Other·August 4, 2025

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident number 963122. The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. A deficiency was written for facility reported incident number 963122 at F-tag 609. HSC § 1418.91 (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. 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. An annual recertification survey was conducted on 5/19/25 - 5/22/25 and Resident 1 reported an allegation of physical abuse. Resident 1 was an 81-year-old female admitted on 3/13/25 with diagnoses of History of falling and Osteoarthritis (stiffness and pain) of the knee. Based on interview and record review, the facility failed to report allegations of physical abuse to the California Department of Public Health (CDPH) within 24 hours for three of four sampled residents (Resident 1, Resident 2, and Resident 3). This failure had the potential for abuse allegations not being investigated and residents experiencing continued physical abuse. Findings: During an interview on 5/19/25 at 3:31 p.m. with Resident 1, Resident 1 stated during her last shower, a CNA (Certified Nursing Assistant 1) described as a big lady, put a lot of soap on her face, and was rubbing her face so hard she could not breathe. Resident 1 stated she tried to stop the CNA (1) but continued to rub soap on her face. Resident 1 stated the CNA did not stop until she screamed and yelled, "Rape! Rape!" Resident 1 stated, "I could not do anything I was naked, and she was bigger than me, I am scared of her." Resident 1 stated she reported the incident to the head of the department and was informed; they were going to keep an eye on the CNA (1). Resident 1 stated CNA 1 still works in the facility and went to her room. During a review of Resident 1's "Minimum Data Set (MDS-comprehensive assessment tool)," dated 3/20/25, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 12 (score of 8-12 means moderate cognitive impairment). During an interview on 5/19/25 at 3:39 p.m. with Director of Nursing (DON), DON stated she was not aware of the abuse incident. During an interview on 5/21/25 at 2:17 p.m. with CNA 1, CNA 1 stated there has been complaints about her being rough a couple months ago, a resident (2) was not happy about the shower she (CNA 1) gave. CNA 1 stated she reported the allegation of physical abuse to the Director of Staff Development (DSD). CNA 1 stated she showered Resident 1 on 5/14/25 and was not happy and started screaming "Rape! Rape!" During an interview on 5/20/25 at 8:29 a.m. with DON, DON stated she spoke with Resident 1 and the incident happened on 5/14/25 (six days ago). During an interview on 6/4/25 at 8:57 a.m. with DON, DON stated she was not aware of all of the three allegations of abuse prior to the survey on 5/19/25 and were not reported to the CDPH. During an interview on 6/4/25 at 9:53 a.m. with DSD, DSD stated she did not receive a report from CNA 1 regarding the allegations of abuse. During a review of the facility's policy and procedure titled, "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating" dated September 2022, the P&P indicated, "Reporting Allegations to the Administrator and Authorities: 3. Immediately as defined as: b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury." In violation of the above cited, the facility failed to report alleged abuse to the Department within 24 hours for Resident 2. This failure resulted in the Department being unaware of the alleged abuse and had the potential to result in abuse to continue. This violation had a direct or immediate relationship to the health, safety, or security of patients, and represents a Class B citation.