Health inspection·October 16, 2025

§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 9/4/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident (FRI) regarding resident-to-resident physical abuse (intentional act of causing injury or trauma to a person through bodily contact). The facility failed to report an allegation of physical abuse involving Resident 1 when the following events occurred: 1. On 8/22/2025, at approximately 9:30 p.m., Resident 1 reported to Certified Nursing Assistant (CNA) 1 that Resident 2 had hit her (Resident 1) legs. 2. On 8/22/2025, at approximately 9:40 p.m., CNA 1 then reported the allegation to Licensed Vocational Nurse 1 (LVN 1). 3. On 8/22/2025, at approximately 10 p.m., Registered Nurse 1 (RN 1) observed Resident 1 screaming at LVN 1. Resident 1 informed RN 1 that Resident 2 had hit her (Resident 1) legs. RN 1 failed to report the physical abuse allegation to the Administrator, who is the designated Abuse Coordinator. 4. On 8/25/2025, at approximately 3:30 p.m., Resident 1 informed the Administrator that on 8/22/2025 (time not specified), Resident 2 had hit her (Resident 1) legs. The Administrator conducted an internal investigation and determined that CNA 1, LVN 1, and RN 1 had all been made aware of the physical abuse allegation involving Resident 1 on 8/22/2025, but none of them reported the allegation to him (Administrator). 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 Resident 1 from potential harm. A review of Resident 1’s Admission Record indicated the facility originally admitted Resident 1, a 67-year-old female, on 2/14/2025 and readmitted on 5/13/2025 with diagnoses including anxiety disorder (a feeling of fear, dread and uneasiness), multiple sclerosis (MS - a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), and chronic pain syndrome (an ongoing pain that lasts longer than three months, persisting even after the initial injury or illness has healed or is no longer present). A review of Resident 1’s History and Physical (H&P - a comprehensive assessment of a resident’s medical condition), dated 3/17/2025, indicated Resident 1 had the capacity to understand and make decisions.  A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 6/5/2025, indicated Resident 1 had intact cognitive (mental processes that enable people to think, understand, make decisions, and complete tasks) functioning. The MDS indicated Resident 1 was dependent (helper does all the effort) on facility staff with toileting hygiene, showers, upper and lower dressing.  A review of Resident 1’s Care Plan, initiated on 8/25/2025, indicated that on 8/25/2025, Resident 1 was the recipient of physical abuse from another resident (Resident 2).  The Care Plan indicated Resident 1 was at risk for emotional distress related to allegations of physical abuse from another resident.  A review of Resident 1’s Situational Background Assessment and Recommendation (SBAR – a communication tool used to provide concise, clear, and effective information regarding a resident’s condition) Communication Form, dated 8/25/2025, indicated that on 8/25/2025 (time not indicated), Resident 1 reported an incident of physical abuse by Resident 2 (Resident 1’s roommate).  A review of the facility-provided document titled, “5 Day Investigative Summary,” dated 8/30/2025, indicated that on 8/25/2025, at approximately 3:30 pm, Resident 1 had informed the Administrator that Resident 2 hit her (Resident 1) legs. The document indicated Resident 1 was unable to provide the exact date of the incident but stated the incident occurred on either 8/21/2025 or 8/22/2025. The document indicated that Resident 1 verbalized an allegation of abuse by Resident 2. The document indicated that the facility staff had failed to report Resident 1’s allegation of physical abuse based on the facility’s determination that Resident 2 was not capable of hitting Resident 1. The document indicated that the facility did not initiate an investigation into Resident 1’s allegation of physical abuse until 8/25/2025. During an interview on 9/4/2025 at 8:50 a.m., with Resident 1, Resident 1 stated that approximately two weeks prior (unable to recall exact date and time), Resident 1 and Resident 2 (Resident 1’s roommate) were in Room A (Resident 1 and Resident 2’s room) when Resident 2 approached Resident 1’s bed and started hitting both of Resident 1’s legs with her (Resident 2) hands. Resident 1 stated that she (Resident 1) screamed and called for facility staff to help. Resident 1 stated a few minutes later (unable to recall exact time), CNA 1 entered Room A as Resident 2 was walking back to her (Resident 2) bed. Resident 1 stated that she (Resident 1) informed CNA 1 that Resident 2 had hit her (Resident 1) legs. During an interview on 9/5/2025 at 9:38 a.m., with RN 1, RN 1 stated that on 8/22/2025, at approximately 10 p.m., she (RN 1) entered Room A and observed Resident 1 screaming at LVN 1 and requesting pain medication. RN 1 reported that Resident 1 informed her (RN 1) that she (Resident 1) was in pain because Resident 2 had hit her (Resident 1) legs. RN 1 stated that Resident 1’s statement was an allegation of physical