Health inspection·March 13, 2025

§483.12 The facility must develop and implement written policies and procedures that: (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. (c)(2) Have evidence that all alleged violations are thoroughly investigated. (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. 22 CFR § 72527 Patients’ Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. On 2/10/2025, the California Department of Public Health (CDPH) conducted an unannounced annual recertification survey at the facility. During initial tour the CDPH was made aware by Resident 73 of a resident-to-resident allegations of abuse. Upon investigation, the CDPH determined Resident 73 yelled curse words and threw a water pitcher towards Resident 69, which the Licensed Vocational Nurse (LVN 6) was aware but did not report the incident to the CDPH. The facility failed to: 1. Report an alleged resident to resident abuse to the CDPH within two hours. 2. Investigate the resident-to-resident abuse incident. 3. Report the results of the abuse investigation to the CDPH within five (5) working days. As result, there was a delay of an onsite investigation by the CDPH and a potential to place Resident 69 and all residents in the facility at risk for further abuse. A) Resident 69 was a 63-year-old male, admitted to the facility on 10/18/2021. Resident 69’s diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness or paralysis on one side of the body), schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 69’s Minimum Data Set ([MDS] – a resident assessment tool), dated 1/23/2025, indicated Resident 69’s cognitive (the ability to think and process information) skills for daily living was severely impaired. The MDS indicated Resident 69 required maximal (helper does more than half the effort) assistance form 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 69’s situation, background, assessment, recommendation ([SBAR]-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 2/2/2025, indicated Resident 69 had a room change for better roommate compatibility. During an interview on 2/10/2025 at 9:30 a.m., with Resident 69, Resident 69 stated a few days prior (was not able to recall the date), his roommate (Resident 73) yelled at him, called him a bad (curse) word and threw water at him. Resident 69 stated he felt scared and sad. B.) Resident 73’s was a 68-year-old male, admitted to the facility on 11/29/2024. Resident 73’s diagnoses included DM, dysphagia (difficulty swallowing), and hypertension (HTN- high blood pressure). A review of Resident 73’s MDS, dated 12/11/2024, indicated Resident 73’s cognitive skills for daily living was intact. The MDS indicated Resident 73’s required moderate (helper does less than half the effort) assistance from staff for ADLs. A review of Resident 73’s History and Physical (H&P), dated 12/1/2024, indicated Resident 73 had the capacity to understand and make decisions. During an interview on 2/10/2025 at 10:31 a.m., with Resident 73, Resident 73 stated on 2/2/2025 in the early evening hours (was not able to recall the time), he had a verbal, and physical altercation with his roommate (Resident 69). Resident 73 stated he was upset and angry because Resident 69 was eating his (Resident 73) snacks. Resident 73 stated he threw water at Resident 69 and called Resident 69 a “Motherf---er.” During a concurrent interview and record review on 2/12/2025 at 11:00 a.m., with the Director of Nursing (DON), Resident 73’s SBAR dated 2/2/2025 was reviewed. The DON stated the SBAR indicated Resident 73 cursed and threw a water pitcher at his roommate (Resident 69). The DON stated the SBAR indicated Resident 73 was yelling at Resident 69 “I’m going to hit him in the face because he (Resident 69) ate my snacks.” The DON stated Resident 73’s action toward Resident 69 was resident to resident verbal and physical abuse. The DON stated, she did not investigate the abuse incident and did not report it to the CDPH because the staff did not report the incident to her (DON) or Administrator (ADM). During a telephone interview on 2/12/2025 at 12:00 p.m., with Licensed Vocational Nurse (LVN 6), LVN 6 stated in the evening of 2/2/2025, she heard yelling and screaming coming from Residents’ 69 and 73’s room. LVN 6 stated she walked into the room and observed Resident 73 yelling curse words and throwing a water pitcher towards Resident 69. LVN 6 stated Resident 73’s action towards Resident 69 was considered a physical and verbal abuse. LVN 6 stated she did not report the resident-to-resident abuse to the DON, ADM, and/or the CDPH. LVN 6 stated it was important to report any form of abuse to the DON, ADM, and/or the CDPH immediately, to investigate the allegations, and to prevent the risk of Resident 69 and other residents from abused. A review of the facility’s policy and procedure (P&P) titled “Recognizing Signs and Symptoms of Abuse/Neglect”, revised 1/2011, indicated all personnel would report any signs and symptoms of abuse to their supervisor and/or to the Director of Nursing (DON) immediately. A review of the P&P titled “Abuse Reporting and Investigation”, dated 11/2018, indicated: 1. The facility will report all allegations of abuse as required by law and regulations to the appropriate agencies within two (2) hours. 2. The facility will provide a written report of the results of the abuse investigation and appropriate action taken to the CDPH Licensing and Certification within five (5) working days of the reported allegation. The facility failed to: 1. Report an alleged resident to resident abuse to the CDPH within two hours. 2. Investigate the resident-to-resident abuse incident 3. Report the results of the abuse investigation to the CDPH within five (5) working days. As result, there was a delay of an onsite investigation by the CDPH and a potential to place Resident 69 and all residents in the facility at risk for further abuse. These violations had a direct or immediate relationship to the health, safety, or security of patients or residents