Health inspection·April 3, 2025

42 CFR §483.12(c) Reporting of Alleged Violations 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.(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. 22 CCR §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 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. (b) A failure to comply with the requirements of this section shall be a class “B” violation. On 2/14/2025, the California Department of Public Health (CDPH) received a Facility-Reported Incident (FRI) indicating there was a physical altercation between Resident 2 and Resident 3. On 02/21/2025 at 8:00 a.m., the CDPH conducted an unannounced investigation at the facility. The facility failed to: 1. Report an allegation of physical abuse between Resident 2 and Resident 3 to the CDPH As a result, there was a delay in an investigation by the CDPH. 1.Resident 2 was a 48-year-old male, originally admitted on 11/26/2024 and readmitted on 12/30/2024, with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and epilepsy (a brain condition that causes seizures). A review of Resident 2’s Minimum Data Set (MDS- a federally mandated resident assessment tool) indicated Resident 2’s cognitive skills were intact. The MDS indicated Resident 2 required supervision with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). 2.Resident 3 was a 66-year-old male, admitted on 7/20/2023, with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), hypertension (HTN-high blood pressure), and cellulitis (a skin infection that causes swelling and redness). A review of Resident 3’s Minimum Data Set, dated 1/9/2025, indicated Resident 3’s cognitive skills were intact. The MDS indicated Resident 3 required supervision and partial assistance with ADLs. During an interview on 02/21/2025, at 9:40 a.m., with Resident 3, Resident 3 stated while sitting in the hallway, Resident 2 began calling him racial slurs while walking past him. Resident 3 stated [he] and Resident 2 had a verbal altercation. During a telephone interview, on 02/21/2025, at 11:41 a.m., with Certified Nurse Assistant (CNA) 3, CNA 3 stated she observed Resident 3 open-handedly hit Resident 2 on the side of his head after a verbal altercation. CNA 3 stated she did not know if the incident was reported to the CDPH. During an interview, on 02/21/2025, at 11:52 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she reported the incident to the CDPH on 2/9/2025. LVN 1 stated she did not have evidence of a fax confirmation to show the incident was reported to the CDPH. LVN 1 stated the risk of not reporting abuse in a timely manner could result in further abuse. During an interview, on 02/21/2025, at 12:45 p.m., with the Director of Nursing (DON), the DON stated on 2/9/2025 he was informed by LVN 1, that the CDPH was notified of the altercation between Resident 2 and Resident 3, via fax and phone. The DON stated he did not have a fax report or phone confirming the incident was reported to the CDPH. The DON stated the risk of not reporting a physical altercation in a timely manner could result in further abuse. A review of the facility’s policy and procedures (P/P), titled “Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating,” revised 3/2023, indicated the Administrator or the individual making the allegation will immediately report his or her suspicion to the state licensing/certification agency responsible for surveying/licensing the facility (CDPH) within two hours. The facility failed to: 1. Report an allegation of physical abuse between Resident 2 and Resident 3 to the CDPH. As a result, there was a delay in an investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of Resident 2, Resident 3, and other residents in the facility.