator, was not aware of the allegations of abuse against CNA 1 and LVN 1, and the CDPH's investigation of the allegations were delayed. 1. Resident 2, a 78-year-old female, was initially admitted to the facility on 1/9/2023 and readmitted 3/8/2025. Resident 2 had diagnoses including primary essential hypertension ([HTN] high blood pressure), peripheral vascular disease ([PVD] a slow progressive narrowing of the blood flow to the arms and legs), and hypothyroidism (a deficiency of the hormone causing the body to slow down). A review of Resident 2's Minimum Data Set Assessment ([MDS] a resident assessment tool) dated 2/4/2026, indicated Resident 2's cognition (ability to think and reason) was intact. Resident 2 required set up or clean up assistance to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). A review of Resident 2's Change of Condition (COC)/Interact Assessment form ([SBAR] situation, background, assessment, recommendation, a communication tool used by healthcare workers when there is a change of condition among the residents) dated 3/2/2026 and timed at 1 p.m., indicated Resident 2 reported CNA 1 was rough with her, grabbed her wrist and twisted her arm. During an interview on 3/9/2026 at 12 p.m., CNA 1 stated on 3/1/2026 she went to Resident 2's room to change her adult brief. Resident 2 was in bed, and she (CNA 1) rolled her from left to right while putting the adult brief on her. Resident 2 got upset and accused her (CNA 1) of grabbing her left arm and abusing her. CNA 1 stated she left the room and told LVN 3 that Resident 2 accused her of abuse. During an interview on 3/9/2026 at 12:17 p.m., CNA 2 stated she worked with CNA 1 on 3/1/2026 when Resident 2 accused her (CNA 1) of abuse. CNA 2 stated she was standing with CNA 1 when CNA 1 reported the allegation of abuse made by Resident 2 to LVN 3. During an interview on 3/9/2026 at 12:30 p.m., LVN 3 stated on 3/1/2026 CNA 1 told her Resident 2 called her the "B" word and that Resident 2 was aggressive towards her (CNA 1). LVN 3 stated she told RN 2 what Resident 2 reported to her and was told by RN 3 to change CNA 1's assignment. On 3/2/2026 (time unknown) Resident 2 told her (LVN 3) that CNA 1 twisted her left arm on 3/1/2026 and she (LVN 3) reported this allegation to the ADM on 3/2/2026. 2. Resident 1, a 53-year-old male, was initially admitted to the facility on 1/8/2026. Resident 1 had diagnoses including aphasia (a disorder that makes it difficult to speak) following a cerebral infarction (where blood flow to the brain has been blocked). A review of Resident 1's MDS dated 1/14/2026, indicated Resident 1's cognition was severely impaired. Resident 1 was dependent (helper does all the effort) on staff to complete his ADLs. A review of Resident 1's COC/SBAR dated 3/5/2026 and timed at 11:58 a.m., indicated during an Interdisciplinary Team meeting ([IDT] a group of health care professionals with various areas of expertise who work together toward the goals of the residents) Resident 1's FM accused LVN 1 of lifting Resident 1's sheet, and touching Resident 1's diaper. During an interview on 3/6/2026 at 10:48 a.m., Resident 1's FM stated on 3/4/2026 she was in Resident 1's room in the dark when LVN 1 came in, put her hand under Resident 1's sheet, bent over and whispered something in Resident 1's ear. Later that night (time unknown), Resident 1 told her a nurse touched him inappropriately. When LVN 1 came back to the room, she asked Resident 1 if LVN 1 was the one who touched him inappropriately, and the resident said "yes." The FM stated she used a letter board (alphabets used to spell out words) to communicate with Resident 1, when Resident 1 reported this to her, she reported the allegation to LVN 2, who told her he would report it to RN 1. During a telephone interview on 3/6/2026 at 1:12 p.m., RN 1 stated on 3/4/2026 at approximately 2 a.m., Resident 1's FM told her that LVN 1 touched Resident 1's private area inappropriately. RN 1 stated she called the Director of Nursing (DON) on 3/5/2026 (time unknown) but did not get an answer back and did not report the allegation to the DON. During an interview on 3/10/2026 at 2:46 p.m., the ADM stated he was never notified of the abuse allegation made by Resident 1's FM on 3/4/2026 until 3/5/2026 during an IDT meeting with the family. The ADM stated he was not aware of Resident 2's allegation of abuse on 3/1/2026 until 3/2/2026. The ADM stated staff was expected to notify him of any allegation of abuse immediately. A review of the facility's Policy and Procedure (P&P) titled, "Abuse Neglect Exploitation or Misappropriation - Reporting and Investigating" revised 9/2022, indicated "if resident abuse, neglect, exploitation, misappropriation of resident's property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. "Immediately" is defined as within two hours of an allegation involving abuse or resulting in serious bodily injury; or within 24 hours if an allegation that does not involve abuse or results in serious bodily injury. The facility failed to: Report allegations of abuse to the ADM and/or the CDPH when: 1. CNA 1 reported to LVN 3 that Resident 2 accused her of abuse on 3/1/2026 and when Resident 2 reported to LVN 3 that CNA 1 twisted her (Resident 2) arm on 3/2/2026. 2. RN 1 was made aware of an allegation that LVN 1 inappropriately touched Resident 1 on 3/4/2026. As a result, the ADM, who was the facility's abuse coordinator, was not aware of the allegations of abuse made against CNA 1 and LVN 1, and the CDPH's investigation into the allegations of abuse were delayed. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1 and Resident 2.