Health inspection·July 2, 2025

REGULATORY VIOLATIONS:  California Code, Welfare and Institutions Code - WIC § 15630  (a) A person who has assumed full or intermittent responsibility for the care or custody of an elder or dependent adult, whether or not they receive compensation, including administrators, supervisors, and any licensed staff of a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care custodian, health practitioner, clergy member, or employee of a county adult protective services agency or a local law enforcement agency, is a mandated reporter. (b)(1) A mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that they have experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an internet report shall be made through the confidential internet reporting tool established in Section 15658, within two working days. (A) If the suspected or alleged abuse is physical abuse, as defined in Section 15610.63, and the abuse occurred in a long-term care facility, except a state mental health hospital or a state developmental center, the following shall occur: (i) If the suspected abuse results in serious bodily injury, a telephone report shall be made to the local law enforcement agency immediately, but also no later than within two hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse, and a written report shall be made to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse. (ii) If the suspected abuse does not result in serious bodily injury, a telephone report shall be made to the local law enforcement agency within 24 hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse, and a written report shall be made to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within 24 hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse. (iii) When the suspected abuse is allegedly caused by a resident with a physician's diagnosis of dementia, and there is no serious bodily injury, as reasonably determined by the mandated reporter, drawing upon their training or experience, the reporter shall report to the local ombudsman or law enforcement agency by telephone, immediately or as soon as practicably possible, and by written report, within 24 hours. Cal. Code Regs., Tit. 42,  §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.  (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 Residentof, 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.    On 5/7/2025 at 9:15 AM, an unannounced visit was made to the facility to investigate a Facility Reported Incident (FRI) regarding of an incident of alleged Resident Abuse.  The facility failed to report immediately and/or no later than within 24 hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse, and a written report made to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within 24 hours when the verbal and physical abuse that happened with Resident1 and Resident 6 on 5/3/2025. Resident 6 reported that on 5/3/2025 around 9 AM, Resident1 stopped Resident 6 in the hallway in his wheelchair, and yelled profanity (offensive or vulgar language, often considered impolite, rude, or disrespectful) at him and while in his wheelchair, he was pushed fast, spun around and grabbed his shirt by Resident 1, prior to the staff separating them.  As a result, Resident 6 verbalized feeling upset, sad and discouraged, which negatively affected his quality of life. Also, it had the potential for a recurrence resulting in harm to other patients and staff in the facility.  On the same day, 5/3/2025, approximately four hours after the altercation with Resident 6, the facility failed to report another incident of Resident 1 choking Certified Nurse Assistant (CNA) 1 on 5/3/2025, while CNA 1 was inside another resident’s room (Resident 5).   Resident1 was transferred to the General Acute Care Hospital (GACH 1) on 5/3/2025 via “5150” (temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness).  A review of Resident1’s Admission Record indicated the facility admitted a 65 year old male Resident initially admitted on 9/20/2024 and readmitted on 4/14/2025 with diagnoses that included cognitive communication deficit (communication difficulties stemming from underlying cognitive impairments, rather than from speech or language deficits), schizoaffective disorder- bipolar type (a mental illness that combines symptoms of schizophrenia [like hallucinations and delusions) with those of bipolar disorder (like mania and depression)], and psychotic disorder (when you see reality very differently to people around you).  A review of Resident 1’s History and Physical Examination (HPE), dated 4/18/2024, indicated Resident 1was alert to time, person and situation.  