Health inspection·March 3, 2026

F607 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b)(4) Establish coordination with the QAPI program required under §483.75. §483.12(b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. §483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. §483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.

F609   §483.12(b) The facility must develop and implement written policies and procedures that:  §483.12(b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.  (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a patient of, or is receiving care from, the facility.  (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury.    On 1/13/2026 at 8:45 AM, an unannounced visit was made to the facility to investigate a facility reported incident (FRI) and complaint regarding quality of care and residents respect and dignity. The facility failed to identify, investigate, report to appropriate agencies, and initiate protective measures for an allegation of abuse for Resident 1 in accordance with the facility’s policy and procedure (P&P) titled “Abuse Prohibition Policy and Procedures.”    On 1/11/2026, Resident 1’s family member (FM 4) reported to Licensed Vocational Nurse (LVN 5) that Certified Nursing Assistant (CNA 2) had handled Resident 1 roughly during care and requested that CNA 2 not be reassigned to care for Resident 1. The facility did not identify the allegation as potential abuse, failed to initiate protective measures, and reassigned CNA 2 to care for Resident 1 the next day, on 1/12/2026, before conducting an investigation. LVN 5 failed to report the allegation of abuse to California Department of Public Health (CDPH) and other state agencies as required by the facility’s P&P.  These failures placed Resident 1 at risk for further abuse, retaliation, and psychosocial harm and resulted in the facility underreporting allegations of abuse.  A review of Resident 1’s Admission Record (AR) indicated that Resident 1 was an 80 year old male, originally admitted to the facility on 11/07/2025 with diagnoses including hemiplegia and hemiparesis (the weakness of one entire side of the body) following cerebral infarction (when the blood supply to part of the brain is blocked or reduced) affecting left dominant side, essential hypertension (hen the pressure in your blood vessels is too high).      A review of Resident 1’s History and Physical (H&P) dated 11/08/2025 H&P indicated Resident 1 had the capacity to understand and make decisions.        A review of Resident 1’s Minimum Data Set (MDS), a resident assessment tool, dated 11/13/2025 indicated Resident 1 was cognitively intact (normal thinking and memory).     A review of Nursing Staffing Assignment and Sign in Sheet dated 1/10/2026 for 7 AM to 3 PM and 11 PM to 7 AM shift, indicated CNA 2 was assigned to care for Resident 1 on 1/10/2026.      A review of Resident 1’s Change in Condition Evaluation dated 1/11/2026 time stamped at 10 AM written by LVN 5, “Patient [Resident 1] claims CNA [CNA 2] assigned this AM was rough while turning him [Resident 1]. Assessed patient [Resident 1] no c/o [complained of] pain at this time. Supervisor made aware, reassigned CNA.”     A review of Nursing Staffing Assignment and Sign in Sheet dated 1/12/2026 from 11 PM to 7 AM indicated CNA 2 was assigned to care for Resident 1 on 1/12/2026.     During an interview on 1/13/2026 at 1:30 PM with FM 4, FM 4 stated that on Sunday morning (1/11/2026), she visited Resident 1, who told her that CNA 2 had hurt him. FM 4 reported the incident to LVN 5 that CNA 2 was rough and hurt Resident 1’s left arm. FM 4 stated she reported the incident to LVN 5 and Registered Nurse (RN 3) and requested that CNA 2 not be assigned to care for Resident 1 again. FM 4 further stated that on the morning of 1/13/2026, when she arrived at the facility around 9:00 AM, Resident 1 informed her that no one had checked on him or changed his diaper during the night shift of 1/12/2026. FM 4 said she touched the top part of the diaper and the area toward Resident 1’s back, and it was soaking wet. Resident 1 told FM 4 that the CNA assigned to him was CNA 2—the same CNA she had asked the facility not to assign to Resident 1 due to the previous incident involving rough handling. FM 4 expressed that she did not understand why the facility would assign CNA 2 to Resident 1 again after her request following the reported incident on 1/11/2026.        During an interview on 1/13/2026 at 3:02 PM with LVN 5, LVN 5 stated on 1/11/2026 around 10 AM Resident 1’s FM 4 approached her and complained that CNA 2 had been rough towards Resident 1 while changing his incontinence briefs in bed. LVN 5 stated FM 4 told her she did not want CNA 2 to be assigned care for Resident 1 again. LVN 5 stated she immediately reported the incident to RN 3 and reassigned CNA 2 to a different resident for the remainder of the shift on 1/11/2026. LVN 5 stated she did not report the incident to the DON or Administrator because she assumed RN 3 would report it to the Administrator who is the facility’s abuse coordinator.  During an interview on 1/13/2026 at 3:35 PM with Resident 1, Resident 1 stated that on Sunday (1/11/2025) CNA 2 came to his bedside and said, “I’m going to change you.” Resident 1 stated CNA 2 then proceeded to pull him from his left arm, and Resident 1 screamed and told CNA 2 that the way CNA 2 was pulling him from his left arm hurt. Resident 1 stated CNA 2 did not stop and continued changing him and did not say anything even though he was screaming because he was hurt.    