Health inspection·August 6, 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 6/20/2025, 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) during the annual recertification survey. The facility failed to report an allegation of resident-to-resident abuse immediately, but no later than two hours after the allegation was made, to the State Survey Agency (CDPH), the Ombudsman (a resident advocate), and local law enforcement (LLE) in accordance with federal and state law for Resident 37. On 6/16/2025 at approximately 6:20 a.m., Licensed Vocational Nurse (LVN) 2 found Resident 57 standing over Resident 37 while Resident 37 stated Resident 57 pushed her (Resident 37). LVN 2 stated Registered Nurse (RN) 7 assessed Resident 37 during the incident. LVN 2 informed the Director of Nursing (DON) of the allegation of abuse on 6/17/2025 and RN 7 did not report the allegation of abuse to the DON or Administrator (ADM) on 6/16/2025. As a result, there was a delay for an onsite inspection by CDPH to ensure Resident 37’s and other residents’ safety and had the potential to result in unidentified abuse. Resident 37 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 57's Admission Record (AR) indicated the facility originally admitted Resident 57, a 67-year-old male, on 7/8/2024 and most recently admitted the resident on 5/13/2025 with diagnoses including encephalopathy (a change in your brain function due to injury or disease), unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), and insomnia (difficulty sleeping). A review of Resident 57's Minimum Data Set (MDS - resident assessment tool), dated 5/30/2025, indicated the resident was sometimes able to understand others and was sometimes able to make themself understood. The MDS further indicated that the resident required substantial/maximal assistance from staff for lower body dressing, toileting, personal hygiene, and bathing. A review of Resident 37's AR indicated the facility originally admitted Resident 37, a 87-year-old female, on 1/2/2024 with diagnoses including unspecified dementia, carcinoma (cancer - a disease where some of the body's cells grow out of control and can spread to other parts of the body) of left bronchus (airway that leads from the trachea [windpipe] to a lung) and lung, and restlessness and agitation. A review of Resident 37's MDS, dated 4/10/2025, indicated the resident was sometimes able to understand others and was sometimes able to make themself understood. The MDS further indicated that the resident required partial / moderate assistance from staff for upper body dressing, toileting, and personal hygiene; and the resident required staff supervision for mobility. A review of Resident 37's History and Physical (H&P), dated 1/4/2024, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 37's Physician Orders, dated 6/16/2025, at 7:56 a.m., indicated to transfer the resident via 911 to General Acute Care Hospital (GACH) 1. A review of Resident 37's Change of Condition (COC) Interact Assessment Form, dated 6/16/2025, at 7:55 a.m., indicated Resident 37 was found on the floor at 6:30 a.m. just outside the bathroom in the resident's room, the resident was on their right side pointing to the hip and crying out that it hurts so bad. The COC Interact Assessment Form indicated emergency services were called and the resident was transported to GACH 1. The COC Interact Assessment Form indicated it was completed by Registered Nurse (RN) 7. A review of the facility provided Fax Confirmation Sheet with Letter, dated 6/17/2025, at 10:57 a.m., indicated a fax was sent on 6/17/2025, at 10:57 a.m., that included a letter to CDPH indicating a notification that Resident 37 had sustained a fall, was transferred to the hospital, and it was reported that the resident sustained a comminuted (broken into pieces) mildly displaced (moved a little bit out of the normal position) impacted (jammed together) intertrochanteric (upper part of the thigh bone) fracture (broken bone) of the right hip. A review of Resident 37's Care Plan titled, "Resident and / or responsible party have been made aware that the facility has stable systems to prevent not only abuse, but also those practices and omissions, neglect and misappropriation of property that if left unchecked, lead to abuse," initiated 3/19/2024, indicated an intervention to inform the resident that they may report abuse. During an interview on 6/18/2025 at 6:21 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated on 6/16/2025 at approximately 6:20 a.m., LVN 2 was called to Resident 37's room. LVN 2 stated LVN 2 found Resident 37 on the floor near the restroom. LVN 2 stated Resident 57 was standing over Resident 37 when Resident 37 stated multiple times, "he pushed me.” LVN 2 stated RN 7 came to assess Resident 37 and emergency services were called to take Resident 37 to the hospital. LVN 2 stated LVN 2 spoke with the DON on 6/17/2025 regarding the incident. During a concurrent interview and record review on 