Health inspection·December 19, 2025

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. 22 CFR § 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) 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. The California Department of Public Health (CDPH) received a facility reported incident indicating a Certified Nurse Assistant (CNA) witnessed Resident 1 putting his hands in between Resident 2's thighs on 11/8/2025. On 11/10/2025, the CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: 1) Investigate and report to the CDPH a separate allegation of sexual abuse (non-consensual sexual contact) that took place on 6/13/2025 when Resident 2 kissed Resident 1, who did not have the capacity to understand and make decisions (consent) and was found lying in Resident 1's bed. 2) Adhere to its Policy and Procedure (P&P) titled, "Abuse and Neglect Prevention Management" when it did not report the incident on 6/13/2025 between Resident 1 and Resident 2 to the CDPH. This failure resulted in a delay in the investigation by the CDPH and placed Resident 1 and other residents at risk of abuse by Resident 2. Resident 1 was a 57-year-old male, admitted to the facility on 4/24/2025 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain) and aphasia (a disorder that makes it difficult to speak). A review of Resident 1's History and Physical (H&P) dated 4/27/2025, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 5/7/2025, indicated Resident 1 had severe cognitive (ability to think and reason) impairment and did not exhibit physical behaviors towards others such as abusing others sexually or engaging in public sexual acts. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort) on staff for personal hygiene, bed mobility (the ability to roll from lying on back to left and right side and return to lying on back on the bed) and lying to sitting on the side of the bed. A review of Resident 1's Weekly Nursing Summary dated 6/9/2025, indicated Resident 1 was verbal, alert and confused. A review of Resident 1's Progress Notes dated 6/14/2025, indicated (on 6/13/2025 at 7:30 p.m.,) another resident (Resident 2) kissed Resident 1 and attempted to climb into Resident 1's bed. The progress notes did not indicate the incident was reported to the Administrator (Admin) nor to the CDPH. Resident 2 was a 40-year-old female, admitted to the facility on 10/18/2024 with diagnoses including hydrocephalus (increased pressure in the brain which could cause problems with cognition and amnestic disorder (a condition with partial or total memory loss). A review of Resident 2's MDS dated 5/28/2025, indicated Resident 2 had severe cognitive impairment and could independently (resident completes the activity by themselves with no assistance) wheel 150 feet in a manual wheelchair. The MDS indicated Resident 2 required setup assistance (helper assists only prior to or following the activity, resident completes the activity) to transfer between a wheelchair and bed. A review of Resident 2's Progress Notes dated 6/13/2025, indicated Certified Nurse Assistant (CNA) reported Resident 2 kissed Resident 1 and attempted to climb into Resident 1's bed. The Progress Notes did not indicate the incident was reported to the Admin nor to the CDPH. During a concurrent interview and record review on 11/12/2025 at 2:48 p.m., with the Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled, "Abuse and Neglect Prevention Management" dated 2/2018, Resident 1's Progress Notes dated 6/2025, Resident 1's MDS dated 5/7/2025 and Resident 2's Progress Notes dated 6/13/2025 were reviewed. The DON stated on 6/13/2025, Licensed Vocational Nurse (LVN) 5 notified her that Resident 2 was found kissing Resident 1 and had climbed on top of him (Resident 1) in his bed. The DON stated she did not instruct LVN 5 to investigate and report the incident to the CDPH. The DON stated nonconsensual sexual contact of any type was considered sexual abuse. The DON stated Resident 2 kissing Resident 1 was considered sexual contact and sexual abuse because Resident 1 and Resident 2 had severe cognitive impairment and neither residents could consent to sexual contact. The DON stated the incident on 6/13/2025 between Resident 1 and Resident 2 should have been investigated and reported to the CDPH. The DON also stated the incident was not investigated and reported to the CDPH in part, because Resident 2 had forgotten about the incident and there were no complaints from the residents or the residents' representatives. The DON stated it was important to ensure allegations of sexual abuse were investigated and reported to the CDPH for residents' safety. During a concurrent interview and record review on 11/12/2025 at 3:43 p.m., with the Admin, Resident 2's Progress Note dated 6/13/2025, was reviewed. The Admin stated he was the facility's Abuse Coordinator, and the licensed nurses did not notify the CDPH of the incident (alleged sexual abuse) between Resident 1 and Resident 2 on 6/13/2025. The Admin stated the incident was not investigated but should have been reported and investigated to prevent future abuse from occurring. During an interview on 11/13/2025 at 9:20 a.m., with CNA 2, CNA 2 stated on 6/13/2025, she observed Resident 2 laying on Resident 1 and kissing Resident 1 on his lips in Resident 1's bed. CNA 2 stated she was a mandated reporter but did not report the sexual abuse incident to the Admin or the CDPH. CNA 2 stated she did not provide a written statement about the incident and was not interviewed about the incident by any facility staff as part of an investigation. A review of the facility's P&P titled, "Abuse and Neglect Prevention Management" dated 2/2018, indicated sexual abuse is non-consensual sexual contact of any type with a resident. The P&P indicated all facility employees are required to report any known or suspected abuse immediately upon identifying a concern. The P&P indicated all allegations of abuse will be reported to the Admin and the state survey and certification agency no later than two hours after the allegation is made. The P&P indicated all allegations of abuse will be investigated and written findings of the investigation will be reported to the department of public health within five days of the alleged occurrence. The facility failed to: 1) Investigate and report to the CDPH a separate allegation of sexual abuse that took place on 6/13/2025 when Resident 2 kissed Resident 1, who did not have the capacity to understand and make decisions (consent) and was found lying in Resident 1's bed. 2) Adhere to its P&P titled, "Abuse and Neglect Prevention Management" when it did not report the incident on 6/13/2025 between Resident 1 and Resident 2 to the CDPH. This failure resulted in a delay in the investigation by the CDPH and placed Resident 1 and other residents at risk of abuse by Resident 2. These violations had a direct or immediate relationship to the health, safety, or security of residents.