Health inspection·March 4, 2025

§483.12(c) Reporting of Alleged Violations 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. 22CCR §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. HSC 1418.91 (a) Abuse Reporting (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. On 2/6/2025, the California Department of Public Health (CDPH) conducted a standard annual recertification survey. The facility failed to: 1. Implement its Policy and Procedure (P&P) titled, “Reporting Suspected Crimes Under The Federal Elder Justice Act” which indicated the reporting individual will notify local law enforcement immediately by phone and the Long Term care Ombudsman (an agency who investigates, reports on, and helps settle complaints against the facility) and licensing agency (California Department of Public Health) within 2 hours by fax, when an incident involves abuse or serious bodily injury, after Resident 56 alleged to have been kicked in the stomach, two weeks ago, by Resident 14. As a result, there was a delayed investigation by the CDPH. Resident 56 was a 57-year-old male, initially admitted to the facility on 4/6/2021 and readmitted on 8/22/2024 with diagnoses including cerebral infarction (a brain injury caused by a lack of blood flow) and vascular dementia (a condition that affects memory, thinking, and behavior due to reduced blood flow to the brain). A review of Resident 56’s History and Physical (H&P), dated 4/2/2024, indicated Resident 56 did not have the capacity to understand and make decisions. A review of Resident 56’s Minimum Data Set ([MDS] – a resident assessment tool), dated 12/30/2024, indicated Resident 56’s cognitive (ability to think and reason) skills for daily decision making was moderately impaired. The MDS indicated, Resident 56 required supervision (helper provides verbal cues) with eating and oral hygiene and moderate assistance (helper does less than half the effort) with personal hygiene. Resident 14 was a 78-year-old male, initially admitted to the facility on 7/16/2021 and readmitted on 9/27/2023 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and anxiety disorder (a mental health condition that causes excessive fear and worry). A review of Resident 14’s H&P, dated 11/10/2024, indicated Resident 14 did not have the capacity to understand and make decisions. A review of Resident 14’s MDS, dated 11/6/2024, indicated Resident 14’s cognitive skills for daily decision making was intact. The MDS indicated, Resident 14 required supervision (helper provides verbal cues) with oral hygiene and toileting hygiene. During a medication pass observation on 2/6/2025 at 12:30 p.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 56 reported to LVN 3 that he was kicked in the stomach by someone. LVN 3 stated he will talk to Resident 56 later. A review of the facility’s Report of Suspected Dependent Adult/Elder Abuse (SOC 341) faxed to CDPH on 2/7/2025 at 12:16 p.m. (approximately 24 hours after the allegation was reported to LVN 3, indicated Resident 56’s alleged to have been kicked by Resident 14 in the stomach 2 weeks ago. A review of Resident 56’s Situation, Background, Assessment, Recommendation ([SBAR] – a communication tool used by healthcare workers when there is a change of condition among the residents), dated 2/7/2025 at 7:23 a.m., indicated, on 2/6/2025 at 5:00 p.m., Resident 56 stated 2 weeks ago, another resident kicked him in the stomach. During an interview on 2/7/2025 at 1:49 p.m., with LVN 3, LVN 3 stated on 2/6/2025 at around 12:30 p.m. during the medication pass observation, Resident 56 alleged he was kicked in the stomach. LVN 3 stated he did not report the allegation to the Director of Nursing (DON) and Administrator (ADM). LVN 3 stated he was busy with other tasks and forgot about the allegation. LVN 3 stated he was a mandated reporter, and any allegation of abuse should be reported immediately or within 2 hours to the ADM, Ombudsman, and the CDPH. During a concurrent interview and record review on 2/7/2025 at 3:33 p.m., with ADM 2, the facility’s undated P&P titled, “Reporting Suspected Crimes Under the Federal Elder Justice Act” was reviewed. ADM 2 stated the P&P indicated, “The reporting individual will notify local law enforcement immediately by phone and the Long-Term Care Ombudsman, law enforcement and licensing agency within 2 hours by fax when an incident involves abuse or serious bodily injury” ADM 2 stated the DON notified him today, 2/7/2025 between 8:30 a.m. to 9:00 a.m., that Resident 56 alleged he was kicked in the stomach by Resident 14. ADM 2 stated he completed the SOC 341 and faxed to the Ombudsman and CDPH on 2/7/2025 at approximately 12:00 p.m. ADM 2 stated the allegation of abuse should have been reported to the Ombudsman and CDPH on 2/6/2025, as soon as staff was made aware. ADM 2 stated it was important to report any allegation of abuse within 2 hours to the CDPH so they could intervene and prevent the recurrence of abuse. The facility failed to: 1. Implement its P&P titled, “Reporting Suspected Crimes Under The Federal Elder Justice Act” which indicated the reporting individual will notify local law enforcement immediately by phone and the Long-Term care Ombudsman the CDPH within 2 hours by fax, when an incident involves abuse or serious bodily injury, after Resident 56 alleged to have been kicked in the stomach, two weeks ago, by Resident 14. As a result, there was a delayed investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of Resident 56 and other residents in the facility.