Health inspection·December 12, 2024

The following reflects the findings of the California Department of Public Health during a compliant investigation. Complaint Number: CA00932230. A Class B citation was issued. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations § 483.12(c): Freedom from Abuse, Neglect, and Exploitation. 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)(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. 22 CCR § 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. On 11/26/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about resident abuse. The facility failed to report an allegation of physical abuse for Resident 1. As a result, there was a delay in the investigation of the alleged abuse by CDPH and also placed Resident 1, and others are at risk for potential abuse. A review of Resident 1's Admission Record indicated the facility admitted this 71-year-old male on 10/16/2024 with diagnoses including bilateral primary Osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage of the knee), Hypercalcemia (high calcium in the blood), presence of right artificial knee joint, presence of right artificial hip joint, Hypothyroidism condition in which the thyroid gland does not produce enough thyroid hormone), and Hyperlipidemia high fat in the blood). A review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 10/21/2024, indicated Resident 1's cognition (mental ability to make decisions for daily living) was intact. Resident 1 was independent with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair. On 11/25/2024 the CDPH received a complaint alleging a staff member pushed the door onto Resident 1 causing the resident to lose balance. During an interview on 11/26/2025 at 10:45 a.m. Resident 1 stated on 11/23/2024 at 11:00 p.m. the Licensed Vocational Nurse (LVN) 1 opened the door to the room while Resident 1 was asleep. Resident 1 then asked LVN 1 why LVN 1 was in the room and awakened Resident 1. LVN 1 then stated LVN 1 had to check on everyone and Resident 1 could not stop LVN 1 from entering the room. LVN 1 then walked out and left the door open. Resident 1 then got up to close the door and LVN 1 returned to the door and stated, "don't slam the door" then pushed the door against Resident 1 causing Resident 1 to lose balance and grab onto the foot board of the bed to regain balance and prevent a fall. Resident 1 stated right after this, an email was sent to the Director of Social Services (DSS) to report the incident. Resident 1 further stated the facility had not responded to the report. During an interview on 11/26/2024 at 11:32 a.m. the DSS stated the email from Resident 1 was seen on Sunday11/24/2024 in the morning. The DSS then forwarded the email to the administrator (Adm) that same day. The DSS then followed up with the Adm on 11/25/2024 to confirm receipt of the email. The DSS further stated, the Adm confirmed receipt of the email and did not ask the DSS to investigate nor report the incident. During an interview on 11/26/2024 at 1:08 p.m. the Adm stated a phone call from the DSS was received on 11/24/2025 informing the Adm of the allegation of abuse from Resident 1. The Adm then called the Director of Nursing (DON) to interview LVN 1 and get a statement so that we could determine if it was abuse and report it. The Adm stated the facility investigation indicated Resident 1 was upset and slammed the door and LVN 1 never pushed the door into Resident 1. The Adm stated we did not think it was abuse so we did not report it to CDPH. During a review of the facility policy and procedures (P&P) titled, "Abuse and Neglect- Clinical Protocol," with revised date of July 2017, the P&P indicated: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, 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 (Sponsor) of Record; 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. 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. 3. Verbal/written notices to agencies may be submitted via special carrier, fax, e-mail, or by telephone. 4. Notices will include, as appropriate: a. The name of the resident; b. The number of the room in which the resident resides; c. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.); d. The date and time the alleged incident occurred; e. The name(s) of all persons involved in the alleged incident; and f. What immediate action was taken by the facility. 5. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. During a review of the facility's P&P titled, "Abuse Investigation and Reporting ", with no date, the P&P indicated: 1.If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation. 4. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. 6. The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Role of the Investigator: 1. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate). f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition. g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors. i. Interview other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident. Resolution The facility failed to report an allegation of physical abuse for Resident 1. As a result, there was a delay in the investigation of the alleged abuse by CDPH and also placed Resident 1, and others are at risk for potential abuse. The above violations had direct or immediate relationship to the health, safety, or security of Resident 1.