Health inspection·January 7, 2026

F609 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(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. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual’s obligation to comply with the following reporting requirements. (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 §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 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 11/25/2025 and 11/26/2025, the California Department of Public Health (CDPH- a governmental body or institution established by a state government to perform specific functions or responsibilities like enforcing laws) conducted an unannounced visit at the facility to investigate a facility reported incident (FRI) regarding an abuse (willful infliction of injury resulting to physical harm/pain or mental anguish) incident between Resident 1 and 2 on 11/25/2025 at 4:30 PM. The facility failed to report an alleged abuse to the State Survey Agency (CDPH), Ombudsman (OMB- advocated for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement (PD) in accordance with State law within two (2) hours after the allegation of abuse was made by Resident 1. This deficient practice 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 indicated Resident 1 is a 72-year-old-female resident who was initially admitted to the facility on 7/9/2025 and was readmitted on 11/6/2025 with diagnoses that included hereditary and idiopathic neuropathy (a disorder causing slow weakness, numbness, tingling, and foot deformities with nerve damage), chronic obstructive pulmonary disease (COPD- a long-term lung disease causing difficulty breathing), bronchiectasis unspecified (a chronic lung condition where the airways become permanently widened and damaged). A review of Resident 1’s Minimum Data Set (MDS- a resident assessment tool), dated 10/16/2025, indicated Resident 1 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 was independent (resident completes the activity by themselves with no assistance from a helper) with eating, toileting/personal hygiene, and upper/lower body dressing. The MDS indicated Resident 1 required setup or clean-up assistance with sit to lying, sit to stand, and toilet transfer. A review of Resident 2’s Admission Record indicated Resident 2 is a 68-year-old male resident who was admitted to the facility on 8/26/2025 with diagnoses that included other COPD, hypertensive heart disease (a medical condition where the heart is affected by high blood pressure), and schizophrenia (a mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). A review of Resident 2’s MDS, dated 9/2/2025, indicated Resident 2 was assessed to have intact memory and cognitive skills for daily decision making. The MDS indicated Resident 2 required supervision or touching assistance with eating, oral/toileting hygiene, upper body dressing, personal hygiene, sit to stand and toilet transfer. The MDS indicated Resident 2 required partial/moderate assistance with shower/bathe self, lower body dressing, and tub/shower transfer. A review of Resident 2’s Change of Condition (COC) form, dated 11/25/2025 entered at 5:47 PM, indicated Resident 1 came up to staff in the hallway, reporting that a resident in Room A (Resident 2) had allegedly rolled Resident 2’s wheelchair into Resident 1’s arm. The COC form indicated the resident (Resident 2) was coming out from the activities room when Resident 1 claimed that Resident 2 bumped Resident 1’s arm with Resident 2’s wheelchair. During an interview on 11/26/2025, at 10:37 AM with Resident 1, Resident 1 stated, on 11/25/2025 at approximately 4:40 PM, Resident 2 came out of the Activities Room and saw Resident 1 wheel herself to the Nurse’s Station. Resident 1 stated Resident 2 sped up his wheelchair when Resident 2 saw Resident 1 and Resident 2 rammed his wheelchair against Resident 1. Resident 1 stated Resident 2’s wheelchair hit her left arm and Resident 2 also kicked her left leg. Resident 1 stated she immediately informed Licensed Vocational Nurse 2 (LVN 2), LVN 3, and the Assistant Director of Nursing (ADON) about the incident with Resident 2. Resident 1 stated she saw the Social Services Director (SSD), ADON, and the Administrator (ADM) go to the office to talk about the incident after it happened. Resident 1 stated the police did not come and talk to her after the incident. During an interview on 11/26/2025, at 12:07 PM, with LVN 2, LVN 2 stated that on 11/25/2025, at around 4:45 PM, Resident 1 informed LVN 2 that Resident 2 hit her left arm with Resident 2’s wheelchair while Resident 2 is on the way to the Nurse’s Station. LVN 2 stated ADON, the Director of Nursing (DON), and Administrator (ADM) were notified about the incident between Resident 1 and 2. LVN 2 stated what Resident 1 reported about the incident with Resident 2 prompted an investigation of an allegation of abuse. LVN 2 stated if an investigation is prompted then abuse was suspected and should be reported to CDPH immediately or within two hours of the incident or when the allegation was made. LVN 2 stated he was not sure if the incident between Resident 1 and 2 was reported to CDPH. During an interview on 11/26/2025, at 12:59 PM, with SSD, SSD stated that on 11/25/2025, at approximately 5:20 PM, SSD was notified that Resident 2 allegedly ran over and hit Resident 1’s left arm with Resident 2’s wheelchair. SSD stated he did not know if the incident between Resident 1 and 2 was reported to CDPH. During an interview on 11/26/2025 at 1:13 PM, with the ADM, the ADM stated she was informed about the incident between Resident 1 and 2 on 11/25/2025, at approximately 5 PM. The ADM stated she did not report the incident to CDPH, local PD and OMB because she did not see any contact between Resident 1 and 2 in the hallway when she checked the closed-circuit television (CCTV- video surveillance). ADM stated suspected abuse should be reported to CDPH immediately or within 2 hours of the incident or when the allegation was made on 11/25/2025 around 4:45 PM. ADM stated abuse was suspected if the incident prompted her to check the CCTV. ADM stated she should have reported the incident between Resident 1 and 2 to CDPH. During an interview on 11/26/2025, at 3:32 PM, with ADON, ADON stated she and the ADM watched the CCTV recording after Resident 1 reported the alleged abuse by Resident 2 last 11/25/2025 around 4:45 PM and did not see Resident 2 hit Resident 1. The ADON stated they thought the facility did not need to fill out an SOC 341 (abuse reporting form) form and report the incident to CDPH since there was no proof or witness regarding what happened between Resident 1 and 2. A review of the facility’s policy and procedure (P&P), titled, “Abuse Investigation and Reporting,” revised on 1/21/2025, indicated the following: * All reports of resident abuse shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. * All alleged violations involving abuse will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: the State licensing/certification agency responsible for surveying/licensing the facility; the local/State Ombudsman; Law enforcement officials. * An alleged violation of abuse will be reported immediately, but not later than: two hours if the alleged violation involves abuse OR has resulted in serious bodily injury. A review of the facility’s P&P, titled, “Abuse Prevention Program,” revised on 2/21/2025, indicated as part of the resident abuse prevention, the administration will investigate and report any allegations of abuse within timeframes as required by federal requirements. The facility failed to report an alleged abuse to CDPH, OMB, and PD in accordance with State law within two (2) hours after the allegation of abuse was made by Resident 1. This deficient practice 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.