Health inspection·September 11, 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. 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. 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 7/29/2025, the California Department of Public Health (CDPH) received a complaint indicating that Certified Nursing Assistant (CNA) 1 had allegedly physically abused Resident 1. On 8/12/25, the CDPH conducted an unannounced visit to the facility to investigate the allegation. The facility failed to: 1.Report a staff-to-resident physical abuse allegation to the CDPH within 2 hours. As a result, there was a delay in an investigation by the CDPH. Resident 1 was a 69-year-old male initially admitted to the facility on 5/4/2025 and was readmitted on 7/7/2024. Resident 1 diagnoses included hemiplegia (a condition characterized by loss of muscle strength), hemiparesis (weakness on one side of the body), osteoarthritis (a condition that causes pain, stiffness, and impaired mobility. A review of Resident 1's History and Physical (H&P), dated 3/26/2025, indicated Resident 1 had the ability to make decisions for activities of daily living. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 5/9/2025, indicated Resident 1 cognition (ability to learn, reason, remember, understand, and make decisions) was intact. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) by staff for toileting hygiene, showering, and dressing. The MDS indicated Resident 1 was always incontinent (inability to control the flow of urine from the bladder) with urine. During an interview, on 8/12/2025 at 8:45 a.m., with Resident 1, Resident 1 stated the Certified Nursing Assistant (CNA) 1 on the night shift (11 p.m. to 7 a.m.) pushed on his leg, hit him with his pillow, and was telling him he can clean himself with a rude tone (a manner of speaking that is disrespectful, impolite, and often characterized by a harsh aggressive, or dismissive attitude). Resident 1 stated he notified the head nurse (Director of Staff Development) that morning. During an interview, on 8/12/2025 at 9:17 a.m., with Director of Staff Development (DSD), the DSD stated on 7/17/2025 at 6 a.m., Resident 1 told her CNA 1 rough handled him during care and spoke rudely to him. The DSD stated on 7/17/2025, she notified the Administrator (ADM) of the allegation. The DSD stated the alleged actions of CNA 1 were considered abuse and needed to be reported to the CDPH within two hours. During an interview, on 8/12/2025 at 12:55 p.m., with the ADM, the ADM stated the DSD reported CNA 1 was rude and rough handled Resident 1. The ADM stated the DSD was a mandated reporter. The ADM stated when there was an allegation of abuse the staff were to report within two hours to the ADM, CDPH, Ombudsman, and police. The ADM stated CNA 1 displayed unprofessional conduct by being rude to Resident 1 and not providing customer service. The ADM stated that since the CNA was terminated due to unprofessional conduct there was nothing to report. A review of facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigation," dated 3/2023, if resident abuse is suspected, the suspicion must be reported immediately, within two hours of an allegation involving abuse or within 24 hours of an allegation that did not involve abuse or result in serious bodily injury. The P&P on leave pending investigation. The P&P indicated if the investigation revealed that the allegation of abuse was founded, the employee would be terminated. The facility failed to: 1. Report a staff-to-resident physical abuse allegation to the CDPH within 2 hours. 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 1 and other residents in the facility.