Health inspection·May 6, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint number: CA00953158 and Facility Reported Incident number CA00955469. A Class B citation was written. Regulatory Violations: §483.12: Freedom from Abuse, Neglect, and Exploitation: §483.12(c) 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. §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Title 22 § 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. On 4/4/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident-to-resident altercation and a facility reported incident regarding resident-to-resident altercation. The facility failed to implement their policy regarding reporting of a resident-to-resident altercation and to submit a conclusion report of investigation within five days or in accordance with state or federal law for Resident 1 and Resident 2. This resulted in a delay in an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further abuse for Resident 1 and Resident 2. A. During a review of the Resident 1's Admission Record, it indicated Resident 1, a 64 years old male was originally admitted to the facility on 4/1/2022 and readmitted on 6/26/2023 with diagnosis including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought) and peripheral vascular disease (PVD - a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 3/12/2025, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were mildly impaired. The MDS indicated Resident 1 was independent from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's History and Physical (H&P) dated 5/17/2024, the H&P indicated Resident 1 has the capacity to understand and make decisions. During a review of Resident 1's Progress Notes dated: i. On 3/27/2025, the Progress Notes written by Registered Nurse 1 (RN 1) indicated, "Staff approached Registered Nurse 1 (RN 1) and notify that at around 12 p.m., they witnessed Resident 1 being physically aggressive to another resident (Resident 2). The incident occurred when Resident 2 was attempting to open the patio door to go inside, Resident 1 was behind him was doing the same thing too, Resident 2's action startled Resident 1 and he (Resident 1) began screaming and yelling inappropriately to Resident 2. Resident 1 started raising his fist and became physically aggressive to Resident 2 who was trying to defend himself... Resident 1 continued to scream and yell and stated that there will be a round two later." ii. On 4/3/2025, the Progress Notes, written by Licensed Vocational Nurse 1 (LVN 1) indicated, "Resident (1) was seen arguing with another resident outside the patio. A Certified Nursing Assistant witnessed the altercation and has provided a statement... Resident 1 stated that other resident got on his personal space, and both argued about space." During an interview with LVN 1 on 4/4/2025 at 11:05 a.m., LVN 1 stated, on 4/3/2025, there was a verbal altercation between Resident 1 and Resident 2. LVN 1 stated, she reported the incident to the Administrator and Director of Nursing (DON). B. During a review of the Resident 2's Admission Record, it indicated Resident 2, a 72 years old male was admitted to the facility on 3/18/2025 with diagnosis including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side, aphasia (a disorder that makes it difficult to speak) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of the MDS dated 3/25/2025 indicated Resident 2's cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 2 required moderate assistance to supervision for ADLs. During a review of Resident 1's H&P dated 3/18/2025, the H&P indicated, Resident 2 was unable to communicate/make decisions for self. During a review of Resident 1's Progress Notes dated: i. On 3/27/2025, the Progress Notes written by LVN 1 indicated, "Resident (2) is alert and oriented, difficulty with speech but is able to answer questions with a yes and no. Resident 2 was involved in an untoward incident with another resident. Frequent round checks were done for this resident, no noted and reported emotional or psychological distress." ii. On 4/3/2025, the Progress Notes written by Licensed Vocational Nurse 2 (LVN 2) indicated Resident (2) was seen arguing with another resident outside the patio. A Certified Nursing Assistant witnessed the altercation and has provided a statement... Resident 2 stated that other resident got in his personal space and both argued about space." During a concurrent interview and record review with Director of Nursing (DON) on 4/4/2025 at 12 p.m., DON stated, Resident 1 and Resident 2 had altercation on 3/27/2025 and again on 4/3/2025, where they separated both residents from each other. DON stated, they investigated the incidents but were unable to provide any documentation of the investigation and the outcome. DON further stated, this was not reported to the State Agency (SA). During an interview with the Administrator (ADM) on 4/4/2025 at 12:26 p.m., the ADM stated, she was not made aware of the incident between Resident 1 and Resident 2. The ADM reviewed Resident 1 and Resident 2's medical record and stated, she will now be reporting the incident to the SA. During a review of the facility's policy and procedures (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating", revised on 4/2024, 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. Findings of all investigations are documented and reported... The Administrator or individual making the allegation immediately reports his or her suspicion to the following persons or agencies: A. the state licensing/certification agency responsible for surveying/licensing the facility b. the local/state ombudsman c. The resident's representative d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. "Immediately" is defined as: within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury... Within five business days of the incident, the administrator will provide a follow-up investigation report. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified." During a review of the facility's P&P titled, "Resident-to-Resident Altercations", revised on 4/2024, the P&P indicated, "All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the nursing supervisor, the director of nursing services and to the administrator... If two residents are involved in an altercation, staff will: report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy. The facility failed to implement their policy regarding reporting of a resident-to-resident altercation and to submit a conclusion report of investigation within five days or in accordance with state or federal law for Resident 1 and Resident 2. This resulted in a delay in an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further abuse for Resident 1 and Resident 2. The above violation had a direct relationship to the health, safety, and security of Residents 1 and 2.