Health inspection·September 4, 2025

42 CFR § 483.12 - Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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 (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. (b) A failure to comply with the requirements of this section shall be a class “B” violation. On 7/14/2025, the California Department of Public Health (CDPH) received a facility reported incident regarding alleged physical abuse between Resident 1 and Resident 2. On 7/28/2025 CDPH conducted an unannounced visit at the facility to investigate the facility reported incident. During interview and record review CDPH determined the facility failed to: 1. Failed to report the alleged physical abuse between Resident 1 and Resident 2 to CDPH within two hours of the occurrence. 2.Implement its Policy and Procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating," dated 2021, which indicated the facility will report to CDPH the allegation of abuse within regulated two hours. As a result, there was a delay in CDPH’s investigation and a delay in preventing potential ongoing physical abuse. A review of Resident 1's Admission Record indicated Resident 1, a 77-year- old female, was initially admitted to the facility on 8/10/2024 and readmitted on 6/14/2025 with diagnoses including anxiety disorder, depression, and osteoarthritis. A review of Resident 1 's History and Physical (H&P), dated 6/16/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1 's Minimum Data Set (MDS - a resident assessment tool), dated 6/21/2025, indicated Resident 1 required moderate assistance from one staff for bed mobility and transfers. A review of Resident 2's Admission Record indicated Resident 2, a 79- year-old female, was initially admitted to the facility on 10/9/2024 and readmitted was on 2/10/2025 with diagnoses including dementia, and malignant neoplasm of colon. A review of Resident 2's H&P, dated 4/7/2025, indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 2’s MDS, dated 6/12/2025, indicated Resident 2 required moderate assistance from one staff for bed mobility and maximal assistance (helper does more than half the effort) from one staff for transfer. During an interview on 7/28/2025, at 10:55 a.m., with Resident 1 in the activity room, Resident 1 stated that on 7/12/2025 during dinner time she was talking with another resident (unknown) in a hallway near the smoking and dining room area. Resident 1 stated she was discussing her upcoming wedding on 7/12/2025 (with unknown resident), and Resident 2 bumped into her wheelchair. Resident 1 stated Resident 2 and her ended up having a big argument and Resident 2 slapped her on the left side of her face. Resident 1 stated she reported that Resident 2 slapped her to the nurse (unknown), who came to separate them, regarding the incident because she did not want Resident 2 to hit her again. During an interview on 7/28/2025, at 11:20 a.m., with Resident 2 in her room, Resident 2 stated she did not recall the incident. Resident 2 stated she did not do anything. During an interview on 7/28/2025, at 12:35 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated she heard about the incident that occurred on 7/12/2025 between Resident 1 and Resident 2. CNA 1 stated Licensed Vocation Nurse (LVN) 1 and Registered Nurse Supervisor (RNS)1 did not report the incident in a timely manner, and they got suspended. CNA 1 stated alleged abuse should be reported right away because all healthcare workers are mandatory reporters for abuse. During a concurrent interview and record review on 7/28/2025, at 12:55 p.m., with RNS 2 Resident 1's Change in Condition Evaluation, dated 7/12/2025 was reviewed. The Change in Condition Evaluation indicated Resident 1 stated another resident came by and hit the left side of her face, and the primary physician was notified. RNS 2 stated, LVN 1 and RNS 1 did not and should have reported the alleged physical abuse within two hours of occurrence to the Abuse Coordinator (Administrator), State Agency, Ombudsman, and local police per facility’s policy. During a telephone interview on 7/28/2025, at 3:10 p.m., CNA 2 stated he was at the dining room at the time of the incident, and he heard someone yelling for help. CNA 2 stated he went to a hallway and witnessed Resident 1 and Resident 2 yelling at each other and another resident was holding Resident 1. CNA 2 stated RNS 1 came few minutes later and he (CNA 2) reported to RNS 1 what he witnessed. CNA 2 stated he reported the incident to LVN 1 as well. During an interview on 7/28/2025, at 3:45 p.m., the Administrator (ADM)stated RNS 1 and LVN 1 concurred that they should have reported the alleged abuse within two hours of occurrence, but they did not. The ADM stated that the facility has taken this incident very seriously. The ADM stated “unfortunately LVN 1 and RNS 1 did not do their due diligence.” The ADM stated this incident was noted during the daily change in condition evaluation audit by other staff the next day on 7/13/2025. The ADM stated delays in reporting and investigations could lead to continuation of abuse situations and inability to protect the residents from repeated abuse situations. During a review of the facility's P&P titled, “Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating", dated 2021, the P&P indicated "Policy Statement: AH reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or the theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency (CDPH) responsible for surveying/licensing the facility; The local/state ombudsman; The resident's representative; Adult protective services (where state law provides jurisdiction in long-term care): Law enforcement officials; The resident's attending physician; and the facility medical director. "Immediately" is defined as Within two hours of an allegation involving abuse or result in serious bodily injury; or Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury." 1. Failed to report the alleged physical abuse between Resident 1 and Resident 2 to CDPH within two hours of the occurrence. 2.Implement its Policy and Procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating," dated 2021, which indicated the facility will report to CDPH the allegation of abuse within regulated two hours. As a result, there was a delay in CDPH’s investigation and a delay in preventing potential ongoing physical abuse. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.