Health inspection·September 4, 2025

42 CFR § 483.12 - Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. (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. CCR§72523(a) 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. 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. On 7/13/2025 the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) regarding alleged staff to resident abuse. On 7/22/2025, CDPH conducted an unannounced visit at the facility. During interview and record review CDPH determined the facility failed to: 1. Report to CDPH within the regulated two hours Resident 1’s allegation that Certified Nursing Assistant (CNA) 1 touched him in the rectum with her finger while cleaning him and that he was experiencing pain. 2. Implement its abuse reporting and prevention policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappreciation-Reporting and Investigation" which indicated to report to CDPH the allegation involving abuse or result in serious bodily injury within two hours. As a result, there was a delay in CDPH’s investigation. These deficient practices placed Resident 1 and other residents at risk for ongoing abuse, neglect, or mistreatment. A review of Resident 1’s Admission Record indicated Resident 1 a 64-year-old male, was initially admitted on 4/6/2025 and readmitted on 6/17/2025 with diagnoses including muscle wasting and atrophy, lack of coordination, and Type 2 Diabetes Mellitus (DM0. A review of Resident 1's History and Physical (H&P) dated 6/18/2025, indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 6/20/2025, indicated Resident 1 was cognitively intact. The MDS indicated Resident 1 was dependent on toileting hygiene, lower body dressing, chair/bed-to-chair transfer, roll left and right, toilet transfer, required maximal assistance for bathing and upper body dressing, and required moderate assistance. A review of Resident 1 's Change of Condition form (COC) dated 7/13/2025 at 2:47a.m., indicated around 2:00 a.m., Resident 1 alleged a CNA 1’s finger touched his anal area. The COC indicated Resident 1 complained of pain in his “butt” and was given Hydrocodone-Acetaminophen (medication used to treat pain) oral tablet 10-325 milligram (mg). During a review of the facility’s fax to report the incident to CDPH, dated 7/13/2025 and timed at 8:45 p.m., indicted the facility reported the allegation of abuse involving Resident 1 and CNA 1 that occurred on 7/13/2025 around 2:00 a.m. about 18 hours and 45 minutes later. During an interview on 7/22/2025 at 9:58 a.m., Registered Nurse Supervisor 1 (RNS) 1 stated he was informed Resident 1 complained about pain in his rectum and went to assess Resident 1. RNS 1 stated Resident 1 indicated he felt pain around his rectum almost right after CNA 1 cleaned him in that area. RNS 1 stated when a resident (in general) has a COC, he assesses the resident and notifies the Director of Nursing (DON) and the Administrator (ADM). RNS 1 stated he informed the DON about the incident but did not try calling the ADM (the abuse coordinator) as it was around 2:00 a.m. in the morning. During a concurrent interview and record review on 7/22/2025 at 11:09 a.m., RNS 2 stated if there was an incident that could be considered abuse, she informs the ADM, does her own investigation and informs the doctor. RNS 2 stated if allegations of abuse are not reported and investigated in a timely manner, it can result in a resident’s physical harm, decline in mental state, feeling of being unsafe, result in more serious injury, or death due to being neglected in their care. During a concurrent interview and record review on 7/22/2025 at 4:26 p.m. the ADM stated an allegation of abuse is when there is a resident that said someone slapped another resident or hit a resident. The ADM stated that when she was informed of an alleged abuse allegation, she will follow her 24 hours reporting for alleged abuse when there is no bodily injury. The ADM stated the facility is the one that determines the outcome of any abuse allegations. The ADM stated this incident was not an allegation of abuse. During an interview on 7/23/2025 at 2:17p.m. the DON stated everyone is a mandated reporter, and if he sees or witnesses any type of allegation of abuse, he must report it. The DON stated that anyone can call CDPH and does not have to wait for the ADM to report abuse. The allegation of abuse reporting time is within two hours. During a review of the facility's P&P titled, "Abuse, Neglect, Exploitation or Misappreciation-Reporting and Investigation" undated, the P&P 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) and thoroughly investigated by facility management. If resident abuse, neglect, exploitation, misappropriation or 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. "Immediately" is defined as: within 2 (two) hours of an allegation involving abuse or result in serious bodily injury; or within 24 (twenty-four) hours of an allegation that does not involve abuse or result in serious bodily injury. The facility failed to: 1. Report to CDPH within the regulated two hours Resident 1’s allegation that CNA 1 touched him in the rectum with her finger while cleaning him and that he was experiencing pain. 2. Implement its abuse reporting and prevention P&P titled, "Abuse, Neglect, Exploitation or Misappreciation-Reporting and Investigation" which indicated to report to CDPH the allegation involving abuse or result in serious bodily injury within two hours. As a result, there was a delay in CDPH’s investigation. These deficient practices placed Resident 1 and other residents at risk for ongoing abuse, neglect, or mistreatment. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.