Health inspection·April 22, 2026

F607 §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,

F609 §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. HSC § 1418.91 (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. WIC § 15630 (a) (b) (a) A person who has assumed full or intermittent responsibility for the care or custody of an elder or dependent adult, whether or not they receive compensation, including administrators, supervisors, and any licensed staff of a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care custodian, health practitioner, clergy member, or employee of a county adult protective services agency or a local law enforcement agency, is a mandated reporter. (b)(1) A mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that they have experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an internet report shall be made through the confidential internet reporting tool established in Section 15658, within two working days. (C) If the suspected or alleged abuse is abuse other than physical abuse, and the abuse occurred in a long-term care facility, except a state mental health hospital or a state developmental center, a telephone report and a written report shall be made to the local ombudsman or the local law enforcement agency. CRR§ 72523(a) 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. 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. §72527. Patients' Rights (a)(10) To be free from mental and physical abuse During an annual recertification survey conducted from 3/9/2026 to 03/12/2026, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) while onsite and initiated an onsite investigation into Resident 47's reported allegation of abuse. The facility failed to: 1.Protect the resident's right to be free from physical abuse when Resident 78 hit Resident 47 on the face on 11/7/2025 at 11:40 a.m. inside their shared room, after the physical altercation staff did not separate roommates Resident 47 and Resident 78 2. Follow their abuse policy titled, "Abuse and Neglect Prohibition Policy" to report the physical abuse within the regulation frames of two hours to CDPH and other agencies. As a result of this failure, Resident 47 was placed at risk of physical injury, the facility did not effectively implement its abuse prevention and response policy and procedures, and did not ensure resident safety as required. A review of Resident 47's Admission record indicated the facility admitted Resident 47, a 90-year-old female, on 4/20/2020 and readmitted on 9/20/2025 with diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), dementia (a progressive state of decline in mental abilities), and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). A review of Resident 47's Minimum Data set ([MDS)], a resident assessment tool), dated 2/2/2026, indicated that the resident's cognitive (ability to make decisions of daily living) was moderately impairment. The MDS indicated that Resident 47 required supervision or touching (helper provides verbal cues) assistance with eating. The MDS indicated that Resident 47 required substantial/maximal (helper does more than half the efforts) assistance with toileting, shower/bathe, lower body dressing and putting on/taking off footwear. A review of Resident 78's Admission record indicated the facility admitted Resident 78, a 74-year-old-female, on 10/16/2025 and readmitted on 11/12/2025 with diagnoses including diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia, and history of falling. A review of Resident 78's "History and Physical" (H&P) dated 11/14/2025, the H&P indicated that Resident 78 has fluctuating capacity (ability) to understand and make decisions. A review of Resident 78's care plan report initiated on 10/31/2025 and titled, "Resident 78 has behavior of screaming and cursing to others, throwing things and trying to hit." The care plan intervention indicated "monitor for throwing things and trying to hit. Assist Resident 78 in developing more appropriate methods of coping and interacting." A review of Resident 47's interview report titled "Content of interview" dated 11/7/2025, indicated that "Resident 47 was lying on the bed then suddenly Resident 78's hand hit my right side of the face." During a concurrent interview and record review on 3/11/2026 at 12:45 p.m. with the Director of Nursing (DON), Resident 47 and Resident 78's Incident Report titled "Interdisciplinary Team (IDT-team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) Summary and Recommendations" were reviewed. The DON stated that the incident (on 11/7/2025) was reported by Housekeeper (HK) 1 to Licensed Vocational Nurse (LVN) 4. The DON stated that LVN 4 interviewed both residents and documented on Resident 47's IDT note that "Resident 78 was sitting on the edge of the bed while Resident 47 was in her bed. HK 1 observed Resident 78 