Health inspection·February 6, 2026

F609 42 CFR §483.12(b) The facility must develop and implement written policies and procedures that: (b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. 42 CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(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 § 72527 Patient’s 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. 22 CCR § 72315 Nursing Service - Patient Care (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. (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 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. On 12/19/2025 at 12 NN, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint allegation of abuse to Resident 1. The facility failed to: 1. Investigate an allegation of abuse by Resident 2 to Resident 1 on 12/18/2025. On 12/18/2025, Resident 1 reported to Registered Nurse 1 (RNS 1) that Resident 1 was getting harassed (to experience persistent, unwelcome conduct that is offensive, intimidating, or humiliating, often targeting a person’s protected traits like race, gender, or religion, or simply making them feel threatened, distressed, or that creates a hostile environment) and assaulted (threatening or attempting to physically harm someone, causing them to reasonably fear immediate injury, even without actual contact) by Resident 2. 2. Report an alleged abuse (willful infliction of injury resulting to physical harm/pain or mental anguish) to the State Survey Agency (California Department of Public Health-CDPH- where state law provides for jurisdiction in long-term care facilities), Ombudsman (OMB- advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement (PD) within two (2) hours after the allegation of abuse between Resident 1 and 2 was reported to RNS 1 and before Resident 1 contacted the local PD herself. These deficient practices had the potential to place Resident 1 and 2 at risk for further abuse and/or under reporting from the facility. A review of Resident 1’s Admission Record, the Admission Record indicated Resident 1 is a 63- year- old- female resident who was admitted to the facility on 12/9/2025 with diagnoses that included type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), essential hypertension (HTN- high blood pressure), and schizoaffective disorder (a mental health problem where a person experiences loss of contact with reality as well as mood symptoms). A review of Resident 1’s Minimum Data Set (MDS- a resident assessment tool), dated 12/13/2025, the MDS indicated Resident 1 was assessed to have moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 required supervision or touching assistance with eating, oral/toileting hygiene, upper/lower body dressing, putting on/taking off footwear, sit- to- lying, sit- to- stand, and toilet transfer. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with shower/bathe self. A review of Resident 2’s Admission Record, the Admission Record indicated Resident 2 is a 83-year-old- female resident was initially admitted to the facility on 9/3/2024 and was readmitted on 1/30/2025 with diagnoses that included malignant neoplasm of vulva (a rare cancer of the external female genital), chronic diastolic heart failure (when the heart muscle gets stiff making it hard to relax and fill with enough blood between beats), and cardiomegaly (enlarged heart). A review of Resident 2’s MDS, dated 10/20/2025, the MDS indicated Resident 2 was assessed having moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 2 required supervision or touching assistance with eating. The MDS also indicated Resident 2 required partial/moderate assistance with oral/toileting/personal hygiene, upper/lower body dressing, sit- to- stand, and toilet transfer. During an interview on 12/19/2025, at 12:50 PM, with Resident 1, Resident 1 stated, on 12/16/2025 (unable to recall time), Resident 1 saw Resident 2 go through her clothes. Resident 2 punched Resident 1 on the chest when Resident 1 told Resident 2 to stop. Resident 1 stated Resident 2 called her a “hoe (a derogatory slang term often used for a promiscuous woman)” and told her (Resident 1) to kiss Resident 2’s black ass. Resident 1 stated she reported the incident to RN 1 on 12/18/2025 (unable to recall time). Resident 1 stated she called the PD and reported the abuse incident with Resident 2 to RN 1 on 12/18/2025. During an interview on 12/19/2025, at 2:08 PM, with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated, facility staff were all mandated reporters (a person who is legally required to report known or reasonably suspected abuse to authorities). CNA 1 stated suspected abuse, or an allegation of abuse should be reported to CDPH, Ombudsman, and police immediately or within two hours from the incident or from when the staff was made aware. During an interview on 12/19/2025, at 2:24 PM, with CNA 2, CNA 2 stated abuse should always be reported to the three State Agencies for the safety of the residents. CNA 2 stated that abuse should be reported immediately or within two hours even if it was not witnessed by staff. During an interview on 12/19/2025, at 2:41 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated if Resident 1 reported to the staff the resident was hit by another resident, then the staff should report the incident to the abuse coordinator and the three State Agencies (CDPH, local PD and