Health inspection·February 10, 2025

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (b) The facility must develop and implement written policies and procedures that: (b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. 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. On 1/13/2024, the California Department of Public Health (CDPH) conducted a revisit survey for the facility’s annual recertification survey. During the revisit, on 1/14/2025, the CDPH identified a resident-to-resident altercation that occurred on 12/29/2024, involving Resident 3 and Resident 30. The incident was not reported to the State Agency. The facility failed to: 1. Report Resident 3’s and Resident 30’s altercation to the State Agency. This failure resulted in a delayed the investigation of the State Agency. The failure also increased the potential for additional resident-to-resident abuse in the facility. Resident 3 was a 96-year-old female, originally admitted to the facility on 3/18/2017, and recently re-admitted on 3/15/2023, with diagnoses including dementia (a progressive state of decline in mental abilities) and lack of coordination. A review of Resident 3’s History and Physical (H&P) dated 1/4/2022, indicated Resident 3 did not have the capacity to understand or make decisions. A review of Resident 3’s Minimum Data Assessment (MDS, a resident assessment tool), dated 10/22/2024, indicated Resident 3 had severe cognitive impairments (a condition that affects a person's ability to think, learn, and remember). The MDS indicated Resident 3 was dependent on staff for all activities of daily living (activities such as bathing, dressing and toileting a person performs daily), and mobility while in bed. A review of Resident 3’s Change of Condition (COC) Assessment, dated 12/30/2024 indicated Resident 3’s roommate (Resident 30) threw a blanket at her face and yelled at her on 12/29/2024. Resident 30 was a 92-year-old female, originally admitted to the facility on 12/2/2015, and most recently re-admitted on 9/22/2023 with diagnoses including dementia and mood disorder (a mental health condition that affects a person's emotional state). A review of Resident 30’s H&P dated 10/20/2024, indicated Resident 30 did not have the capacity to understand or make decisions. A review of Resident 30’s MDS dated 11/22/2024, indicated Resident 30 had severe cognitive impairments. The MDS indicated Resident 30 did not have any impairments to any of her arms or legs. The MDS indicated Resident 30 required supervision or touch assistance from staff to transition from a sitting to standing position. During an interview on 1/14/2025 at 3:04 PM, the Administrator (ADM) stated the resident-to-resident altercation between Resident 3 and Resident 30, that occurred on 12/29/2024, was not reported to the State Agency because Resident 30 (the alleged abuser) had a diagnosis of dementia. During a concurrent interview and record review, on 1/16/2025 at 1:46 PM, with the ADM, the facility’s policies and procedures (P&Ps) titled “Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating” (revised 4/2021) and “Policy and Procedure on Patient Abuse and Prevention” (undated) were reviewed. The ADM stated that neither of the P&Ps indicated incidents or allegations of suspected abuse did not need to be reported to the SA. The ADM stated it was important to report all allegations of abuse timely to ensure that investigations could be conducted, and residents’ rights were preserved. The ADM stated the resident-to-resident altercation between Resident 3 and Resident 30, which occurred on 12/29/2024, was reported to the State Agency on 1/15/2024. A review of the facility P&P titled “Policy and Procedure on Patient Abuse and Prevention” (undated), indicated verbal abuse was considered abuse regardless of the alleged abuser’s age, ability to comprehend, or disability. The P&P did not indicate an exception for alleged abusers with a diagnosis of dementia. A review of the facility P&P titled “Resident to Resident Altercation” (12/2017), indicated it was the facility’s policy to provide an environment that kept residents safe from abuse. The P&P indicated incidents of resident-to-resident altercations were to be reported to the appropriate agencies as indicated in the facility’s abuse reporting policy. A review of the facility P&P titled “Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating” (revised 4/2021), indicated incidents of abuse were to be reported immediately to the facility ADM. The P&P further indicated the ADM (or the individual making the allegation of abuse) was to report the abuse immediately to “the state licensing/certification agency responsible for surveying/licensing the facility”. The P&P indicated “immediately” was defined as within two hours if the allegation involved abuse. The P&P did not indicate an exception to reporting if the alleged abuser had a diagnosis of dementia. The facility failed to: 1. Report Resident 3’s and Resident 30’s altercation to the State Agency. This failure resulted in a delayed the investigation of the State Agency. The failure also increased the potential for additional resident-to-resident abuse in the facility. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.