6/18/2025 at 8:41 a.m. with the DON, the Fax Confirmation Sheet with Letter, dated 6/17/2025, at 10:57 a.m., was reviewed. The DON stated the facility policy and procedure (P&P) is to report all allegations of abuse to CDPH, the ombudsman, and the police within two hours of learning of the allegation. The DON stated the facility process is for any staff member that is made aware of an allegation of abuse to report the allegation to their supervisor and the ADM. The DON stated the ADM is the abuse coordinator and reports all allegations to CDPH, the ombudsman, and the police within two hours. The DON stated it was important to report all allegations of abuse within two hours to proceed with the investigation to determine if abuse occurred and to ensure resident safety. The DON stated on 6/17/2025, after reporting Resident 37's injury to CDPH, LVN 2 informed the DON that Resident 37 made an allegation of abuse that Resident 57 pushed Resident 37. The DON stated LVN 2 did not inform the DON or ADM of Resident 37's allegation of abuse when it occurred on 6/16/2025, but LVN 2 should have. The DON stated Resident 37's allegation of abuse was not reported to CDPH, the police, or the ombudsman because the DON and ADM were not aware of the allegation. The DON stated on 6/17/2025, when LVN 2 notified the DON of Resident 37's allegation of abuse, the DON also did not report the allegation to CDPH, the police, or the ombudsman. The DON stated looking back, the DON also should have reported the allegation on 6/17/2025 and did not. During an interview on 6/20/2025 at 12:48 p.m. with the ADM, the ADM stated on 6/17/2025 the ADM was made aware that on 6/16/2025, at approximately 6:30 a.m., Resident 37 alleged that Resident 57 pushed Resident 37. The ADM stated Resident 37's allegation was an allegation of abuse. The ADM stated LVN 2 and RN 7 had a responsibility to ensure the allegation of abuse was reported within two hours, but LVN 2 and RN 7 did not. The ADM stated on 6/17/2025, the ADM had already reported Resident 37's injury to CDPH, and the ADM did not think to also report the allegation of abuse. The ADM stated looking back, the facility should have reported the allegation of abuse and called the police, but they did not. The ADM stated it was an error on their part. The ADM stated when Resident 37's allegation of abuse was not reported until two days after the allegation was made, there was a potential for a delay in investigating to ensure abuse was stopped and residents were safe. The ADM stated the facility’s P&P was not followed. During an interview on 6/20/2025 at 1:35 p.m. with LVN 2, LVN 2 stated on 6/16/2025 Resident 37 alleged Resident 57 hurt Resident 37. LVN 2 stated RN 7 was also aware of Resident 37's allegation. LVN 2 stated LVN 2 thought RN 7 would report the allegation, but LVN 2 did not follow up with RN 7. During an interview on 6/20/2025 at 2:30 p.m. with the DON, the DON stated the DON spoke with RN 7 and RN 7 did not report Resident 37's allegation of abuse to anyone on 6/16/2025. The DON stated RN 7 did not give a reason for not reporting Resident 37's allegation of abuse. The DON stated the facility’s P&P was not followed. A review of the facility provided P&P titled, "Accidents and Incidents - Investigating and Reporting," last reviewed 7/2024, indicated all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The following data, as applicable, shall be included on the Report of Incident/Accident form: a) The date and time the accident or incident took place; b) The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c) The circumstances surrounding the accident or incident; d) Where the accident or incident took place; e) The name(s) of witnesses and their accounts of the accident or incident; f) The injured person's account of the accident or incident. A review of the facility provided P&P titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," last reviewed 7/2024, indicated all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting Allegations to the Administrator and Authorities 1. 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 other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. "Immediately" is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone. 5. Notices include, as appropriate: a. the resident's name; b. the resident's room number; c. the type of abuse that is alleged (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. 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. The facility failed to report an allegation of resident-to-resident abuse immediately, but no later than two hours after the allegation was made to the State Survey Agency, the Ombudsman, and LLE in accordance with federal and state law for Resident 37. As a result, there was a delay for an onsite inspection by CDPH to ensure Resident 37’s and other residents’ safety and had the potential to result in unidentified abuse. Resident 37 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 37.