Health inspection·September 12, 2025

§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. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (c)(2) Have evidence that all alleged violations are thoroughly investigated. (c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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. HSC 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. On 7/28/2025 at 8:00 a.m., the California Department of Health (CDPH) conducted an unannounced standard annual recertification survey at the facility. The facility failed to: 1. Report Resident 74's allegation of physical abuse by Certified Nursing Assistant (CNA) 1 to the CDPH. 2. Implement its policy and procedures (P&P) titled, "Abuse Reporting and Investigation," which indicated "All allegations of abuse, neglect, mistreatment, exploitation or injury of unknown origin will be reported by the facility Administrator to the CDPH." As a result of these failures there was a delay in reporting to the CDPH and CDPH's investigation, and a potential risk of continuous abuse, neglect, and mistreatment of Resident 74 and other residents in the facility. A review of Resident 74's Admission Record indicated Resident 74, an 80-year-old female, was admitted to the facility on 6/26/2025 with diagnoses including osteoarthritis and rheumatoid arthritis. A review of Resident 74's Minimum Data Set (MDS- a resident assessment tool) dated 7/3/2025, indicated Resident 74 had severe cognitive impairment and required maximal assistance with ADLs. During an interview on 7/29/2025 at 1:03 p.m., with Resident 74's family member (FM) 1, FM 1 stated there was a CNA 1 that was rough with Resident 1 while changing her incontinence brief on 7/22/2025. FM 1 stated facility staff were informed of CNA 1 being rough with Resident 1 while changing her incontinence brief. During an interview on 7/30/2025 at 10:20 a.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 74 told her a CNA on the night shift was rough with her when changing her incontinence brief. The ADON stated she did not report the allegation because Resident 74 told her she was fine. During a phone interview on 7/30/2025 at 11:23 a.m., with CNA 1, CNA 1 stated she was made aware that Resident 74 accused her of being rough with her while changing her incontinence brief. CNA 1 stated she was going to be suspended by the facility. During an interview on 7/30/2025 at 11:39 a.m., with the Director of Staff Development (DSD), the DSD stated if a resident (in general) stated a staff member was rough with the resident, it should be considered a form of abuse, and it should be reported to the CDPH and investigated immediately. The DSD stated it was important to report and investigate the allegations of abuse to ensure it does not happen to other residents. During an interview on 8/1/2025 at 3:03 p.m., with the Director of Nursing (DON), the DON stated she was informed that Resident 74 was refusing personal care (changing incontinent brief) but CNA 1 continued to change Resident 74's incontinent brief. The DON stated the allegation should have been reported to CDPH and investigated but at the time they did not consider it as a form of abuse. A review of the facility's policy and procedure (P&P) titled, "Abuse Reporting and Investigation," dated 1/10/2024, indicated, "To promptly report all allegations of abuse as required by law and regulations to the appropriate agencies within the required time frames. The P&P indicated all allegations of abuse, will be reported by the facility Administrator to the following agencies: The State licensing/certification agency responsible for surveying/licensing the facility, the local/State Ombudsman, and local law enforcement." The facility failed to: 1.Report Resident 74's allegation of physical abuse by Certified Nursing Assistant (CNA) 1 to the CDPH. 2. Implement its policy and procedures (P&P) titled, "Abuse Reporting and Investigation," which indicated "All allegations of abuse, neglect, mistreatment, exploitation or injury of unknown origin will be reported by the facility Administrator to the CDPH." As a result of these failures there was a delay in reporting to the CDPH and CDPH's investigation, and a potential risk of continuous abuse, neglect, and mistreatment of Resident 74 and other residents in the facility. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 74.