During an interview on 1/13/2026 at 3:50 PM with Resident 10 (Resident 1’s roommate), Resident 10 stated that on 1/11/2026, two days ago, he heard Resident 1 scream and say “you hurt me” while CNA 2 was changing Resident 1 and CNA 2 did not stop. Resident 10 stated CNA 2 kept going and seemed like CNA 2 was in a hurry and just wanted to finish. Resident 10 also stated that CNA 2 was assigned back to both him and Resident 1 the next night (1/12/2026).         During an interview on 1/13/2026 at 4:30 PM with the ADM, the ADM stated she was not aware of FM 4’s complaint to facility staff regarding CNA 2’s rough handling towards Resident 1 on 1/11/2026. The ADM stated if she was made aware by facility staff, she would have suspended CNA 2 and started an investigation that would include suspending CNA 2, interviewing Resident 1, FM 4 and other facility staff involved and doing necessary reporting as per facility's Abuse Policy. The ADM stated CNA 2 should not have been reassigned to Resident 1 on 1/12/2026 pending investigation.        During an interview on 1/16/2026 at 8:40 AM with CNA 2, CNA 2 stated that Resident 1 speaks in a different language that she does not understand. CNA 2 stated she observed Resident 1 talking to “his left hand” and assumed “he [Resident 1] was not 100% there (confused).” CNA 2 stated that when she or other CNAs provide care to Resident 1, he begins talking a lot and appears afraid of everyone. CNA 2 stated she could not recall much about what happened when she changed Resident 1 on 1/11/2026 but remembered leaning over the resident to reach the other side of the bed while changing him. CNA 2 stated that on 1/11/2026, she was informed by licensed nurses that FM 4 had complained about her, saying something was wrong during care, and then she was reassigned to a different resident that same day. CNA 2 stated she returned to work on the night of 1/12/2026 and was reassigned back to Resident 1. CNA 2 stated no one from the facility interviewed her or explained why she was reassigned on 1/11/2026.  A review of the facility’s policy and procedures (P&P) titled “Abuse Prohibition Policy and Procedure” dated 2/23/2021, the P&P indicated the facility would ensure that facility staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown sources, misappropriation of property for all patients. The P&P indicated the facility would implement the Abuse Prohibition Program through the following:    * Screening of potential hires  * Training of employees  * Prevention of occurrences  * Identification of possible incidents or allegations which needs investigation   * Investigation of incidents and allegations   * Protection of patients during investigations  * Reporting of incidents, investigation and response to the results of their investigations    Furthermore, the facility P&P information included but not limited to the following:  * Staff would identify events that may constitute abuse. The employee to have committed the act of abuse will be immediately removed from duty pending investigation.  * Upon receiving information concerning a report of suspected or alleged abuse... the designee would report allegations involving abuse not later than two hours after the allegation is made, notify local law enforcement, ombudsman, licensing district office, licensing boards, registries and other agencies as required. Additionally, initiate an investigation within two hours of an allegation of abuse that included documentation of witness interviews and protect patients from further harm during an investigation.   During a review of the facility’s policy and procedures (P&P) titled “Abuse Prohibition Policy and Procedure” dated 2/23/2021, the P&P indicated upon receiving information concerning a report of suspected or alleged abuse... the designee would report allegations involving abuse not later than two hours after the allegation is made, notify local law enforcement, ombudsman, licensing district office, licensing boards, registries and other agencies as required. Additionally, initiate an investigation within two hours of an allegation of abuse that included documentation of witness interviews and protect patients from further harm during an investigation.    The facility failed to identify, investigate, report to appropriate agencies, and initiate protective measures for an allegation of abuse for Resident 1 in accordance with the facility’s P&P titled “Abuse Prohibition Policy and Procedures.”    On 1/11/2026, Resident 1’s FM 4 reported to LVN 5 that Certified CNA 2 had handled Resident 1 roughly during care and requested that CNA 2 not be reassigned to care for Resident 1. The facility did not identify the allegation as potential abuse, failed to initiate protective measures, and reassigned CNA 2 to care for Resident 1 the next day, on 1/12/2026, before conducting an investigation. LVN 5 failed to report the allegation of abuse to CDPH and other state agencies as required by the facility’s P&P.    These failures placed Resident 1 at risk for further abuse, retaliation, and psychosocial harm and resulted in the facility underreporting allegations of abuse. These violations had a direct or immediate relationship to the health and safety, or security of Resident 1, and all residents of the facility.