Health inspection·April 4, 2025

42 CFR §483.12 Freedom from abuse, neglect, exploitation (a) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. 22 CCR § 72315 Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 22CCR §72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be implemented to ensure that patient related goals and facility objectives are achieved. HSC 1418.91 (a) A long-term health care facility shall report all incident of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) Failure to comply with the requirements of this section shall be a class "B" violation. On 3/2/2025 at 11:00 a.m., the California Department of Public Health (CDPH) received a facility reported incident alleging a Registered Nurse (RN) 1 hit Resident 1 on the right side of the face. On 3/13/2025 at 11:00 a.m., the CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: 1. Report an allegation of abuse to the CDPH, within two hours, when Resident 1 was allegedly hit by Registered Nurse (RN) 1 on the right side of face. This failure resulted in a delay of an investigation by the CDPH. Resident 1 was a 76-year-old female, admitted to the facility on 2/18/2025, with diagnoses including muscle weakness and anxiety disorder (mental health condition characterized by excessive, persistent, and often irrational worry, fear, and unease that can interfere with daily life). A review of Resident 1's "History and Physical" (H&P) dated 2/19/2025, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Admission Reassessment document dated 2/19/2025, indicated Resident 1 had a puffy face and the peri-orbital (around eyes) area. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/24/2025, indicated Resident 1 could sometimes make herself understood and was understood by others. The MDS indicated Resident 1 was dependent for oral hygiene, toileting hygiene, shower/bath, dressing, putting on/taking off footwear and for personal hygiene. A review of Resident 1's progress notes dated 3/1/2025 did not indicate documentation about the resident being hit by RN 1. During an interview on 3/13/2025 at 12:27 p.m., with Family Member 2 (FM 2), FM 2 stated on 3/1/2025 around 2 p.m., when FM 2 visited Resident 1, RN 1 entered Resident 1's room and Resident 1 covered her face. FM 2 stated Resident 1 told her that RN 1 hit her (Resident 1). FM2 stated RN 1 told her (FM 2), that she did not hit Resident 1. During an observation and interview on 3/13/2025 at 1:00 p.m., with Resident 1, Resident 1 had a puffy face and the periorbital area of both eyes. Resident 1 was noted with dark skin discoloration on the face. Resident 1 stated RN 1 hit her on the face, pointing to her right eye. Resident 1 stated she could not remember the date it happened. Resident 1 stated RN 1 was handling her g-tube (gastrostomy tube, a tube surgically inserted through the abdomen into the stomach, used to deliver food, liquids, and medications) and hit her. Resident 1 stated she had a black eye, but no one saw when RN 1 hit her. During an interview on 3/13/2025 at 2:14 p.m., with RN 1, RN 1 stated on 3/1/2025, Resident 1 was very agitated and confused. RN 1 stated Resident 1 was pulling her g-tube and RN 1 went to assess the resident while FM 2 was visiting. RN 1 stated she was told by FM 2 that she hit Resident 1. RN 1 stated she told FM 2 that she did not hit the resident. RN 1 stated she did not report the incident to the Administrator because she was going through personal issues. RN 1 stated she forgot and was shocked to be accused of hitting a Resident 1. RN 1 stated according to the facility's policy, staff was supposed to report any suspicion or allegation of abuse to the CDPH. RN 1 stated she did not know the allegation was to be reported to CDPH within two hours so it could be investigated. RN 1 stated she reported the incident to the Administrator (ADM) the following day, 3/2/2025 around 10:00 a.m. when FM 1 showed up at the facility alleging RN had hit Resident 1. During an interview on 3/13/2025 at 3:30 p.m. with the ADM, the ADM stated the alleged abuse that happened on 3/1/2025 around 2 p.m. was only reported to the CDPH on 3/2/2025 around 10:30 a.m. because he was informed about the incident on 3/2/2025. The ADM stated the facility was supposed to report allegation of abuse to the CDPH within two hours, for prompt investigation and resident's safety. A review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," dated 9/2022, indicated all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) immediately, within two hours of an allegation involving abuse or result in serious bodily injury. The facility failed to: 1. Report an allegation of abuse to the CDPH, within two hours, when Resident 1 was allegedly hit by RN 1 on the right side of face. This failure resulted in a delay of an investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of the resident.