Health inspection·January 24, 2025

F609 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual’s obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. §483.12(c) 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 §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. H &S § 1418.91 (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 12/12/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding an employee to resident physical abuse (intentional act of causing injury or trauma to a person through bodily contact). The facility failed to implement its policy and procedure by not reporting to CDPH an allegation of physical abuse involving Resident 1, within 24 hours, which occurred on 11/25/2024. As a result, there was a delay for an onsite inspection by CDPH to ensure the safety of Resident 1 and other residents and had the potential to result in unidentified abuse. Resident 1 was placed at an increased risk for further distress such as physical harm, emotional pain, and further trauma associated with the allegation of abuse. A review of Resident 1's Record of Admission indicated the facility admitted the 28-year-old male resident on 1/6/2024 with diagnoses including chronic respiratory failure (a long-term condition that prevents the body from exchanging oxygen and carbon dioxide properly), traumatic hemorrhage of cerebrum (a collection of blood in the brain due to traumatic injury to the head), and diabetes insipidus (a disorder affecting the body's ability to regulate water balance, leading to excessive thirst and urination). A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/10/2024, indicated that Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making tasks were intact. During an interview with the Director of Staff Development (DSD) on 12/12/2024 at 2:14 p.m., the DSD stated that all staff are mandated (officially required) reporters for abuse. The DSD further stated that reporting of abuse is to be done immediately, or no later than two (2) hours to the local police, Long-term Care Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to CDPH. The DSD stated the importance of reporting to the investigative agencies is for the agencies to come and do a thorough investigation of the allegation. During a concurrent interview and record review with Registered Nurse 1 (RN 1) on 12/12/2024 at 3:40 p.m., Resident 1's Nursing Progress Notes dated 11/25/2024 at 6:54 p.m. was reviewed. The progress notes indicated on 11/25/2024 at 6:54 p.m. Resident 1 alleged being hit by staff (name not indicated) two times on the jaw. The progress notes indicated that the Abuse Coordinator was informed of the allegation of abuse. RN 1 stated that types of abuse include physical abuse. RN 1 stated the importance of reporting allegations of abuse is "To investigate it, to ensure safety for the resident. If it is not reported, it can happen again, so it needs to be addressed so that it does not happen again." During an interview and record review with the Administrator (ADM) on 12/12/2024 at 4:11 p.m., Resident 1's Nursing Progress Notes, dated 11/25/2024 at 6:54 p.m., was reviewed. The progress notes indicated the Vice President of Operations (who was the Abuse Coordinator) was informed of Resident 1’s allegation of physical abuse on 11/25/2025 at 6:54 p.m. The ADM stated he is not the abuse coordinator. The ADM stated the Vice President of Operations is the abuse coordinator for the facility. The ADM stated this was his first time hearing about Resident 1's allegation of abuse and was not able to provide the facility's investigation report for the allegation or proof of attempts to contact the outside investigative agencies. A review of the facility-provided policy and procedure titled, "Reporting of Alleged Abuse, Neglect and Involuntary Seclusion (a resident is isolated or confined to a specific area such as a bedroom)," with last revised date of 8/16/2022, indicated, "Alleged Violation: Is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated yet and if verified, could be non-compliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation (unauthorized, improper, or unlawful use) of residential property." The policy stated that should any employee of the facility be apprised or witness an allegation of abuse as defined in this policy, the employee is charged with the responsibility of reporting the alleged incident immediately. All Licensed employees are considered Mandated Reporters; however, the facility requires that all employees report such information. A thorough investigation will be conducted to ascertain all the events that allegedly occurred. A final written report will be submitted to Department of Health Services within 5 business days. The investigation will be timely and will be given priority. Any authorities that need to be contacted; e.g., Police Department, Ombudsman will be contacted within 24 hours. The Department of Health will be contacted within 2 hours of the initial report. This notification will be the responsibility of the Vice President of Operations (Abuse Coordinator), the Administrator, or Director of Nursing/Assistant Director of Nursing. The facility failed to implement its policy and procedure by not reporting to CDPH an allegation of physical abuse involving Resident 1, within 24 hours, which occurred on 11/25/2024. As a result, there was a delay for an onsite inspection by CDPH to ensure the safety of Resident 1 and other residents and had the potential to result in unidentified abuse. Resident 1 was placed at an increased risk for further distress such as physical harm, emotional pain, and further trauma associated with the allegation of abuse. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.