Health inspection·May 22, 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: (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. 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 4/7/2025, the California Department of Public Health (CDPH) conducted an unannounced annual recertification survey at the facility. The facility failed to: 1. Report an allegation of resident-to-resident physical abuse to the State Agency (SA) in accordance with federal regulations within two (2) hours after being made aware of the allegation. This failure had the potential for ongoing abuse. a. Resident 44 was a 51 year-old female, originally admitted to the facility on 10/27/2021 and was most recently readmitted on 10/18/2024 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). A review of Resident 44’s Minimum Data Assessment (MDS, a resident assessment tool), dated 3/3/2025, indicated Resident 44 did not have cognitive impairments (problems with thinking and memory). The MDS indicated Resident 44 required supervision and/or touch assistance from staff for mobility while in and out of bed. b. Resident 42 was 71 year-old female, originally admitted to the facility on 11/28/2018 and was most recently re-admitted on 1/27/2025 with diagnoses including schizoaffective disorder, paranoid schizophrenia, anxiety disorder (mental health conditions characterized by excessive fear or worry that interferes with daily life), and psychosis. A review of Resident 42’s MDS, dated 3/26/2025, indicated Resident 42 did not have cognitive impairments. The MDS indicated Resident 42 was independent in repositioning herself while in bed and required set-up or clean-up assistance from staff (staff set up or clean up, but resident completes the activity) to get out of bed and to walk. During an interview on 4/7/2025 at 9:50 a.m., with Resident 44, Resident 44 stated her previous roommate (Resident 42) “threw a chair at her.” Resident 44 could not recall the date the incident occurred but stated the incident occurred in Room A. Resident 44 stated she was moved to Room B after the alleged incident. Resident 44 stated this was her first and only altercation with Resident 42. During a concurrent interview and record review, on 4/8/2025 at 10:05 a.m., with Social Worker (SW) 1, Resident 44’s progress note, dated 3/10/2025 at 10:45 a.m., was reviewed. SW 1 stated the progress note indicated Resident 44 was moved to another room on 3/10/2025 due to incompatibility with her roommate. SW 1 was informed of Resident 44’s allegation that Resident 42 threw a chair at her. During an interview on 4/8/2025 at 4:04 p.m., the facility’s Program Director (PD) stated she was made aware on 4/8/2024 of the alleged resident-to-resident altercation between Resident 44 and Resident 42. The PD stated she was responsible for reporting the allegation to the State Agency. The PD stated the allegation was not yet reported to the State Agency District Office because the facility had 24 hours to report. During an interview on 4/10/2025 at 11:57 a.m., the Director of Nursing (DON) stated that timely reporting of alleged abuse was important for the safety of the facility residents and stated that failing to report timely could negatively impact the safety of the residents. During an interview, on 4/10/2025 at 12:41 p.m., with the Administrator (ADM), the ADM stated it was the facility’s policy and process to report resident-to-resident altercations to the State Agency within two (2) hours. A review of the document titled “Report of Suspected Dependent Adult/Elder Abuse” (SOC-341), dated 4/8/2025, indicated the form was completed by the PD, and indicated social services staff were made aware of Resident 44’s abuse allegation on 4/8/2025 around 10 a.m. A review of the document titled “Fax Transmission Details,” dated 4/8/2025, indicated the SOC-341 (a mandated reporting form used when someone suspects elder or dependent adult abuse or neglect) was sent to the State Agency District Office on 4/8/2025 at 4:52 p.m. A review of the facility’s policy and procedure (P&P) titled “Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin,” dated 2018, the P&P indicated all allegations of abuse were to be reported in accordance with state and federal regulations. The facility failed to: 1. Report an allegation of resident-to-resident physical abuse, to the State Agency (SA) in accordance with federal regulations within two (2) hours after being made aware of the allegation. This failure had the potential for ongoing abuse. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.