Health inspection·April 8, 2025

W&I 15630(b)(1) (b) (1) A mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that they have experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an internet report shall be made through the confidential internet reporting tool established in Section 15658, within two working days. Freedom from Abuse, Neglect, and Exploitation 42 CFR §483.12(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. 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. § HSC 1418.91 Abuse Reporting (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 2/24/2025, the California Department of Public Health (CDPH) conducted an unannounced annual recertification survey at the facility. The facility failed to: 1. Report an abuse allegation to the State Agency (CDPH), when on 2/26/2025 Resident 18 and Resident 103 had a verbal altercation. As a result, there was a delay in the investigation by the CDPH. 1a. Resident 18 was a 77-year-old female, initially admitted to the facility on 1/20/2020 and readmitted on 1/7/2025, with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 18’s Minimum Data Set ([MDS], a resident assessment tool), dated 1/9/2025, indicated Resident 18’s cognition (process of thinking) was severely impaired. The MDS indicated Resident 18 required moderate assistance (helper does less than half the effort) with toileting, bathing, dressing, and personal hygiene. A review of Resident 18’s History and Physical (H&P), dated 1/8/2025, indicated Resident 18 had the capacity to understand and make decisions. A review of Resident 18’s Progress Note, dated 2/26/2025 at 6:20 p.m., indicated Resident 18 was making “bad comments” to Resident 103. 1b. Resident 103 was a 60-year-old female, admitted to the facility on 1/25/2025 with diagnoses including epilepsy (a chronic brain disorder that causes seizures), muscle weakness (when muscles do not have the strength they normally do), and hypertension (high blood pressure). A review of Resident 103’s MDS, dated 1/31/2025, indicated Resident 103’s cognition was intact. The MDS indicated Resident 103 required set up or clean-up assistance with eating, oral hygiene, and upper body dressing. A review of Resident 103’s H&P, dated 1/26/2025, indicated Resident 103 had the capacity to understand and make decisions. A review of Resident 103’s Progress Note, dated 2/6/2025 at 5:20 p.m., indicated on 2/6/20205, Resident 18 spoke bad words to Resident 103, and Resident 103 responded to Resident 18 that she “will F [Resident 18] up if [Resident 18] will not stop talking.” During an interview on 2/27/2025 at 12:36 a.m., with Registered Nurse (RN) 1, RN 1 stated on 2/26/2025, she was informed of the verbal altercation between Resident 18 and Resident 103. RN 1 stated, on 2/26/2025, she informed the DON and the Administrator (ADM). During an interview on 2/27/2025 at 2:07 p.m., with the ADM, the ADM stated when there was knowledge of an abuse allegation or altercation, it had to be reported to the CDPH within two hours. The ADM stated he was aware of the verbal altercation between Resident 18 and Resident 103, but he did not know Resident 103 stated, “I will F*** you up” to Resident 18. The ADM stated the altercation was not reported because he thought the altercation was a simple argument. The ADM stated due to Resident 103’s verbal threat towards Resident 18, the altercation should have been reported to the CDPH. A review of the facility’s policy and procedure (P&P) titled, “Abuse and Neglect Prohibition Policy,” dated 6/2022, indicated all alleged violations regarding suspected or alleged abuse were to be reported, no later than two hours to the State Agency. The facility failed to: 1. Report an abuse allegation to the CDPH, when on 2/26/2025 Resident 18 and Resident 103 had a verbal altercation. As a result, there was a delay in the investigation by the CDPH. This violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 103 and other residents in the facility.