Health inspection·March 6, 2026

22 CCR § 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. 22 CCR § 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility 42 CFR §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. On 1/23/2026 an unannounced visit was conducted by California Department of Public Health (CDPH) to investigate a complaint regarding an allegation of resident-to-resident abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), which a staff claimed that a resident slapped another resident. The facility failed to report an allegation of physical abuse (any intentional and deliberate act of force that results in harm, injury, or trauma to the victim's body; which can include a range of behaviors from hitting, slapping, and punching) between Resident 1 and Resident 2 within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities) and the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), in accordance with the facility's abuse policy. As a result, this deficient practice had the potential to compromise or impede the protection of Resident 1 from potential physical abuse, which could negatively affect Resident 1’s physical and/or emotional wellbeing. A review of Resident 1’s Admission Record, the Admission Record indicated Resident 1 was initially admitted to the facility on 1/25/2022 with diagnoses that included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), unspecified dementia (a progressive state of decline in mental abilities) and peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs). A review of Resident 1’s “History & Physical (H&P),” dated 6/9/2025, the H&P 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 12/26/2025, the MDS indicated Resident 1 had modified independent (some difficulty in new situations only) cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 1 needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, oral and personal hygiene and supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with toileting hygiene. A review of Resident 2’s Admission Record, the Admission Record indicated Resident 2 was initially admitted to the facility on 1/4/2023 with diagnoses that included unspecified dementia, type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and peripheral vascular disease. A review of Resident 2’s “H&P,” dated 5/10/2025, the H&P indicated that Resident 2 did not have the capacity to understand and make decisions. A review of Resident 2’s “MDS,” dated 12/12/2025, the MDS indicated Resident 2 with severely impaired cognitive skills for daily decision making. The MDS also indicates Resident 2 was dependent (helper does all of the effort) with oral, personal and toileting hygiene, shower/bathing self and partial/moderate assistance (helper does less than half the effort) with eating. During an interview on 1/23/2026 at 3:21 PM with the Director of Nursing (DON), the DON stated she and the Administrator were informed on Wednesday 1/21/2026 by the Director of Staffing (DSD) regarding an alleged incident between Residents 1 and 2 on Sunday, 1/18/2026, where Resident 2 allegedly slapped Resident 1. The DON also stated she spoke with Certified Nurse Assistant 1 (CNA 1) on 1/21/2026 and CNA 1 stated Resident 1 and Resident 2 allegedly hit each other in the facility’s activity room on 1/18/2026. During an interview on 1/23/2026 at 3:32 PM with the Administrator, the Administrator stated he was made aware of the alleged incident of abuse on Wednesday 1/21/2026 and investigated the incident without reporting to any agencies. The Administrator also stated because he was informed late, it would have been reported late [alleged incident occurred on Sunday, 1/18/2026] as well but per protocol, once abuse is alleged, it should have been reported to the ombudsman, CDPH, and local law enforcement. During an interview on 1/23/2026 at 3:42 PM with the Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she was informed by a certified nurse assistant (CNA) on the day after the alleged incident, [1/19/2026], that Resident 2 allegedly “slapped” Resident 1. During an interview on 1/26/2026 at 9:31 AM with CNA 1, CNA 1 stated while in the facility’s activity dining room on Sunday 1/18/2026, “It looked as if Resident 2 struck Resident 1,” from my perspective. During an interview on 1/26/2026 at 12:01 PM with the DON, the DON stated facility did not report the alleged incident of abuse because it was investigated within the facility and there was no evidence it occurred. The DON stated the alleged hitting or slapping of a resident is considered abuse and per facility policy, the facility should have reported the alleged incident of abuse within 2 hours on Sunday 1/18/2026 to the ombudsman, CDPH and local law enforcement. The DON further stated it is the responsibility of the facility staff to report to the ombudsman, CDPH, and local law enforcement within the timeframe of 2 hours to protect the residents. During an interview on 1/26/2026 at 12:22 PM with CNA 1, CNA 1 stated on the day of alleged incident [1/18/2026], LVN 1 said she would make a report, so she did not report the alleged incident to the Administrator or any other facility staff that day. During an interview on 1/26/2026 with the Administrator at 12:28 PM, the Administrator stated the facility did not report this alleged incident of abuse to any local, state or federal agencies, but “will next time.” A review of the facility’s policy titled. “Abuse, Neglect, Exploitation or Misappropriation – Reporting and investigating,” revised 9/2022, the policy indicated: A. All reports of resident abuse are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. B. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be immediately reported to the administrator and to the other officials according to state law. C. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility b. The local/state ombudsman c. The resident’s representative d. Adult Protective Services e. Law enforcement officials f. The resident’s attending physician; and g. The facility medical director D. Immediately is defined as within 2 hours of an allegation involving abuse The facility failed to report an allegation of physical abuse (any intentional and deliberate act of force that results in harm, injury, or trauma to the victim's body; which can include a range of behaviors from hitting, slapping, and punching) between Resident 1 and Resident 2 within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities) and the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), in accordance with the facility's abuse policy. As a result, this deficient practice had the potential to compromise or impede the protection of Resident 1 from potential physical abuse, which could result in physical and/or emotional distress for Resident 1. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.