Health inspection·May 1, 2025

F609 Reporting of Alleged Violations Section 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Section 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. Section 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. The following citation was written as a result of an unannounced visit to the facility on 4/15/2025 for a Standard Abbreviated Survey. As a result of the investigation, The California Department of Public Health (CDPH) determined that the facility failed to report an incident of physical abuse to the Department for 1 of 4 sampled residents (Resident 4), when Resident 1 was witnessed throwing a walker at Resident 4 hitting his left knee in the facility's rehabilitation room. This failure decreased the facility's potential to protect vulnerable residents and provide a safe environment. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility in early 2025 with multiple diagnoses including Huntington's Disease (a progressive brain disorder that worsens over time causing gradual decline in movement, thinking, and mood). A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 3/24/25, reflected a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14 out of 15 indicating Resident 1 had intact cognition. A review of Resident 4's admission record indicated Resident 4 was admitted to the facility in early 2025 with multiple diagnoses which included chronic kidney disease. A review of Resident 4's MDS, dated 4/7/25, reflected a BIMS score of 13 out of 15 which indicated Resident 4 was cognitively intact. A review of progress notes dated 4/10/2025.... indicated Resident 1 claimed the "Asian man" [Resident 4] "grunted" towards him, making him feel "inferior" to [Resident 4]... [Resident1] states that the "grunt" and "feelings of inferiority and dislike" triggered him to throw his walker " towards [Resident 4]..." During a telephone interview on 4/15/25 at 11:34 a.m. with Director of Rehab (DOR), the DOR stated Resident 1 came back from a walk with staff and returned to the rehab room. While in the rehab room and out of nowhere, Resident 1 threw their walker at Resident 4. DOR stated the situation was unprovoked. DOR confirmed what he observed was a resident to resident abuse. DOR stated that he informed the facility's Administrator and DON (Director of Nursing) of the incident, and they had informed the DOR that it had been reported and they would handle the documentation further. DOR confirmed he is a mandated reporter. During an interview on 4/15/25 at 1:15 p.m. with Physical Therapy Assistant (PTA) in the rehabilitation room, the PTA stated she witnessed the incident together with the DOR. PTA stated she saw [Resident 4] get hit by the walker, saw it hit [Resident 4's] left knee, "we checked it." PTA further stated after the walker was thrown by Resident 1, Resident 1 got up again and attempted to attack Resident 4 and tried to hit him again and was screaming at him. PTA stated the DOR and PTA held him back, he wasn't responding to questions and was focused on that situation. PTA further stated they managed to get him [Resident 1] in the wheelchair and to leave the rehab room. PTA further stated she understood there was a state telephone line that could have been called for reporting witnessed altercations and confirmed she was a mandated reporter. During an interview on 4/15/25 at 11:43 a.m. with Licensed Nurse 1 (LN 1) assigned to Resident 1 and Resident 4 in the hallway, the LN 1 stated Resident 1 reported Resident 4 grunted at him in rehab room which is why he tried to throw a walker towards Resident 4 and tried to harm Resident 4. LN 1 further stated Resident 1's family member had told LN he had a history of throwing things at others due to diagnoses of Huntington's disease. During a follow up interview on 4/15/25 at 12:56 p.m. with LN 1 assigned to Resident 1 and Resident 4, LN 1 stated this was a resident-to-resident altercation that was unprovoked, and the LN added she had interviewed both residents. LN further stated it should have been reported to the Department. During an interview on 4/15/25 at 11:57 a.m. with Director of Nursing (DON) in the DON's office, the DON stated [Resident 1] stated [Resident 4] grunted at him and it provoked him. DON further stated it was not deemed resident to resident abuse by the facility because it was a behavioral outburst so the IDT [interdisciplinary- a group of professionals that collaborates patient care] team treated it as an outburst. During a concurrent follow up interview and record review on 4/15/25 at 1:56 p.m. with DON, the Nurse's progress note dated 4/10/25 was reviewed. The DON stated this was a behavioral incident where Resident 1 tried to harm Resident 4. A review of the facility's policy and procedure titled, "Abuse Investigation and Reporting," dated July 2017 indicated, "... Reporting ... all alleged violations involving abuse, neglect, exploitation or mistreatment... will be reported by the facility Administrator and or his/her designee to... State licensing/certification agency... local ombudsman... Law enforcement official ... will be reported immediately but not later than: ... 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 ...Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury..." This failure decreased the facility's potential to protect vulnerable residents and provide a safe environment. Therefore, the Department determined the facility failed to report an incident of physical abuse to the Department for 1 of 4 sampled residents (Resident 4), when Resident 1 was witnessed throwing a walker at Resident 4 hitting his left knee in the facility's rehabilitation room. This violation had a direct or immediate relationship to the health, safety, or security of long-term care clients.