Health inspection·October 17, 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 9/9/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident regarding an allegation of employee-to-resident abuse. The facility failed to report an allegation of an employee-to-resident verbal abuse (harmful use of language to control, intimidate or hurt someone) and physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) to the State Survey Agency (SSA) involving Resident 1. On 8/29/2025, Restorative Nursing Assistant (RNA) 1 reported to the Director of Nursing (DON) that on 8/5/2025, between 10 a.m. to 10:30 a.m., an allegation that Life Enrichment Coordinator 1 (LEC 1) had verbally and physically abused Resident 1.  The facility did not report the allegation of abuse to the SSA until 8/29/2025, 24 days after the 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 other residents from potential harm. A review of Resident 1’s Admission Record (undated) indicated the facility admitted the 93-year-old male resident on 2/10/2023 with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the right dominant side, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and dysphagia (a condition that makes it difficult to swallow). A review of Resident 1’s Minimum Data Set (MDS - resident assessment tool), dated 6/25/2025, indicated Resident 1’s cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was moderately impaired.   A review of Resident 1’s Situation Background Assessment Recommendation (SBAR - an organized communication method used in healthcare to help people clearly and quickly give important information) Communication Form, dated 8/29/2025, indicated that on 8/5/2025, (between 10 a.m. to 10:30 a.m.), RNA 1 reported to the DON that he (RNA 1) observed LEC 1 throw a piece of cloth (a sweater) toward the resident (Resident 1) and begin yelling, during which the resident (Resident 1) appeared shaken. The Registered Nurse (RN) Supervisor conducted a head-to-toe assessment (a comprehensive, systematic physical examination of the body, performed by a healthcare professional to evaluate a resident’s overall health status from head to toe), no abnormalities were noted, and the resident’s (Resident 1) skin was intact (no break in skin integrity). During an interview on 9/9/2025 at 12:04 p.m., with RNA 1, RNA 1 stated that on 8/5/2025, between approximately 10 a.m. and 10:30 a.m., he (RNA 1) observed LEC 1 throw a towel or sweater at Resident 1’s face in the dining room. RNA 1 further stated that he (RNA 1) heard LEC 1 yelling at Resident 1 during the same time (on 8/5/2025, between approximately 10 a.m. to 10:30 a.m.). RNA 1 stated LEC 1’s actions are considered to be allegations of verbal and physical abuse. RNA 1 stated that he (RNA 1) reported the alleged verbal and physical abuse to the DON on 8/29/2025 because he (RNA 1) did not know who the charge nurse was. RNA 1 stated he (RNA 1) received training on his first day of hire (specific date not mentioned) and that any abuse should be reported within two hours to the charge nurse, RN Supervisor or the Administrator. During an interview on 9/9/2025 at 4:05 p.m., with the Assistant Administrator (AADM), the AADM stated that he (AADM) serves as the facility’s Abuse Coordinator. The AADM stated that on 8/29/2025 (unable to recall specific time), RNA 1 reported to the DON the allegations of verbal and physical abuse that had allegedly occurred on 8/5/2025. The AADM stated that RNA 1 should have reported the allegations of verbal and physical abuse within two hours. The AADM further stated that all allegations of abuse must be reported within two hours to the SSA, the Ombudsman (a resident advocate), and Local Law Enforcement (LLE).  During an interview on 9/9/2025 at 4:34 p.m., with the DON, the DON stated that on 8/29/2025, RNA 1 informed her (DON) of an allegation of verbal and physical abuse by LEC 1 toward Resident 1, which allegedly occurred on 8/5/2025. The DON stated that not reporting allegations of verbal and physical abuse in a timely manner had the potential to allow abuse to continue unaddressed. The DON further stated that RNA 1 failed to report the allegation of abuse within two hours, resulting in the facility not reporting the incident until 8/29/2025.  A review of the facility’s policy and procedure (PnP) titled, “Abuse Prevention and Prohibition Program,” last reviewed on 7/23/2025, indicated, “the facility will report allegations of abuse … immediately… no later than two hours after forming the suspicion….” The facility failed to report an allegation of an employee-to-resident verbal abuse (harmful use of language to control, intimidate or hurt someone) and physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) to the State Survey Agency (SSA) involving Resident 1. On 8/29/2025, Restorative Nursing Assistant (RNA) 1 reported to the Director of Nursing (DON) that on 8/5/2025, between 10 a.m. to 10:30 a.m., an allegation that Life Enrichment Coordinator 1 (LEC 1) had verbally and physically abused Resident 1.  The facility did not report the allegation of abuse to the SSA until 8/29/2025, 24 days after the 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 other residents from potential harm. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.