Health inspection·July 21, 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 6/11/2025, the California Department of Public Health (CDPH) received a Facility-Reported Incident (FRI) indicating a resident stated that another resident had pushed him. On 6/24/2025, the California Department of Public Health (CDPH) conducted a standard annual recertification survey. The facility failed to: 1. Implement policies and procedures for ensuring the reporting of a resident-to-resident altercation within 2 hours to the CDPH. As a result, there was a delay in the investigation by the CDPH. A. Resident 118 was a 67-year-old male, originally admitted on 1/17/2024 and readmitted to the facility on 6/17/2025 with diagnoses which included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), anxiety (feelings of worry, nervousness, or unease), polyosteoarthritis (a form of osteoarthritis that affects multiple joints in the body) and myalgia (muscle pain). A review of Resident 118's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 6/8/2025, indicated Resident 118's cognitive skills were moderately impaired. The MDS indicated Resident 118 required partial assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 118's care plan, titled "Resident is verbally aggressive", dated 5/27/2025, indicated Resident 118 had a history of confabulation of stories, being verbally aggressive, yelling and screaming at staff, using obscene and racial remakes, and recording staff as they enter his room. The care plan's interventions indicated to assess and anticipate Resident 118's needs, assess his understanding of the situation and allow time for the resident to express self and feelings towards the situation. A review of Resident 118's change of condition (COC) form, dated 6/8/2025, indicated Resident 118 was found on the floor in his room at 7:30 a.m. The COC indicated Resident 118 stated his roommate had tripped him. The COC indicated Resident 59 denied tripping Resident 118. B. Resident 59 was a 66-year-old male admitted to the facility on 5/6/2025 with diagnoses which included abnormalities of gait and mobility (a change in a person's walking pattern), psychosis, muscle wasting and atrophy and lack of coordination. A review of Resident 59's MDS dated 5/10/2025, indicated Resident 59's cognitive skills were moderately impaired. The MDS indicated Resident 59 required maximal assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 59's progress note, dated 6/11/2025, indicated Resident 59 stated he did not remember pushing or tripping Resident 118 to the Social Services Director and law enforcement. A review of Resident 59's care plan did not indicate any behavioral issues for Resident 59. During an interview, on 6/24/2025, at 12:47 p.m., with Resident 118, Resident 118 stated on 6/8/2025, Resident 59 had tripped and pushed him from his walker and fell. During a concurrent interview and record review, on 6/26/2025, at 1:47 p.m., with the Director of Nursing (DON), the DON stated Resident 118 called the facility on 6/10/2025 from the hospital and stated Resident 59 had tripped him. The DON stated she did not know the alleged altercation occurred on 6/8/2025. The DON stated the facility reported the allegation to the CDPH on 6/10/2025. The DON stated the time frame for reporting abuse allegations was 2 hours. The DON stated the risk of not reporting in a timely manner could result in "obviously getting some sort of deficiency." During a concurrent interview and record review, on 6/26/2025, at 3:45 p.m., with the Assistant Administrator (Asst Admin), the Asst Admin stated Resident 118 had called the facility and spoke with him on 6/10/2025 stating Resident 59 had pushed him. The Asst Admin stated, after reading Resident 118's COC, the COC indicated the allegation occurred on 6/8/2025. The Asst Admin stated he was informed of the allegation by Resident 118 during a phone call on 6/10/2025, which was 2 days later. The Asst Admin stated the allegation should have been reported within 2 hours on 6/8/2025. The Asst Admin stated the risk of not reporting in a timely manner could result in further abuse and an unsafe environment. A review of the facility's policy and procedures (P&P), titled "Abuse and Neglect Prohibition Policy dated 6/2022, indicated "Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect, or exploitation, the Administrator or designee will perform the following: All alleged violations- must be reported immediately, but no later than 2 hours if the alleged violation involves abuse or results in serious bodily injury." The facility failed to: 1. Implement policies and procedures for ensuring the reporting of a resident-to-resident altercation within 2 hours to the CDPH. As a result, there was a delay in the investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of Resident 118, Resident 59 and other residents in the facility.