Health inspection·February 21, 2025

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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(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) 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 01/21/2025 at 8:00 a.m., the California Department of Public Health (CDPH) conducted an unannounced annual recertification survey at the facility. The facility failed to: 1. Notify the CDPH that Resident 58 left the facility on 11/19/2024 and did not return. As a result, there was a delayed investigation by the CDPH. Resident 58 was a 60-year-old male, admitted on 11/1/2024 with diagnoses including osteomyelitis (inflammation of bone or bone marrow, usually due to infection), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), dysphagia (difficulty swallowing), and acute kidney failure (a sudden loss of kidney function that prevents the kidneys from filtering waste and regulating electrolytes and fluids in the body). A review of Resident 58’s History and Physical (H&P), dated 11/4/2024, indicated Resident 58 had the capacity to understand and make decisions. A review of Resident 58’s Minimum Data Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 58 cognitive skills were intact. The MDS indicated Resident 58 required partial to moderate 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 the facility’s out on pass (a temporary permission of a patient to leave the hospital in a specified time) log indicated Resident 58 signed in and out of the facility multiple times a week. The out on pass indicated Resident 58 signed out of the facility on 11/19/2024 at 9:54 a.m. During an interview on 01/24/2025 at 2:35 p.m., with the Director of Nursing (DON), the DON stated Resident 58 left the facility on 11/19/2024 and did not return to the facility. The DON stated Resident 58’s housing case worker and nurse practitioner were notified by the Social Services Director. The DON stated the facility did not notify Resident 58’s physician, local law enforcement or CDPH that Resident 58 did not return to the facility on 11/19/2024. The DON stated there was no documentation by licensed staff to indicate Resident 58 did not return to the facility on 11/19/2024. The DON stated the risk of not reporting a resident not returning to the facility in a timely manner could result in “not knowing whether the resident is safe or alive.” The DON stated the staff should have been concerned. During an interview on 01/24/2025 at 3:28 p.m., with the Administrator (ADM), the ADM stated Resident 58 have left the facility multiple times for hours a day, and always returned to the facility. The ADM stated on 11/19/2024, Resident 58 took some of his belongings when he left, and did not return. The ADM stated Resident 58 left “on his own will.” The ADM stated law enforcement and the CDPH were not notified because “residents have a right to go out on pass and not return to the facility.” A review of the facility’s policy and procedures titled “Reporting Unusual Occurrences”, revised 03/2023, indicated the facility will report the unusual occurrences that interfered with the facility’s operations and affect the welfare, safety, or health of residents, employees or visitors, to the appropriate agencies via telephone within 24 hours of such incident or as required by federal and state regulations. The facility failed to: 1.Notify the CDPH that Resident 58 left the facility on 11/19/2024 and did not return. As a result, there was a delayed investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of Resident 58.