A review of Resident 1’s Minimum Data Set (MDS) dated 4/18/2025, indicated the Patient1’s cognitive status (ability to think, remember, and reason) was moderately impaired. The MDS indicated Resident1 required supervision or touching assistance (Helper provides verbal cues and or touching steadying) with eating, partial/moderate assistance (helper does less than half the effort) with personal hygiene, dressing, toileting and bathing.  A review of Resident 6’s Admission Record indicated the facility admitted a 67 year old male Resident on 9/29/2023 with diagnoses that included osteoarthritis (a degenerative joint disease where the cartilage cushioning the bones in your joints wears away over time) of both shoulders and both knees, diabetes mellitus (disease of inadequate control of blood levels of glucose), and hypertension (high blood pressure).  A review of Resident6’s HPE, dated 10/11/2024, indicated Resident6 has the capacity to understand and make decisions.  A review of Resident6’s MDS dated 4/18/2025, indicated the Resident6’s cognitively status (ability to think, remember, and reason) was intact. The MDS indicated Patient6 required Setup and clean-up assistance (helper sets up and cleans up; Residentcompletes activity) with eating and oral hygiene, substantial/maximal assistance (helper does more than half the effort) with dressing and personal hygiene, and dependent (helper does all the effort) with bathing and toileting.  A review of Resident 6’s admission record indicated the facility admitted a 97 year old female Resident on 6/21/2017 with diagnoses that included Alzheimer’s disease (a progressive brain disorder that primarily affects memory and thinking skills, eventually leading to difficulty with everyday tasks and behavior changes), aortic aneurysm (a bulge that occurs in the wall of the body's main artery, called the aorta) and palliative care (focuses on improving the quality of life for people with serious illnesses by providing comfort and support, even when a cure isn't possible).  A review of Resident 6’s HPE, dated 5/1/2024, indicated Resident 6 did not have the capacity to understand and make decisions.  A review of Resident 6’S MDS dated 4/14/2025, indicated Resident 6 was dependent with eating, oral hygiene, toileting, bathing, dressing and personal hygiene.  A review of Resident1’s facility document titled, “Progress Notes” (PN), dated 5/3/2025 timed at 1:45 PM, indicated Resident1 was aggressive and placed his hands around Certified Nurse Assistant (CNA) 1 neck, and the police came and took Resident1 to GACH 1 for physical aggression via “5150” (California law code for the temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness).  During an interview on 5/7/2025 at 3:30 PM with Family 2, Fam 2 stated, on 5/3/2025 around 1 PM, while inside Resident 6’s room (which was adjacent to Resident1’s room), Fam 2 was talking to CNA 1, when Resident1 came to Resident 6’s room and without warning attacked and started to choke CNA 1. Fam 2 stated she helped CNA 1 and had to remove Resident1’s hand around CNA 1’s neck. Fam 2 stated, the police came and took Resident1 away. Fam 2 stated, she was concerned for Resident 6’s and other residents safety since Resident 6 was cognitively impaired, and other patients could not protect themselves. Fam 2 stated, she informed the Director of Social Services (DSS) and the facility leadership regarding the safety of Resident 6 and all other vulnerable patients in the facility. During an interview on 5/7/2025 at 3:50 PM with CNA 1, CNA 1 stated, on 5/3/2025 around 1 PM she was talking to FAM 2 inside Resident 6’s room, when Resident1 came inside Resident 6’s room and grabbed her (CNA 1) neck and started choking her without warning. CNA 1 stated the staff came to help, and the police took Resident1 away on 5/7/2025.  During a concurrent observation and interview on 5/7/2025 at 4:30 PM with Resident 6, in Resident 6’s room, Resident 6 was sitting at the side of the bed, next to his wheelchair, face was flushed, eyebrows drawn together, clenched teeth with teary eyes and would look up and down while being interviewed. Resident 6 stated, the incident with Resident 1 started with him, on 5/3/2025 around 9 AM, he was in the hallway going towards the smoking area, when Resident 1 blocked his way and started yelling profanity, grabbed his wheelchair and pushed him in the hallway so fast, even touching his back and he almost fell. Resident 6 stated, he struggled, then Resident 1turned his wheelchair around and grabbed his jacket, and then facility staff separated them. Resident 6 stated he reported the incident to the charge nurse, and there were other nurses there, but Resident 6 did not remember their names. Resident 6 stated, he felt discouraged and sad and what upsets him the most was no one talked to him about the incident, and he felt he was a nobody and no one cares for him.  