Health inspection·May 28, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00958960. A Class "B" citation was written. §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. California Code Regulations 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. § 72527 - Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. On 5/8/2025, the California Department of Public Health (State Agency) made an unannounced visit to the facility to investigate an anonymous complaint regarding resident abuse. The facility failed to implement its' policy and procedures (P&P) regarding reporting of an employee to resident altercation within 2 hours and to submit a conclusion report of investigation within five days of occurrence to law enforcement, the State Agency, and Ombudsman for Resident 2. As a result, there was a delay in an onsite inspection by the State Agency to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further abuse for Resident 2. 1a. During a review of the Resident 2's Admission Record, it indicated Resident 2, a 85 year-old female was originally admitted to the facility 2/27/2025 and readmitted on 4/22/2025 with diagnosis including nontraumatic intraverbal hemorrhage (a type of stroke where bleeding occurs within the brain tissue itself), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 4/17/2025, indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 required maximal assistance to total dependence 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 2's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 4/15/2025, the SBAR indicated, "Certified Nursing Assistant 1 (CNA 1) concern of resident (Resident 2) care... Resident 2 complaining of left knee pain, no visible signs of injury, no redness notes upon body assessment." During a review of the facility's staffing assignment from 4/16/2025 to 4/18/2025, it indicated that CNA 1 worked in the facility on the 2ndfloor. 1b. During a review of Resident 1's Admission Record, it indicated Resident 1 was originally admitted to the facility 9/9/2023 and readmitted on 11/28/2023 with diagnosis including sepsis (a life-threatening blood infection) and type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of the MDS dated 2/24/2025, Resident 1's cognitive skills for daily decisions were intact. The MDS indicated Resident 1 required supervision from staff for ADLs. During an interview with Resident 1 on 5/8/2025 at 10:43 a.m., Resident 1 stated, CNA 1 was roughed with her roommate in Bed B (Resident 2) during ADL care and she was not very nice with care. Resident 1 stated, she reported it to the nurses, but the facility did not do anything about it. Resident 1 further stated, she saw CNA 1 in the facility that whole week. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 5/8/2025 at 10:51 a.m., LVN 1 stated, there was an incident regarding Resident 1's allegation of abuse against CNA 1 on Resident 1 and Resident 2. LVN 1 stated, they separated CNA 1 from Resident 1 and Resident 2 the next day, and CNA 1 continued working on the floor that whole week. During an interview with Registered Nurse 1 (RN 1) on 5/8/2025 at 11:06 a.m., RN 1 stated, Resident 1 reported to him that on 4/15/2025 towards the end of morning shift (around 3 p.m.) CNA 1 was rough on Resident 2 during ADL care and pushed Resident 2 from the bed. RN 1 stated, he did an SBAR and a Change of Condition (COC) on Resident 2 and reported to the Administrator. During an interview with CNA 1 on 5/8/2025 at 11:33 a.m., CNA 1 stated, there was an incident on 4/15/2025 before lunch time (around 11:00 a.m.) when she was about to give a shower to Resident 2, but Resident 2 refused. CNA 1 stated, she did not force Resident 2 and instead gave her a bed bath. CNA 1 stated resident 1 did not like that so Resident 1 reported that she pushed Resident 2 off the bed to the charge nurse that day. CNA 1 stated, she did not do such thing and the next day, she was no longer assigned to Resident 1 and Resident 2 but was still working on the 2ndfloor. During a concurrent interview and record review with Director of Nursing (DON) on 5/8/2025 at 12:41 p.m., DON stated, Resident 1 reported that CNA 1 on 4/15/2025 before end of morning shift (around 3 p.m.) pushed Resident 2 from the bed. DON stated, initially, Resident 1 only reported that CNA 1 did not want to give showers to Resident 2 and during the end of morning shift, Resident 1 then reported that CNA 1 pushed Resident 2 off the bed. During a follow-up interview with RN 1 on 5/8/2025 at 1:09 p.m., RN 1 stated, the incident was not witnessed by another staff, and he reported it to the Administrator (ADM). RN 1 stated, everyone is a mandated reporter, and all alleged abuse must be investigated and reported. RN 1 stated, he did not completely document the SBAR according to what was reported by Resident 1, because he was told to only document that there was a "CNA1 concern of resident (Resident 2)'s care." During a follow-up interview with DON on 5/8/2025 at 1:15 p.m., DON stated, all abuse allegations must be reported and investigated according to their policies. DON stated, during investigation, the staff involved have to be suspended and the allegations must be reported within 2 hours to the district office, Ombudsman's office, physician, family member and the Police. DON stated, there was no documentation that this incident was reported to all reporting agencies. A review of the facility's P&P titled, "Abuse Investigation and Reporting", reviewed on 11/21/2024, the P&P indicated, "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. Verbal/written notices to agencies may be submitted via special carrier, fax, e-mail, or by Telephone. 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. 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 an interview of the P&P titled, "Facility Responsibilities for Reporting Allegations", reviewed date 11/21/2024, the P&P indicated, "Reporting Staff-to-Resident Abuse: a. All allegations/occurrences of all types of staff-to-resident abuse -must be reported to the administrator and to other officials, including the State Survey Agency and adult protective services, where state law provides for jurisdiction in nursing homes." The facility failed to implement its' P&P regarding reporting of an employee to resident altercation within 2 hours and to submit a conclusion report of investigation within five days of occurrence to law enforcement, the State Agency, and Ombudsman for Resident 2. As a result, there was 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 2. This violation had a direct or immediate relationship to the health, safety, or security of Resident 2.