Health inspection·September 4, 2025

F609 §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. On 7/22/2025, the California Department of Public Health (CDPH) made an unannounced visit to conduct the annual recertification survey and investigate two Facility-Reported Incidents (FRIs) regarding resident abuse. The facility failed to: 1. Implement policies and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report an allegation of financial abuse for Resident 1 to the State Survey Agency (SSA) within the required timeframe.   2. Implement its P&P on abuse for an allegation of financial abuse for Resident 1 by failing to:   a. Conduct a thorough investigation of the alleged financial abuse. b. Ensure the facility’s Social Services Director (SSD) reported a suspicion of financial abuse to the Abuse Coordinator on 6/26/2025. c. Complete and submit a written five (5) day follow-up investigation report indicating the results of the investigation for the allegation of financial abuse that occurred on 6/26/2025.   As a result, Resident 1 was placed at risk for further financial exploitation and resulted in a delay in investigation of a suspicion of financial abuse. A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 5/19/2025 with diagnoses including generalized arthritis (swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age), syncope (a sudden temporary loss of consciousness, commonly known as fainting or passing out) and collapse (fall down), type two (2) diabetes mellitus (high levels of sugar in the blood) and depression (a mood disorder characterized by persistent feelings of sadness, loss of interest, and a range of other emotional and physical symptoms that significantly interfere with daily life).   A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 7/2/2025 indicated Resident 1 had moderate cognitive (the mental process involved in knowing, learning, and understanding things) impairment. The MDS indicated Resident 1 required supervision or touching assistance with toileting hygiene, shower/bathing, dressing and mobility (movement).   A review of Resident 1’s Social Service Note dated 6/26/2025, timed at 5:12 p.m. indicated that on 6/26/2025, the SSD received an email from Resident 1’s Responsible Party (RP) containing a copy of Resident 1’s advance directive (a written statement of a person’s wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) and power of attorney (POA – a legal document that allows someone else to act on your behalf). The Social Service Note indicated that upon review, she (SSD) noted that the documents were incomplete (with page four [4] missing). The Social Service Note indicated that on 6/26/2025, the SSD contacted Resident 1’s RP to request a complete set of Resident 1’s advance directive and POA, and Resident 1’s RP responded that she (Resident 1’s RP) would provide them as soon as the documents were available. The Social Service Note further indicated that the SSD then contacted Resident 1’s attorney, who confirmed that the incomplete advance directive and POA had been initiated by Resident 1’s RP. The Social Service Note indicated that Resident 1’s attorney would investigate the matter, contact Resident 1’s RP directly, and inform the SSD once the attorney had more information.    During an interview on 7/22/2025 at 10:00 a.m., with the Administrator (ADM), the ADM stated that she (ADM) is the facility’s abuse coordinator. The ADM stated that she (ADM) was not aware of any suspected financial abuse allegation until this morning (7/22/2025). The ADM stated that she (ADM) did not complete or submit a written five (5) day follow-up investigation report to the SSA regarding the financial abuse allegation on 6/26/2025, as she (ADM) was not made aware of the allegation at the time. During an interview on 7/22/2025 at 10:30 a.m., with the SSD, the SSD stated that the ADM is the facility’s abuse coordinator. The SSD stated that she (SSD) did not report Resident 1’s suspected financial abuse to the ADM on 6/26/2025. When asked why the SSD did not report the suspected financial abuse to the ADM, the SSD did not answer. The SSD stated that she should have reported the suspicion of financial abuse to the ADM on 6/26/2025, when the SSD first became aware of the concern, so that the ADM could initiate an investigation into the allegation.   During a concurrent interview and record review on 7/22/2025 at 11:49 a.m. with the SSD, the SSD reviewed Resident 1’s Social Services Notes dated 6/26/2025. The SSD stated that on 6/26/2025, she (SSD) contacted Resident 1’s RP to obtain a complete set of Resident 1’s advance directive and POA since the documents emailed to her by Resident 1’s RP on 6/26/25 were incomplete (page four [4] missing). The SSD stated that after multiple attempts of trying to obtain a complete copy of Resident 1’s advance directive and POA, the SSD suspected financial abuse on 6/26/2025. The SSD stated that she (SSD) notified the SSA of the suspected financial abuse on 7/23/2025 (seven days after she [SSD] initially became aware of the concern. The SSD further stated that she did not inform the ADM, who is the facility’s Abuse Coordinator. The SSD stated that this was her (SSD) first time reporting an allegation of abuse and she (SSD) was confused about the reporting procedure.   During an interview on 7/22/2025 at 3:30 p.m. with the ADM, the ADM stated that the SSD should have immediately reported the suspicion of financial abuse to her (ADM) and to the SSA on 6/26/2025, when the SSD first became aware of the allegation. The ADM further stated that the SSA was notified seven (7) days later, resulting in a delayed notification.   A review of the facility’s P&P titled “Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigation,” last reviewed on 5/28/2025, 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 other officials according to state law. All allegations are thoroughly investigated. The administrator initiates investigations. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report. The follow up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. The follow up investigation report will provide as much information as possible at the time of submission of the report. The residents and/or representative are notified of the outcome immediately upon conclusion of the investigation. 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; g. and the facility medical director.” The facility failed to: 1. Implement P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report an allegation of financial abuse for Resident 1 to the SSA within the required timeframe.   2. Implement its P&P on abuse for an allegation of financial abuse for Resident 1 by failing to:   a. Conduct a thorough investigation of the alleged financial abuse. b. Ensure the facility’s SSD reported a suspicion of financial abuse to the Abuse Coordinator on 6/26/2025. c. Complete and submit a written five (5) day follow-up investigation report indicating the results of the investigation for the allegation of financial abuse that occurred on 6/26/2025.   As a result, Resident 1 was placed at risk for further financial exploitation and resulted in a delay in investigation of a suspicion of financial abuse. The above violation had a direct relationship to the health, safety, or security of Resident 1.