Ombudsman). LVN 1 stated it was the facility’s policy to report suspected abuse to the abuse coordinator and the three State Agencies right away or within two hours of the incident. During a concurrent interview and record review on 12/19/2025, at 3:02 PM, with Social Services Director (SSD), Resident 1’s Progress Note, dated 12/18/2025, was reviewed. SSD stated the Progress Note indicated Resident 1 was assaulted by another resident (Resident 2) and Resident 1 had called the police and CDPH on 12/18/2025. SSD stated she was not informed that Resident 1 reported getting assaulted by Resident 2. SSD stated she was not informed that Resident 1 called the police and the police came and talked to Resident 1 on 12/18/2025. SSD stated RNS 1 should have reported Resident 1’s abuse allegation to the abuse coordinator and the Director of Nursing (DON) or the ADM will then start and conduct an investigation about the abuse incident to find out what happened. SSD stated it was important to report abuse to the State Agencies, to investigate thoroughly and to have documentation on what took place and to ensure the safety of the residents involved. SD stated Resident 1’s abuse allegation should have been reported to the State Agencies immediately or within two hours after the allegation was made. During an interview on 12/19/2025, at 3:24 PM, with RNS 1, RNS 1 stated on 12/18/2025, Resident 1 was agitated and upset about her HTN medication. RNS 1 stated while she was trying to calm Resident 1 down, Resident 1 informed her that Resident 1 was being harassed in the facility and was assaulted by Resident 2. RNS 1 did not report Resident 1’s allegation of abuse by Resident 2 to the Administrator (ADM). RNS 1 stated that according to the facility’s abuse policy, any report of abuse should be investigated and reported to the abuse coordinator. RNS 1 stated the reported incident between Resident 1 and 2 should have been reported to the three State Agencies immediately or within two hours after Resident 1 reported it to her. RNS 1 stated it was important to report any allegation of abuse and investigate the abuse allegation to find out if the abuse did or did not occur and to prevent further abuse. RNS 1 stated she did not follow the facility’s abuse policy. During an interview on 12/19/2025 at 4:06 PM, with the DON, the DON stated he saw the police arrive at the facility on 12/18/2025. The DON stated he was informed by RNS 1 that Resident 1 was the one who called and spoke to the police. The DON stated he did not know the reason for the police visit and the DON did not ask or investigate why the police came. The DON stated RNS 1 did not inform him on 12/18/2025 that Resident 1 reported to RNS 1 that Resident 1 was getting harassed and was assaulted by Resident 2. The DON stated if there is any report of suspected abuse, it should be reported to the State Agencies within two hours. The DON stated it was important to report suspected abuse to the abuse coordinator, CDPH, Ombudsman, and police so an investigation can be started, prevent future abuse in the facility, and for the safety of the residents. During a review of the facility’s policy and procedure (P&P), titled, “Abuse Prevention and Prohibition Program,” revised 8/2023, the P&P indicated the following: 1. The Facility promptly and thoroughly investigates reports of resident abuse. 2. The Administrator will submit initial and follow-up written reports of the results of abuse investigations and consequent actions to the appropriate agencies. 3. The Facility shall retain documentation relating to the investigation in a separate investigation file. 4. The Facility will report allegations of abuse immediately but no later than 2 hours after forming the suspicion- if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman. 5. A telephone or internet report of known or suspected instance of abuse shall include the following information if known: a. The name of the person making the report; b. The name and age of the resident; c. The present location of the resident; d. The names and addresses of the resident’s responsible party, family members, or any other adult responsible for the resident’s care; e. The nature and extent of the resident’s condition; f. The date of the incident; and g. Any other information, including information that led to that person to suspect abuse. 6. The Investigator may record the initial investigation results on an initial report form and must complete and submit the CDPH SOC 341 (a form used by healthcare workers to report suspected abuse in California). 7. The Investigator provides a copy of the completed investigation report to the Administrator within 5 working days of the initial report. The Facility will submit a follow-up investigative report form or a substantively similar form. The facility failed to: 1. Investigate an allegation of abuse by Resident 2 to Resident 1 on 12/18/2025. On 12/18/2025, Resident 1 reported to RNS 1 that Resident 1 was getting harassed and assaulted by Resident 2. 2. Report an alleged abuse to CDPH, OMB and local PD within 2 hours after the allegation of abuse between Resident 1 and 2 was reported to RNS 1. These deficient practices had the potential to place Resident 1 and 2 at risk for further abuse and/or under reporting from the facility. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1 and 2.