Health inspection·June 16, 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 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. (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 5/20/2025, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) indicating Licensed Vocational Nurse (LVN) 1 had allegedly sexually abused Resident 4. On 5/21/2025, 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 reported an allegation of sexual abuse. This failure resulted in a delay of an investigation by the CDPH. Resident 4 was a 76-year-old female, admitted to the facility on 8/14/2021 and readmitted on 5/19/2025 with diagnoses including dementia (decline in mental abilities), depressive disorder (feelings of sadness and loss of interest), and transient cerebral ischemic attack (a lack of blood flow to the brain). A review of Resident 4's History and Physical (H&P) dated 6/4/2024, indicated Resident 4 did not have the capacity to understand and make decisions. A review of Resident 4's Minimum Data Set ([MDS] a resident assessment tool) dated 5/9/2025, indicated Resident 4 had the ability to understand. The MDS indicated Resident 4 was dependent for showering, toileting hygiene, and dressing. A review of the facility's Social Services Notes dated 5/16/2025, indicated the Social Worker called the facility to report an allegation of sexual abuse. During a concurrent interview and record review, on 5/21/25, at 1:49 p.m., with the Social Service Director (SSD), the SSD stated the General Acute Care Hospital (GACH) Social Worker (SW) called her on 5/16/25 informing her of Resident 4 allegations of sexual abuse at the facility. The SSD stated, when Resident 4 had returned to the facility, on 5/20/2025, she asked Resident 4 if she had been sexually abused by someone at the facility. The SSD stated Resident 4 stated, "LVN 1 touched my breast." The SSD stated she was a mandated reporter, and any allegations of abuse should be reported immediately or within 2 hours and did not notify the Administrator (ADM). During an interview on 5/21/2025 at 4:00 p.m. with the Administrator (ADM), the ADM stated staff should report all allegations of abuse or within 2 hours, and/or as soon as staff was made aware. A review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating," dated 3/2023, the P&P indicated all reports of resident abuse findings of all investigations are documented and reported. The P&P indicated abuse was suspected it must be reported immediately to the administrator and to other officials. The P&P indicated immediately is defined as within two hours of an allegation involving abuse. The facility failed to: 1. Report an allegation of abuse to the CDPH, within two hours, when Resident 1 reported an allegation of sexual abuse. 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 Resident 4 and other residents in the facility.