Health inspection·December 16, 2025

22CCR §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. HSC 1418.91 (a) 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. On 11/10/2025 at 9:20 a.m., the California Department of Public Health (CDPH) received a complaint regarding Nursing Services and Patient Transfer and Discharge Rights. On 11/10/2025, the CDPH conducted an unannounced visit to the facility to investigate the complaint allegations. During the investigating, the CDPH was made aware of an unrelated incident regarding Resident 1's allegation to have been abused by another resident. The facility failed to: 1.Implement its Policy and Procedure (P&P) titled "Abuse Prevention and Management" which indicated the facility will notify and send a written SOC 341 report (Report of Suspected Dependent Adult/Elder Abuse) within 2 hours of an allegation of abuse to the CDPH, law enforcement, and the Ombudsman (an agency who investigates, reports on, and helps settle complaints against the facility) when Resident 1 reported to LVN1 he had been hit by another resident, in the stomach. This resulted in a delay of an investigation by the CDPH and placed Resident 1 at risk for further abuse. Resident 1 was a 70 y/o male, admitted to the facility on 5/25/2025 and readmitted on 6/20/2025. Resident 1's diagnoses included chronic atrial fibrillation (irregular and rapid heart rhythm), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), and chest pain. A review of Resident 1's History and Physical (H&P), dated 6/21/2025, 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 9/14/2025, indicated Resident 1's cognitive (ability to think and reason) skills for daily decision making were intact. The MDS indicated Resident 1 required set-up assistance (helper assist only prior to or following the activity) from staff with oral hygiene, toileting hygiene, and upper and lower body dressing. During an interview on 11/10/2025 at 4:15 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated on 11/9/2025 at approximately 6 p.m., Resident 1 reported to him that he had a verbal altercation with another resident a week ago. LVN 1 stated Resident 1 told him he felt threatened. LVN 1 stated he did not inform anybody of Resident 1's allegation of abuse. LVN 1 stated he did not report Resident 1's allegation of abuse and did not complete the SOC 341 to the CDPH and Ombudsman because it was just an allegation of verbal altercation with no physical contact. During an interview on 11/12/2025 at 9:00 a.m., with Resident 1, Resident 1 stated he reported to LVN 1 at approximately 6 p.m., that he was involved in a verbal altercation and was hit in the stomach by another resident. Resident 1 stated he was more comfortable in reporting an allegation of abuse to LVN 1. During an interview on 11/12/2025 at 9:56 a.m., with the Director of Nursing (DON), the DON stated resident altercations whether physical or verbal should be reported and investigated. The DON stated verbal altercations could lead to physical harm. The DON stated it's a Federal and State requirement to report any allegations of abuse immediately or within 2 hours to the CDPH, Law Enforcement Agency and to the Ombudsman. The DON stated the allegation of abuse by Resident 1 should have been reported to the CDPH and Ombudsman on 11/9/2025, as soon as the staff was made aware. The DON stated it was important to report allegations of abuse to the CDPH in a timely manner to protect the residents involved from further harm. During a concurrent interview and record review on 11/12/2025 at 10:15 a.m., with the Administrator (ADM), the facility's P&P titled, "Abuse Prevention and Management," dated 6/12/2024, was reviewed. The ADM stated the P&P indicated, "The ADM or designated representative will notify law enforcement by telephone immediately but no longer than 2 hours of an initial report and send a written SOC 341 report within 2 hours of an allegation of abuse to the CDPH Licensing and Certification, Law Enforcement, and the Ombudsman." The ADM stated the facility did not follow their abuse reporting policy. The ADM stated everyone was a mandated reporter when it came to abuse. The ADM stated it was important to notify the CDPH within 2 hours because the facility was mandated by the State to investigate any allegations of abuse immediately. A review of the facility's SOC 341 faxed to CDPH on 11/12/2025 at 12:24 p.m., (approximately 58 hours after the allegation was reported to LVN 1) indicated on 11/9/25, Resident 1 was involved in a verbal altercation and possibly hit by another resident. The facility failed to: 1.Implement its (P&P) titled "Abuse Prevention and Management" which indicated the facility will notify and send a written SOC 341 report within 2 hours of an allegation of abuse to the CDPH, law enforcement, and the Ombudsman. This resulted in a delay of an investigation by the CDPH and placed Resident 1 at risk for further abuse. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.