Health inspection·March 9, 2026

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 CCR § 72315 Nursing Service-Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 22 CFR § 72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be implemented to ensure that patient related goals and facility objectives are achieved. § 72527 Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. On 1/23/2026, the California Department of Public Health (CDPH) received a complaint indicating an employee hitting Resident 1's bilateral shin (lower leg) area with a back scratcher and was noted to have yellowish/purplish skin discoloration. On 1/23/2026, the CDPH conducted an unannounced visit at the facility to investigate the allegations. The facility failed to: 1). Investigate and report to the CDPH when Resident 1's left dorsal hand (back of hand) had yellowish-purplish skin discoloration on 1/21/2026 and ecchymosis (a type of bruise caused by blood leaking from broken blood vessels into the skin, resulting in a flat, discolored patch) on 1/23/2026. 2). Implement its policy and procedure (P&P) titled, "Abuse Prevention and Management," dated 6/12/2024, which indicated, when the Administrator or designated representative received a report of an allegation of an injury of unknown source, the Administrator or designated representative, will initiate an investigation immediately and notify the CDPH Licensing and Certification, by telephone, immediately, or as soon as practicably possible, but no longer than two (2) hours. These failures delayed the investigation by the CDPH and placed Resident 1 and other residents at risk of continuous abuse or injury of unknown origin. Resident 1 was a 100-year-old female, originally admitted to the facility on 8/10/2022 and readmitted on 12/12/2025. Resident 1's diagnoses included Chronic Obstructive Pulmonary Disease ([COPD], a chronic lung disease causing difficulty in breathing) and generalized (affecting throughout the body) muscle weakness. A review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated 12/19/2025, indicated Resident 1 had moderate (not extreme) cognitive impairment (problems with the ability to think, remember, and solve problems). The MDS indicated Resident 1 was dependent (helper does all the effort) with Activities of Daily Living (ADLs) such as toileting and personal hygiene. The MDS indicated Resident 1 was dependent on staff in rolling from a lying on back position to her left and right side, from sitting to lying position, lying to sitting on side of bed and sitting to standing position. A review of Resident 1's Change of Condition (COC), dated 1/2/2026, indicated Resident 1 had redness on her left dorsal (back) hand. The COC indicated Resident 1 stated the blood pressure was too tight on her wrist. During a concurrent observation and interview on 1/23/2026 at 12:08 p.m., with Resident 1, Resident 1 had yellowish- purplish skin discoloration on her left dorsal hand. Resident 1 stated the discoloration happened after someone (unnamed) took her blood pressure (BP) too tight (could not recall when) in the left hand. During a concurrent interview and record review on 1/23/2026 at 2:59 p.m., with the Treatment Licensed Vocational Nurse (LVN), Resident 1's COC, dated 1/2/2026 was reviewed. The Treatment LVN stated Resident 1 told her that the redness on Resident 1's left dorsal hand was when someone (unidentified staff) checked her BP and put on the BP cuff on too tight. During an interview on 1/27/2026 at 12:19 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 1/21/2026, she reported to LVN 2, Resident 1's yellowish-purplish skin discoloration on the left dorsal hand. LVN 2 told CNA 1 that he will check on the resident. During an interview on 1/27/2026 at 2:04 p.m., with LVN 2, LVN 2 stated he was not notified by CNA 1 of any skin discolorations on Resident 1's left dorsal hand on 1/21/2026. During an interview on 1/28/2026 at 1:32 p.m., with the Treatment LVN, the Treatment LVN stated, on 1/21/2026, she saw red skin discoloration on Resident 1's left dorsal hand. The Treatment LVN stated on 1/23/2026, the wound physician assessed Resident 1's left dorsal hand as ecchymosis (a type of bruise caused by blood leaking from broken blood vessels into the skin, resulting in a flat, discolored patch). The Treatment LVN stated redness and ecchymosis were different. The Treatment LVN stated ecchymosis could be an injury of unknown origin (a physical injury whose cause cannot be determined and is considered suspicious for potential abuse or neglect, requiring careful assessment and reporting) and should have been reported (unspecified) because of the possibility that Resident 1 might have been injured by a staff. During an interview on 1/28/2026 at 4:03 p.m., with the Administrator (Admin), the Admin stated he was not aware of the unexplained bruising on Resident 1. The Admin stated an injury of unknown origin is when the facility is not sure how the injury happened. The Admin stated an investigation should have been done by asking Resident 1 how it happened. The staff should have investigated the unexplained bruise to rule out abuse. The Admin stated if it came out as an alleged abuse, the facility would report it to CDPH. The Admin stated if the facility concluded it was not abuse; it was not reportable to CDPH. A review of facility's policy and procedure (P&P) titled, "Abuse Prevention and Management," dated 6/12/2024, defined Injury of Unknown Source as, an injury that meets both of the following conditions: the source of the injury was not observed by any person, and the injury was suspicious because of the extent of the injury, the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma). The P&P indicated, when the Administrator or designated representative received a report of an allegation of an injury of unknown source, the Administrator or designated representative, will initiate an investigation immediately and notify the CDPH Licensing and Certification, by telephone, immediately, or as soon as practicably possible, but no longer than 2 hours." The facility failed to: 1). Investigate and report to the CDPH when Resident 1's left dorsal hand had yellowish-purplish skin discoloration on 1/21/2026 and ecchymosis on 1/23/2026. 2). Implement its P&P titled, "Abuse Prevention and Management," dated 6/12/2024, which indicated, when the Administrator or designated representative received a report of an allegation of an injury of unknown source, the Administrator or designated representative, will initiate an investigation immediately and notify the CDPH Licensing and Certification, by telephone, immediately, or as soon as practicably possible, but no longer than 2 hours." These failures delayed the investigation by the CDPH and placed Resident 1 and other residents at risk of continuous abuse or injury of unknown origin. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.