Health inspection·February 12, 2025

Freedom from Abuse, Neglect, and Exploitation 42 CFR §483.12(b)(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 42 CFR §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 CFR § 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 1/10/2025, the California Department of Public Health (CDPH) received a facility reported incident (FRI) indicating a resident (Resident 2) showed physical aggression towards his roommate (Resident 1) for talking loudly. On 1/23/2025, an unannounced visit was conducted at the facility. The facility failed to: 1. Provide the State Survey Agency, a written report of the findings of the investigation of an allegation of abuse within five (5) working days of the occurrence of an incident of physical abuse. This failure resulted in a delay in the investigation by the State Survey Agency. It also had the potential to lead to further abuse in the facility. a. Resident 1 was an 83-year-old male, originally admitted to the facility on 4/12/2024 and readmitted on 10/14/2024, with diagnoses including dementia (a progressive state of decline in mental abilities), anxiety (feeling of fear), dysphagia (difficulty swallowing), and muscle weakness (loss of muscle strength). A review of Resident 1's Minimum Data Set ([MDS]- a resident assessment tool), dated 12/31/2024, indicated Resident 1’s cognitive (the ability to think and process information) skills for daily decision making was moderately impaired. The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).  A review of Resident 1’s History and Physical (H&P), dated 12/3/2024, indicated Resident 1 did not have the capacity for medical decision making. A review of Resident 1’s situation, background, assessment, recommendation ([SBAR]-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 1/9/2025, indicated Resident 1 was monitored for emotional distress manifested by (m/b) a physical altercation with Resident 2 on 1/9/2025. b. Resident 2 was a 65 year-old male, originally admitted to the facility on 10/15/2024 and readmitted on 1/1/2025 with diagnoses including altered mental status (change in person’s mental function), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). A review of Resident 2’s MDS, dated 1/14/2025, indicated Resident 2’s cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and /or touching/steadying assistance as resident completes activity) from staff for ADLs. A review of Resident 2’s SBAR, dated 1/9/2025, indicated on 1/9/2025 Resident 2 was physically aggressive toward Resident 1. The SBAR indicated Resident 2 was agitated and irritate and hit Resident 1. During an interview on 1/23/2025 at 9:50 a.m., Licensed Vocational Nurse (LVN 1) stated on 1/9/2025 around 5:30 p.m., Resident 1 was lying in bed and talking loudly. LVN 1 stated Resident 2 asked Resident 1 if he (Resident 1) could stop talking so loudly. LVN 1 stated while Resident 1 continued talking loudly Resident 2 became irritated and agitated, stood up from his bed approached Resident 1 and hit Resident 1 on the face. A review of a SOC 341 (this form, as adopted by the California Department of Social Services CDSS, is required under Welfare and Institutions Code WIC, to report suspected dependent adult/elder abuse), dated 1/9/2025 indicated the incident between Residents 1 and 2 was reported to the Los Angeles County Department of Public Health, Health Inspection Division on 1/9/2025 via fax (an image of a document made by electronic scanning). During an interview on 1/23/2025 at 2:45 p.m., the Director of Nursing (DON) stated, “I will be honest with you regarding the 5-days Investigation Report, it was completed on 1/16/2025 but was not faxed to CDPH within 5 days.” A review of the facility’s policy and procedure (P&P) titled “Abuse, Neglect, exploitation or Misappropriation-Reporting Investigating”, revised 9/2022, indicated reports of resident abuse would be reported to local and federal agencies. The P&P indicated facility shall provide a written report of the findings of abuse investigations within five (5) working day of the reported allegations. The facility failed to: 1. Provide the State Survey Agency, a written report of the findings of the investigation of an allegation of abuse within five (5) working days of the occurrence of an incident of physical abuse. This failure resulted in a delay in the investigation by the State Survey Agency. It also had the potential to lead to further abuse in the facility. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of the residents.