During an interview on 5/8/2025 at 9:30 AM with Housekeeper (HSK) 1, HSK 1 stated, she worked on 5/3/2025, and around 9AM she saw Resident6 wheeling himself in the hallway, when Resident1 stopped him, and they yelled at each other. HSK 1 stated, Resident1 then grabbed Resident6’s wheelchair, pushed him hard and turned Resident 6’s wheelchair around. HSK 1 stated there were other people around and stopped the altercation, and she did not report it because she thought someone else would tell the administrator.  During an interview on 5/8/2025 at 9:45 AM with CNA 1, CNA 1 stated, on 5/3/2025 around 9 AM Resident1 and Resident6 were yelling at each other, then Resident1 grabbed Resident6’s wheelchair and pushed Resident6’s wheelchair and turned him around and grabbed Resident6’s jacket. CNA 1 stated, she does not know why it was not reported, since there were other staff there. CNA 1 stated, the incident should have been reported, and maybe the incident with her would not have happened.  During an interview on 5/8/2025 at 10:10 AM with CNA 4, CNA 4 stated, on 5/3/2025 around 9 AM Resident1 and Resident 6 were yelling at each other using profanity, Resident1 yelled “motherfucker” to Resident 6. CNA 4 stated, he separated Resident1 and Resident6 and escorted Resident1 to his room while Resident6 went to the nurse’s station. CNA 4 stated, he did not see the physical abuse but saw the verbal abuse and it should have been reported to the abuse coordinator.  During an interview on 5/8/2025 at 10:20 AM with LVN (license Vocational Nurse) 4, LVN 4 stated, on 5/3/25 she heard a commotion around 9 AM, and saw staff separating Resident1 and Resident6. LVN 4 stated, Resident6 told her that Resident1 pushed him in his wheelchair and yelled at him profanity, and Resident6 was concerned that he might get hurt. LVN 4 stated that the incident should have been reported because of verbal abuse and possible physical abuse, for Residentsafety and prevent recurrence. LVN stated the incident was not in the progress notes or change of condition (COC) documentation. LVN 4 stated, she reported it to RN (Registered Nurse) 3.  During an interview on 5/8/2025 at 10:35 AM with RN 3, RN 3 stated, no one told her about the incident between Resident 1and Patient6. RN 3 stated, on 5/3/2025 in the morning, Patient6 came to her very upset and told her Resident 1yelled profanity at him and push his wheelchair while he was in it. RN 3 stated, she was unable to interview Resident 1because he was still agitated. RN 3 stated, the incident should have been reported to the abuse coordinator, the ombudsman, police and California Department of Public Health (CDPH) as per policy. RN 3 stated that not reporting the incident had resulted in upsetting Patient3 and had the potential for abuse to recur or escalate and could affect the safety of the other patients in the facility.  During an interview on 5/8/2025 at 11 AM with Director of Nurses (DON), the DON stated, any suspicion of abuse should be reported within 2 hours as indicated in the facility policy. The DON stated, any type of verbal or physical altercation should be reported, and should be investigated thoroughly, so the incident would be addressed and prevent from potential recurrence or harm to other patients. The DON stated, yelling profanity to another resident was considered verbal abuse, and grabbing a Resident and pushing someone on a wheelchair against their will, was considered physical abuse and should be reported to Police Department (PD), Ombudsman and California Department of Public Health (CDPH). The DON stated, not reporting the incident between Resident 1 and Resident 6 had the potential for recurrence and escalation of the problem that could potentially affect the safety of the patients in the facility.  A review of the facility’s policy and procedure (P&P) titled, “Abuse Prevention/ Prohibition”, revised 11/2018, the P&P indicated; a) the facility does not condone any form of Residentabuse and/or mistreatment and develops a system in order to promote an environment free from abuse and mistreatment, b)Abuse is defined as a willful infliction of injury, involuntary seclusion, intimidation with resulting physical harm pain or mental anguish.  A review of the facility’s “policy and procedure (P&P)” titled, “Abuse Investigation and Reporting”, revised 7/2017, the P&P indicated; a) all reports of patients abuse, mistreatment shall be promptly reported to local , state and federal agencies and thoroughly investigated by facility management, b) under reporting, all alleged violations of abuse or mistreatment will be reported by the facility administrator or his/her designee to the state lice