stood up and took steps forward and suddenly leaned and fell on top of Resident 47. Resident 78 showed aggressive behavior and started cursing at Resident 47." During an interview on 3/11/2026 at 12:45 p.m. with the DON, The DON stated that staff should have immediately separated the residents (on 11/7/2025). The DON stated the incident could have been prevented if HK 1 had called for assistance when Resident 78 attempted to get up, rather than observing without intervening. The DON defined abuse as any action in which one person does harm to another. The DON stated that there is no documentation in nursing progress notes indicating a room change or that the residents were separated. The DON stated that nursing staff only documented in "nursing progress notes" on 11/7/2025 at 2:04 p.m. regarding the incident between Resident 47 and Resident 78. The DON stated that nursing staff on each shift should have monitored Resident 47 for 72 hours after the incident. The DON stated allegations of abuse, verbal, and physical are investigated and reported (to the CDPH ). The DON stated that everyone in the facility is a mandated reporter and should follow the policy for abuse reporting. During an interview on 3/12/2026 at 9:03 a.m. with HK 1, HK 1 stated that on 11/7/25 in the morning (unknown time), HK 1 entered Resident 47's room to clean. At the time, Resident 78 stood up from the bed to use the restroom, lost balance, and hit Resident 47's right side of face with their hand. HK 1 stated that Resident 47 was lying in bed and Resident 78 was sitting at the edge of the bed prior to the incident. HK 1 reported that after standing, Resident 78 remained next to Resident 47 until a nurse (unknown name) entered the room. HK 1 stated that the incident was reported that same day to LVN 4. HK 1 stated that when HK 1 returned later to continue cleaning, both residents still shared same room. During an interview on 3/12/2026 at 11:18 a.m. with the Administrator (Admin), the Admin stated he was aware of the physical incident that occurred on 11/7/2025 between Resident 47 and Resident 78. The Admin stated that he was aware that allegations including physical abuse and must be reported to all appropriate agencies if needed as soon as possible. The Admin stated that he did not report the physical incident on 11/7/2025. During an interview and record review on 3/12/2026 at 12:30 p.m. with Director of Staff Development (DSD), Resident 47's interview report was reviewed. DSD stated that the day of the incident (on 11/7/2025), she was walking by Resident 47's room and HK 1 informed her that Resident 78 tried to get up and fell towards Resident 47's. The DSD stated that Resident 47 "interview report" on 11/7/2025 indicated, "Resident 47 was lying on the bed then suddenly Resident 78's hand hit my right side of the face." The DSD stated that resident hitting another resident is considered abuse and it should be reported to the local law enforcement agency, Ombudsman and to California Department of Public Health (CDPH). A review of the facility's policy and procedures (P&P) titled, "Abuse and Neglect Prohibition Policy" dated 6/2024, indicated that "Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect, or exploitation the Administrator or designee will perform the following: all alleged violation immediately but not later than twenty four hours-if the alleged violation does not involve abuse and does not result in serious bodily injury. Report the incident to the local Ombudsman or the local law enforcement agency by telephone as soon as possible." A review of the facility's policy and procedures (P&P) titled, "Abuse and Neglect Prohibition Policy" dated 6/2024, indicated that the facility will provide the resident with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe. A review of the facility's policy and procedures (P&P) titled, Abuse and Neglect Prohibition Policy" dated 6/2024, indicated that "If you suspect abuse is a resident-to-resident incident, the resident who has in any way threatened or attacked another will be removed from the setting or situation." The facility failed to: 1.Protect the resident's right to be free from physical abuse when Resident 78 hit Resident 47 on the face on 11/7/2025 at 11:40 a.m. inside their shared room, after the physical altercation staff did not separate roommates Resident 47 and Resident 78 2. Follow their abuse policy titled, "Abuse and Neglect Prohibition Policy" to report the physical abuse within the regulation frames of two hours to CDPH and other agencies. As a result of this failure, Resident 47 was placed at risk of physical injury, the facility did not effectively implement its abuse prevention and response policy and procedures, and did not ensure resident safety as required. This violation(s) caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Patient 47.