Health inspection·January 9, 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. On 10/24/2025, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) was attacked by another resident (Resident 2) and it was not the first time this has happened. On 10/25/2025, CDPH conducted an unannounced visit to the facility to investigate the complaint allegations. Upon investigation, CDPH determined Resident 2 intentionally rammed her wheelchair into Resident 1's wheelchair. The facility failed to: 1. Ensure an allegation of resident-to-resident physical abuse was reported to CDPH within 24 hours of being made aware of the allegation. 2. Follow their Policy and Procedure (P/P) titled, "Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment" dated 11/2017, that indicated "The facility will ensure all alleged violations involving abuse... are reported immediately but not later than two hours after the allegation is made if the event that causes the allegation involves abuse or results in serious bodily injury or not later than 24 hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury. involves abuse. The facility will ensure all alleged violations involving abuse are reported to the Administrator of the Facility and The State Survey Agency." These deficient practices resulted in CDPH being unaware of the abuse allegation and their inability to conduct a timely investigation. This deficient practice had the potential for information to be lost and/or forgotten. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on 11/1/2022 with diagnoses that included dementia and an anxiety disorder. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 8/4/2025, indicated Resident 1 had severe cognitive impairment for daily decision making. The MDS indicated Resident 1 required supervision with toilet hygiene, showering, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 1 required set up assistance for eating, oral hygiene, upper body dressing and personal hygiene. A review of Resident 1's History and Physical (H&P) dated 9/13/2025 indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 2's Admission Record (Face Sheet) indicated Resident 2 was admitted to the facility on 10/4/2025 with diagnoses that included schizophrenia. A review of Resident 2's MDS dated 10/13/2025 indicated Resident 2 had moderate cognitive impairment for daily decision making. The MDS indicated Resident 2 required supervision for eating and oral hygiene. The MDS indicated Resident 2 required moderate assistance for upper body dressing and Resident 2 required substantial assistance with toilet hygiene, showering, lower body dressing and putting on/taking off footwear. A review of Resident 2's H&P dated 10/7/2025 indicated Resident 2 had the capacity to understand and make decisions. During an interview on 10/25/2025 at 9:09 a.m., Resident 2 stated she was mad at Resident 1 because Resident 1 called her a "bitch," so she pushed Resident 1's wheelchair. During an interview on 10/25/2025 at 9:26 a.m., Licensed Vocational Nurse (LVN) 1 stated Certified Nursing Assistant (CNA) 1 reported to her that on 10/24/2025 Resident 2 was upset with Resident 1 and pushed her (Resident 1) wheelchair with her (Resident 2) wheelchair. LVN 1 stated Resident 2 was upset at Resident 1 because she thought Resident 1 had gone into her room. During an interview on 10/25/2025 at 9:34 a.m., CNA 1 stated she saw Resident 2 rush her wheelchair into Resident 1's wheelchair and then yelled at Resident 1 to get out of her room. CNA 1 stated Resident 2 intentionally bumped into Resident 1's wheelchair twice before she was able separate them. CNA 1 stated this was considered abuse because Resident 1's head went backwards when she was hit by Resident 2's wheelchair. CNA 1 stated she reported what happened to LVN 2. During an interview on 10/25/2025 at 11:09 a.m., LVN 2 stated CNA 1 reported the physical altercation between Resident 1 and Resident 2 to her and she reported it to the Assistant Director of Nursing (ADON). During an interview on 10/25/2025 at 11:23 a.m., the ADON stated LVN 2 reported to her that Resident 2 wheeled herself really fast towards Resident 1 and bumped into Resident 1's wheelchair. The ADON stated the incident was not considered abuse because the nurses reported to her that Resident 2 bumped Resident 1's wheelchair. During an interview on 10/25/2025, at 10:05 a.m., the Administrator (ADM) stated he was notified of the incident between Resident 1 and Resident 2 on 10/24/2025, he did not report it to CDPH or other agencies because he did not hear of anything that would make him think this was abuse. A review of the facility's P&P titled, "Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment" dated 11/2017, indicated "The facility will ensure all alleged violations involving abuse... are reported immediately but not later than two hours after the allegation is made if the event that causes the allegation involves abuse or results in serious bodily injury or not later than 24 hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury. involves abuse. The facility will ensure all alleged violations involving abuse are reported to the Administrator of the Facility and The State Survey Agency." The facility failed to: 1. Ensure an allegation of resident-to-resident physical abuse was reported to CDPH within 24 hours of being made aware of the allegation. 2. Follow their Policy and Procedure (P/P) titled, "Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment" dated 11/2017, that indicated "The facility will ensure all alleged violations involving abuse... are reported immediately but not later than two hours after the allegation is made if the event that causes the allegation involves abuse or results in serious bodily injury or not later than 24 hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury. involves abuse. The facility will ensure all alleged violations involving abuse are reported to the Administrator of the Facility and The State Survey Agency." These deficient practices resulted in CDPH being unaware of the abuse allegation and their inability to conduct a timely investigation. This deficient practice had the potential for information to be lost and/or forgotten. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security and welfare of residents in the facility.