abuse. RN 1 further stated that she (RN 1) should have immediately reported the allegation to the Administrator, who also serves as the facility’s Abuse Coordinator, in order to ensure appropriate reporting and to prevent potential further abuse of Resident 1. During an interview on 9/5/2025 at 9:59 a.m., with LVN 1, LVN 1 stated that on 8/22/2025, at approximately 9:40 p.m., CNA 1 informed him (LVN 1) that Resident 1 had reported Resident 2 hit her (Resident 1’s) legs. LVN 1 stated that on 8/22/2025 between approximately 9:40 p.m. to 10 p.m., he (LVN 1) entered Room A and found Resident 1 in bed, complaining of pain in her (Resident 1) legs. LVN 1 stated that Resident 1 informed him (LVN 1) that while she (Resident 1) was attempting to go to the bathroom, Resident 2 stopped near Resident 1’s bed and began hitting Resident 1’s legs. LVN 1 stated that he (LVN 1) reported the alleged incident between Resident 1 and Resident 2 to RN 1.   During an interview on 9/5/2025 at 10:22 a.m., with CNA 1, CNA 1 stated that on 8/22/2025, at approximately 9:30 p.m., he (CNA 1) entered Room A after hearing Resident 1 screaming. CNA 1 stated that upon entering the room, he (CNA 1) observed both Resident 1 and Resident 2 in bed. CNA 1 stated that Resident 1 was screaming and informed him (CNA 1) that Resident 2 had hit her (Resident 1) on the legs. CNA 1 stated he (CNA 1) immediately informed LVN 1 of the alleged incident between Resident 1 and Resident 2.  During an interview on 9/5/2025 at 11:46 a.m., with the Director of Nursing (DON), the DON stated that on 8/22/2025, at approximately 10 p.m., Resident 1 informed RN 1 that Resident 2 had hit Resident 1’s legs. The DON stated that RN 1 should have either contacted the Administrator or reported the alleged physical abuse to the required agencies following the instructions outlined in the “Abuse Binder” (a tool used to document suspected abuse in the facility and instructions on abuse reporting requirements available in the nursing stations). The DON stated the importance of immediately reporting any allegation of abuse to ensure that residents receive necessary interventions timely to prevent further harm. The DON further stated that the failure to report the allegation of physical abuse placed Resident 1 at risk for continued abuse and potential injury. During an interview on 9/5/2025 at 12:17 p.m., with the Administrator, the Administrator stated that on 8/25/2025, at approximately 3:30 p.m., Resident 1 reported to him (Administrator) that on 8/22/2025 (time not specified), Resident 2 approached Resident 1’s bed and hit her (Resident 1) legs with Resident 2's hands. The Administrator further stated that during the facility’s internal investigation into the alleged physical abuse, he (Administrator) interviewed facility staff, including CNA 1, LVN 1, and RN 1 and confirmed that on 8/22/2025, Resident 1 reported the alleged physical abuse by Resident 2 to them. The Administrator stated that the facility staff should have reported the allegation immediately to ensure proper monitoring and to prevent potential further abuse but failed to do so. The Administrator stated that the facility staff failed to complete the required and timely reporting of Resident 1’s allegation of physical abuse.   A review of the facility-provided policy and procedure (P&P) titled, “Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating,” last reviewed on 1/28,2025, indicated, “If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to the other officials according to the state law … ‘Immediately’ is defined as: within two hours of an allegation involving abuse or result in serious bodily injury.…”   A review of the facility-provided P&P titled, “Identifying Types of Abuse,” last reviewed on 1/28,2025, indicated “As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents…Physical abuse includes, but is not limited to hitting, slapping, biting, punching or kicking…” The facility failed to report an allegation of physical abuse involving Resident 1 when the following events occurred: 1. On 8/22/2025, at approximately 9:30 p.m., Resident 1 reported to Certified Nursing Assistant 1 that Resident 2 had hit her (Resident 1) legs. 2. On 8/22/2025, at approximately 9:40 p.m., CNA 1 then reported the allegation to Licensed Vocational Nurse 1. 3. On 8/22/2025, at approximately 10 p.m., Registered Nurse 1 observed Resident 1 screaming at LVN 1. Resident 1 informed RN 1 that Resident 2 had hit her (Resident 1) legs. RN 1 failed to report the physical abuse allegation to the Administrator, who is the designated Abuse Coordinator. 4. On 8/25/2025, at approximately 3:30 p.m., Resident 1 informed the Administrator that on 8/22/2025 (time not specified), Resident 2 had hit her (Resident 1) legs. The Administrator conducted an internal investigation and determined that CNA 1, LVN 1, and RN 1 had all been made aware of the physical abuse allegation involving Resident 1 on 8/22/2025, but none of them reported the allegation to him (Administrator). 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 Resident 1 from potential harm. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.