Health inspection·September 25, 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 8/13/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) regarding an allegation of visitor-to-resident sexual abuse (any sexual activity that occurs without consent [permission]). The facility failed to timely report Resident 1’s allegation of visitor-to-resident sexual abuse to the State Survey Agency (SSA) when on 7/2/2025, between 2 p.m. and 3 p.m., a transportation company personnel (TCP) allegedly inappropriately touched Resident 1 on the face and called Resident 1 “babe and beautiful”. Resident 1 reported the sexual abuse allegation to the Social Services Director (SSD) on 7/3/2025. However, the Abuse Coordinator (referring to Administrator [ADM]) did not report the sexual abuse allegation to the SSA until 7/30/2025 (27 days after the sexual abuse allegation was made). As a result, Resident 1 was placed at an increased risk for further abuse, which could have led to additional unreported incidents and failure to protect residents from potential harm. A review of Resident 1’s Admission Record indicated that the facility originally admitted the 62-year-old female resident on 6/12/2025 and readmitted Resident 1 on 7/11/2025, with diagnoses including aftercare following joint replacement surgery, major depressive disorder (mental health condition that causes a persistently low or sad mood and a loss of interest in activities that once brought joy), and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 1’s History and Physical (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 6/13/2025, indicated the resident had the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS - a resident assessment tool), dated 6/24/2025, indicated that Resident 1’s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. A review of the facility-provided Grievance/Complaint Resolution Report, dated 7/3/2025, indicated that Resident 1 reported to the SSD of an allegation involving an incident that occurred on 7/2/2025 between 2 p.m. to 3 p.m., during which TCP allegedly inappropriately touched Resident 1’s face and referred to her (Resident 1) as “beautiful”. During an interview on 8/13/2025 at 9:41 a.m., with the SSD, the SSD stated that on 7/3/2025, Resident 1 reported to her (SSD) that a transportation company personnel (TCP) allegedly touched her (Resident 1’s) face and engaged in other unspecified inappropriate actions. The SSD further stated that she (SSD) notified the Director of Nursing (DON) and the ADM of Resident 1’s allegations on the same day (7/3/2025). During a concurrent interview and record review on 8/13/2025 at 2:23 p.m., with the DON, the facility’s policy and procedure (PnP) titled, “Prevention, Reporting, and Correction of Inappropriate Conduct Including Abuse, Neglect, and Mistreatment of Residents and Investigations of Injuries of Unknown Origin,” last reviewed on 1/2/2025 was reviewed. The DON stated that the PnP indicated “… all personnel, vendors, and volunteers do not abuse … any resident in the facility at any time for any reason.” The DON further stated that the PnP indicated “The Administrator in coordination with General Counsel will … verify that any allegation of abuse is reported … to the California Department of Public Health Licensing and Certification … within two hours.…” The DON stated that on 7/3/2025, the SSD brought Resident 1 to him (DON), at which time Resident 1 reported that the transportation personnel (TCP) was unprofessional, touched her (Resident 1’s) face, and called her “babe” and “beautiful”. The DON stated that the ADM serves as the facility’s Abuse Coordinator. The DON stated that the allegations of inappropriate touching by TCP should have been reported within two hours to the SSA, the Ombudsman (serves as resident advocate), and Local Law Enforcement (LLE). The DON stated that Resident 1 was at risk for experiencing emotional distress and potential harm and further stated that if not properly addressed, similar incidents could occur again either to Resident 1 or to other residents. The DON stated that the facility failed to report the sexual abuse allegation within the required two-hour timeframe. The facility failed to timely report Resident 1’s allegation of visitor-to-resident sexual abuse to the SSA when on 7/2/2025, between 2 p.m. and 3 p.m., a TCP allegedly inappropriately touched Resident 1 on the face and called Resident 1 “babe and beautiful”. Resident 1 reported the sexual abuse allegation to the SSD on 7/3/2025. However, the Abuse Coordinator (ADM) did not report the sexual abuse allegation to the SSA until 7/30/2025 (27 days after the sexual abuse allegation was made). As a result, Resident 1 was placed at an increased risk for further abuse, which could have led to additional unreported incidents and failure to protect residents from potential harm. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.