Health inspection·April 15, 2026

§ HSC 1418.91 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. Freedom from Abuse, Neglect, and Exploitation 42 CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. 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. On 3/9/2026, the California Department of Public Health (CDPH) conducted an unannounced annual recertification survey at the facility. The facility failed to: 1. Report an abuse allegation to the State Agency (California Department of Public Health [CDPH]), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement after Resident 7 allegedly touched Resident 61’s genitals (external reproductive organ). As a result, there was a delay of an onsite investigation by CDPH and had the potential to result in abuse to all residents in the facility. 1. Resident 61 was an 84-year-old male, initially admitted to the facility on 1/21/2025 and readmitted on 9/15/2025. Resident 61’s diagnoses included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic kidney disease (kidney damage that occurs over time), hypertension (high blood pressure). A review of Resident 61’s Minimum Data Set (MDS- a resident assessment tool), dated 1/15/2026, indicated Resident 61’s cognition (process of thinking) was intact. The MDS indicated Resident 61 was independent with eating, oral hygiene, and toileting. A review of Resident 61’s History and Physical (H&P), dated 9/16/2025, indicated Resident 61 had the capacity to understand and make decisions. During an interview on 3/10/2026 at 12:50 p.m., Resident 61 stated on 1/29/2026, while he was sleeping, Resident 7 tried to touch his genitals. Resident 61 stated he was very upset and told Licensed Vocational Nurse (LVN) 3. 2. Resident 7 was an 82-year-old male, initially admitted to the facility on 6/5/2022 and readmitted on 2/6/2026. Resident 7’s diagnoses included dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition characterized by excessive fear or worry that interferes with daily life). A review of Resident 7’s MDS, dated 1/29/2026, indicated Resident 7’s cognition was severely impaired. The MDS indicated Resident 7 required setup or clean-up assistance with oral hygiene, upper body dressing, and personal hygiene. A review of Resident 7’s H&P, dated 2/7/2026, indicated Resident 7 had fluctuating capacity to understand and make decisions. A review of Resident 7’s Change in Condition (COC), dated 1/29/2026, indicated, on 1/29/2026, Resident 7 had sexually inappropriate behavior towards Resident 61. During an interview on 3/10/2026 at 12:20 p.m., with LVN 3, LVN 3 stated, on 1/29/2026, Resident 61 informed her that Resident 7 tried to touch his genitals. LVN 3 stated after separating Residents 7 and 61 she reported the incident to Registered Nurse (RN) 1 and the Administrator (ADM). LVN 3 stated she reported the incident to the ADM because “it is a sensitive situation and could be seen as an allegation of sexual abuse.” LVN 3 stated the ADM was the abuse coordinator and all abuse allegations were reported to him. During an interview on 3/12/2026 at 10:18 a.m., with the ADM, the ADM stated he was responsible for reporting all abuse allegations to the CDPH, law enforcement, and Ombudsman. The ADM stated he was unaware of Resident 61 allegation against Resident 7. The ADM stated staff had the ability to report to the three reporting agencies, however, the staff were responsible for notifying him to ensure that not only the allegation was reported but investigated. The ADM stated immediate reporting was necessary to ensure a thorough investigation was carried out by not only him but by CDPH. A review of the facility’s Policy and Procedure (P&P) titled, “Abuse Investigation and Reporting”, revised 1/2026, indicated all alleged violations involving abuse, neglect, exploitation, or mistreatment would be reported by the facility’s Administrator or designee to the state licensing/certification agency, the local/State ombudsman, and law enforcement officials immediately but no later than two hours. The facility failed to: 1. Report an abuse allegation to CDPH, the Ombudsman, and local law enforcement after Resident 7 allegedly touched Resident 61’s genitals. As a result, there was a delay of an onsite investigation by CDPH and had the potential to result in abuse to all residents in the facility. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.