Health inspection·October 10, 2025

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 if the events that cause the suspicion do not result in serious bodily injury. §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. §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. California Health and Safety Code § 1418.91 (a)(b) (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. Welfare and Institutions Code (WIC) section 15630 (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, suspected, or alleged 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. (A) If the known, suspected, or alleged abuse occurred in a long-term care facility, except a state mental health hospital or a state developmental center, the following shall occur: (i) If the abuse was allegedly caused by another resident of the facility with dementia diagnosed by a licensed physician and there was no serious bodily injury, the reporter shall submit a written report of the known, suspected, or alleged instance of abuse to both of the following agencies within 24 hours: (I) The long-term care ombudsman. (II) The local law enforcement agency. (ii) In all other instances, immediately or as soon as practically possible, but no longer than two hours, the reporter shall submit a verbal report of the known, suspected, or alleged instance of abuse to the local law enforcement agency, and shall submit a written report to all of the following agencies within 24 hours: (I) The long-term care ombudsman. (II) The local law enforcement agency. (III) The corresponding state licensing agency. Cal. Code Regs. Tit. 22, § 77036 - Unusual Occurrences An unusual occurrence means any condition or event which has jeopardized or could jeopardize the health, safety, security or well-being of any patient, employee or any other person while in the facility and shall include, but not be limited to: (8) All instances of patient abuse. On 8/18/25 to 8/25/25, an unannounced visit was conducted at the facility for a recertification survey to investigate a Facility Reported Incident regarding Resident/Patient/Client/Abuse. The facility failed to report allegations of abuse to the appropriate agencies, including the California Department of Public Health (CDPH), within the required timeframe involving two of six sampled residents (Residents 37 and 91). This failure to report allegations of abuse placed Residents 37 and 91 at risk of potential abuse. Findings: Review of Resident 37's Face Sheet (summary page of a patient's important information) indicated Resident 37 was admitted to the facility on 1/17/25 with diagnoses including Schizophrenia (a chronic mental health condition that affects a person's thoughts, perceptions, and behaviors), Anxiety Disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness), Depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities previously enjoyed). Review of Resident 37's Minimum Data Set (MDS, a standardized assessment tool), dated 7/25/25, indicated Resident 37 had a Brief Interview for Mental Status (BIMS, an assessment tool for cognition) score of 10, indicating Resident 37 had a moderate cognitive impairment (decline in one or more cognitive abilities, such as memory, attention, language, reasoning, and problem-solving.) Review of Resident 91's Face Sheet indicated Resident 91 was admitted to the facility on 11/14/23 with diagnoses including Unspecified Dementia, Unspecified Severity, with Agitation (form of dementia that cannot be specified by its type or cause, has not been classified by severity and involves agitated behaviors such as restlessness, shouting, aggression, or physical violence), Cognitive Communication Deficit (a group of impairments that affect a person's ability to communicate effectively due to underlying cognitive difficulties). Review of Resident 91's MDS dated 5/15/25, indicated Resident 91 had a BIMS score of 5, indicating Resident 91 had a severe cognitive impairment (significant decline in cognitive abilities that interfere with daily functioning and independence.) During an observation and interview on 8/18/25 at 2:06 p.m., in resident's room. Resident 37 was sitting in the wheelchair. Resident 37 stated his roommate had "tried to hit him during the night." Resident 37 reported he told the staff at the time of the incident, and staff offered him a room change, which he declined. Resident 37 became agitated when asked further questions. During an interview with Licensed Vocational Nurse P (LVN P) on 8/21/25 at 12;18 p.m., LVN P stated Resident 37 had told her "a couple of weeks ago" that his roommate wanted to hit him. LVN P stated she did not document the allegation because "nothing happened." LVN P stated she did not notify the Director of Nursing (DON) or the Administrator (ADM) but reported it to the Social Service Director (SSD). LVN P stated a room change was offered, but Resident 37 declined. During a concurrent interview and record review with the SSD on 8/22/25 at 11:00 a.m., the SSD stated she was not made aware of Resident 37's allegation until 8/18/25. The SSD provided a "Behavior Note" Progress Note, dated 8/15/25 at 20:03, which indicated: "Resident 37 insisting his roommate hit him while he was taking a nap just now...If his roommate does it again, he is going to punch him in the face." The SSD stated the note showed an abuse allegation and confirmed it should have been reported immediately to the ADM, CDPH, police, and Ombudsman (a neutral advocate for residents of long-term care facilities, acting independently to protect their health, safety, welfare, and rights). During a concurrent interview and record review with the DON on 8/22/25 at 3:50 p.m., the DON stated she was not aware of Resident 37's allegation regarding his roommate until 8/18/25. The DON reviewed the 8/15/25 Behavior Note, the DON confirmed the Behavior Note was an abuse allegation that should have been reported immediately to CDPH, the police, and Ombudsman. During a concurrent interview and record review with the ADM on 8/25/25 at 3:18 p.m., the ADM stated he was not aware of Resident 37's allegation until 8/18/25. The ADM confirmed the allegation should have been reported immediately as per the facility's abuse policy. Review of the facility's policy, titled "Abuse Reporting and Investigation," updated 5/2025, indicated "The Facility staff will report ALL allegations of abuse...as required by law and regulations to the appropriate agencies within 2 hours...For incidents involving resident on resident abuse that did not result in bodily harm where the alleged abuser is a resident diagnosed with Dementia, the facility is required to notify the ombudsman and local law enforcement in writing within 24 hours. The facility must still report to appropriate agencies within 2 hours..." The facility failed to report allegations of abuse to the appropriate agencies, including the California Department of Public Health (CDPH), within the required timeframe involving two of six sampled residents (Residents 37 and 91). This failure to report allegations of abuse placed Residents 37 and 91 at risk of potential abuse. The above violation had a direct or immediate relationship to the health, safety, or security of the residents in the facility.