Health inspection·March 28, 2025

CFR § 483.12 - Freedom from abuse, neglect, and exploitation (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. CCR § 72523(a) Patient Care Policies and Procedures 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. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 2/6/2025, the California Department of Public Health (CDPH) received a facility reported incident (FRI) alleging a resident abuse. On 2/7/2025, CDPH conducted an unannounced visit to the facility to investigate the FRI's allegation of abuse. Upon investigation CDPH determine the facility failed to: 1. Report the allegation of abuse within the regulated time frame of two hours which occurred between Resident 2 and Resident 1 on 12/3/2024. The facility reported the incident on 2/6/2025 (65 days after the incident occurred). 1. Implement its abuse policy and procedure (P&P), titled, "Abuse Program Policy and Procedure," revised 5/30/2024 which indicated "the administrator, or designated representative will notify law enforcement by telephone immediately or as soon as practicably possible, but no longer than two hours of initial report and send a written report to the Ombudsman, law enforcement, and CDPH licensing and certification within two hours." This deficient practice resulted in CDPH's inability to investigate the allegations of abuse timely and had the potential for other allegations of abuse to go unreported. A review of Resident 1's, a 66-year-old male, Admission Record indicated Resident 1 was initially admitted to the facility on 8/20/2022 and readmitted on 1/15/2024 with diagnoses including type 2 diabetes ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and traumatic partial amputation (loss of foot due to injury or accident) of right foot. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 11/6/2024 indicated Resident 1's cognition (ability to make decisions of daily living) was intact. The MDS indicated Resident 1 had the ability to understand and be understood by others. A review of Resident 2's, a 68-year-old male, Admission Record indicated Resident 2 was admitted to the facility on 2/16/2024 with diagnoses including type 2 diabetes, metabolic encephalopathy (brain dysfunction that occurs due to an imbalance of chemicals in the blood) and altered mental status (range of symptoms that can affect how well the brain is working). A review of Resident 2's MDS, dated 12/11/2024, indicated Resident 2's cognition was severely impaired. The MDS indicated Resident 2 was sometimes understood by others and sometimes had the ability to understand others. A review of Resident 2's Change of Condition (COC) Evaluation document (a form of communication between members of a health care team) dated 12/3/2024 at 4:21 p.m., and written by Registered Nurse (RN) 1, indicated Resident 2 demonstrated a change in condition related to behavioral symptoms. The COC indicated Resident 2 was walking in the hallway and noted attempting to strike out at peers. During a phone interview on 2/10/2024 at 8:30 a.m., Ombudsman 1 stated during her recent visit to the facility on 2/6/2025, Resident 1 reported to her that Resident 2 attempted to hit him. The Ombudsman stated she immediately notified the Administrator of the incident. During an interview on 2/10/2024 at 9:30 a.m., Resident 1 stated Resident 2 tried to hit him a few months ago. Resident 1 stated, he was sitting in his wheelchair outside his room, in the doorway, when Resident 2 came up to him and started swinging his arms. Resident 1 stated, he grabbed Resident 2's arms, one in each of his hands to prevent Resident 2 from hitting him. Resident 1 stated, "the MDS nurse witnessed the incident and came to take Resident 2 away." Resident 1 stated, no one came to check on him to make sure he was okay. Resident 1 stated he did not think anything was done about the incident. Resident 1 stated he still sees Resident 2 walking down the hallway and feels like he (Resident 2) might try to hit him (Resident 1) again. During an interview on 2/10/2024 at 1:35 p.m., the MDS nurse stated sometime in December 2024, while she was in her office across from Resident 1's room she heard Resident 1 yelling. The MDS nurse stated, she came out of her office to saw Resident 1 in his wheelchair holding Resident 2's hands. The MDS nurse stated Resident 1 informed her that Resident 2 was trying to hit him. The MDS nurse stated she redirected Resident 2 and separated them. The MDS nurse stated she immediately reported what she witnessed to RN 1. During an interview on 2/10/2024 at 3:15 p.m., RN 1 stated sometime in December 2024, she recalled the MDS nurse informing her of an incident regarding Resident 1 and Resident 2. RN 1 stated she did not report the incident because she did not think it was considered abuse because neither resident was hurt. RN 1 did not notify the administrator. RN 1 stated she made a mistake and should have reported all alleged and suspected cases of abuse to the administrator who was the abuse coordinator. RN 1 stated she Resident 1 was placed at risk for further abuse and harm from Resident 2. RN 1 stated Resident 1 may have needed additional assessments and services due to the incident when Resident 2 attempted to hit him, which were not provided. During an interview on 2/12/2024 at 10:15 a.m., the Assistant Director of Nursing (ADON) stated all allegations, unusual occurrences and suspected abuse incidents should be reported to the Administrator, the police, Ombudsman and CDPH. The ADON stated the facility's failure to report an allegation of abuse placed Resident 1 at risk for further instances of abuse and caused a delay and or lack of needed services to Resident 1 such as behavioral health monitoring. The ADON stated failure to report abuse caused a delay in CDPH investigation and is a violation of the federal regulations. The ADON stated the MDS nurse should have reported the incident to the administrator who is the abuse coordinator. During an interview on 2/12/2024 at 3 p.m., the Administrator stated he was not aware of the incident between Resident 1 and Resident 2 until it was reported to him by the Ombudsman on 2/6/2025 which was when he reported the incident to CDPH. The Administrator stated the facility was in violation of their policy and Federal regulations for not reporting the alleged incident of abuse between Resident 1 and Resident 2 within two hours. During a review of the facilities P&P titled, "Abuse Prevention and Management " revised 5/30/2024, the P/P indicated to address the health, safety, welfare, dignity and respect of residents, reports of resident abuse, mistreatment, neglect, exploitation, injuries of unknown source, and any suspicion of crimes are promptly reported and thoroughly investigated. The P/P further indicates the administrator, or designated representative will notify law enforcement by telephone immediately or as soon as practicably possible, but no longer than two hours of initial report and send a written report to the ombudsman, law enforcement and CDPH licensing and certification within two hours. During a review of the facility's P&P titled, "Unusual Occurrence Reporting," revised 5/30/2024, the P/P indicated the facility reports the following events by phone and in writing to the appropriate State or Federal agencies: allegation of abuse. The facility failed to: 1. Report the allegation of abuse within the regulated time frame of two hours which occurred between Resident 2 and Resident 1 on 12/3/2024. The facility reported the incident on 2/6/2025 (65 days after the incident occurred). 1. Implement its abuse policy and procedure (P&P), titled, "Abuse Program Policy and Procedure," revised 5/30/2024 which indicated "the administrator, or designated representative will notify law enforcement by telephone immediately or as soon as practicably possible, but no longer than two hours of initial report and send a written report to the Ombudsman, law enforcement, and CDPH licensing and certification within two hours." This deficient practice resulted in CDPH's inability to investigate the allegations of abuse timely and had the potential for other allegations of abuse to go unreported. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1.