Health inspection·March 13, 2026

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. 22 CCR § 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility 42 CFR §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. An unannounced recertification visit was conducted by California Department of Public Health (CDPH) on 1/29/2026 to investigate an alleged abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) complaint. The facility failed to follow its policy and procedure to ensure an allegation of physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) was reported to California Department of Public Health (CDPH), local law enforcement, and Ombudsman (an official appointed to investigate individuals' complaints against the facility) within two (2) hours for Resident 1 reviewed for abuse.   This deficient practice had the potential to compromise or impede the protection of Resident 1 from potential physical abuse, which could negatively affect Resident 1’s physical and/or emotional wellbeing and risk for further abuse. A review of Resident 1’s Admission Record, the Admission record indicated Resident 8 was admitted to the facility on 9/30/2025, with the diagnoses including but not limited to schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), bipolar disorder (mental disorder characterized by episodes of mania [extreme highs] and depression [extreme lows]), and cellulitis (an infection of the deeper layers of skin and the underlying tissue) of left lower limb.   A review of Resident 1’s Minimum Data Set (MDS, a resident’s assessment tool), dated 11/12/2025, the MDS indicated Resident 8’s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were intact. The MDS indicated Resident 8 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for toileting hygiene, shower/bathing self, sitting to standing, and walking ten feet.   A record review of Resident 1’s Care Plan, dated 1/27/2026, Resident 1 indicated Resident 8 had an allegation that he was struck by a shadow a month ago. The nursing staff interventions were to closely monitor the resident’s whereabouts through visual checks; room visits every two hours and as needed to ensure safety and assess comfort and needs and follow abuse prohibition protocol.   A record review of Resident 8’s SBAR (an acronym for Situation-Background-Assessment-Recommendation is a technique used to provide a framework for communication between members of the health care team), dated 1/26/2026, the SBAR indicated Resident 1 stated during interview with surveyor that one month ago, someone struck him on his rib and he only saw a shadow.   A concurrent observation and interview on 1/26/2026 at 10:04 AM in Resident 1’s room, Resident 1 was sitting on the side of his bed. Resident 1 stated a month ago (unable to recall exact date) someone hit him really hard and cracked his ribs. Resident 1 stated he was sitting on his bed just as he was doing at the moment and reading when someone hit him really hard and cracked his ribs. Resident 1 stated he did not see who hit him on his right ribs but only saw a shadow.   During an interview on 1/26/2026 at 10:27 AM with the Administrator (ADM) and Director of Nursing (DON), ADM and DON stated Resident 1 made an allegation of abuse. ADM and DON stated being informed that Resident 1 stated someone had hit him on his right ribs but did not see who it was and that he only saw a shadow.   During an interview on 1/27/2026 at 3:33 PM with the DON, the DON stated Resident 1 stated he was struck by a shadow. The DON stated Resident 1 stated he could not continue the conversation since he was going to strike out at the DON.   During an interview on 1/27/2026 at 4:12 PM with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated on 1/26/2026, Resident 1 stated he was struck by a shadow on his right side. RNS 1 stated the DON was notified of Resident 1’s allegation.   During an interview on 1/27/2026 at 4:48 PM with the DON, the DON stated an allegation of abuse when there is actual harm from a staff member hitting a resident would be reported to the ADM who was the abuse coordinator. The DON stated an SOC 341 (Report of Suspected Dependent Adult/Elder Abuse form) would be completed and sent to the California Department of Public Health, Ombudsman, and police. The DON stated the facility did not report the allegation since Resident1 stated a shadow struck him. The DON stated she should have reported the allegation of abuse since striking was physical abuse. The DON stated that when there is an allegation of abuse the ADM is informed and an SOC 341 is sent to CDPH, Ombudsman, and the police department. The DON stated the DON was thinking it was Resident 1’s mentation and behavior given his mental diagnosis and illness and therefore did not report his allegation of abuse.   During a concurrent interview and record review on 1/29/2026 at 10:26 AM with the DON of the facility’s policy and procedure (P&P), the DON stated any allegation of abuse should be reported within two hours. The DON stated based on the P&P all reports of resident abuse are reported are reported to local, state and federal agencies within two hours of an allegation involving abuse.   During an interview on 1/29/2026 at 2:30 PM with the Administrator (ADM), the ADM stated the facility did not and should have reported the allegation of abuse for Resident 1 when they were informed on 1/26/2026.   During a record review of the facility’s P&P titled, “Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating,” revised September 2022, the P&P indicated all reports of resident abuse are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; e. Law enforcement officials. Immediately it is defined as within two hours of an allegation involving abuse. Notices include the type of abuse that is alleged (i.e., verbal, physical, sexual, neglect, etc.). The facility failed to follow its policy and procedure to ensure an allegation of physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) was reported to California Department of Public Health (CDPH), local law enforcement, and Ombudsman (an official appointed to investigate individuals' complaints against the facility) within two (2) hours for Resident 1 reviewed for abuse.   This deficient practice had the potential to compromise or impede the protection of Resident 1 from potential physical abuse, which could negatively affect Resident 1’s physical and/or emotional wellbeing and risk for further abuse. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of residents 1.