Health inspection·October 22, 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) 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. On 7/10/25, an unannounced visit was conducted at the facility to investigate a Complaint regarding Resident/Patient/Client Abuse. The facility failed to follow their abuse reporting policy and procedure for Resident 1. This failure had the potential to compromise Resident 1's safety. During an interview with the Director of Nursing (DON) on 7/10/25 at 10:06 a.m., the DON had been notified of an allegation of abuse. During an interview with Resident 2 on 7/10/25 at 10:16 a.m., Resident 2 was sitting on his wheelchair and stated that on 6/25/25 around 3 a.m., to 5 a.m., a male CNA was rough when changing his roommate's (Resident 1) incontinent brief and he reported the incident to the nurse. During an interview with Resident 2 on 7/10/25 at 2:15 p.m., Resident 2 stated that on 6/25/25 he reported the alleged rough handling of Resident 1 to "the woman medication charge nurse." Resident 2 further stated he was asked what exactly happened. Review of Resident 2's clinical records he was admitted to the facility on 2/14/23 with diagnosis including post-traumatic stress disorder (a mental health condition that develops after experiencing or witnessing a traumatic event). Resident 2's minimum data set (MDS, an assessment tool) dated 5/5/25 indicated his 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 was 15 (score of 15 indicates cognition [ability to remember, judge and use reason] is intact). During an interview on 7/17/25 at 10:56 a.m., with Certified Nursing Assistant B (CNA B), CNA B acknowledged that he was the CNA assigned for Resident 1 at night shift on 6/25/25. CNA B stated that he did not roughly handle Resident 1 during incontinent brief change. CNA B denied that Resident 2, the roommate of Resident 1, notified the charge nurse about a CNA roughly handling Resident 1 during incontinent brief change. During an interview on 7/23/25 at 2:25 p.m., with Licensed Vocational Nurse A (LVN A), LVN A stated that she was the full-time charge nurse working night shift for Resident 1 and did not observe or there was no report of any suspicious of abuse to Resident 1 on 6/25/25. LVN A denied that Resident 2, the roommate of Resident 1, notified her about a CNA that roughly handled Resident 1 during incontinent brief change. During an interview with the DON on 8/13/25 at 12:27 p.m., the DON stated that the allegation of abuse was not brought to her attention by LVN A and CNA B that were interviewed by CDPH (California Department of Public Health) on 7/17/25 and 7/23/25. The DON further stated if they were notified by anyone other than CDPH they would have reported it to CDPH, Ombudsman (long term care ombudsman. representatives that assist residents in the long term care facilities with issues related to day to day care, health and safety concerns) and Police. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, dated 2001. The P&P indicated, ...1. If Resident Abuse, Neglect, Exploitation, misappropriation of resident property, or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The facility failed to report an allegation of abuse for Resident 1. This failure had the potential to delay abuse investigations and compromise Resident 1's safety. The above violation had a direct or immediate relationship to the health, safety, or security of the residents.