Health inspection·February 26, 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. (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. § 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 1/19/2025 the California Department of Public Health (CDPH) received a facility-reported incident indicating on 1/19/2025, Resident 1 alleged Certified Nurse Assistant (CNA) 1 was rough and used boiling hot water to clean her. On 2/3/2025 at 9:56 a.m., the CDPH conducted an unannounced visit at the facility. The facility failed to: 1. Notify the CDPH within 24 hours, when Resident 1 alleged CNA 1 was “rough" and used boiling hot water to clean her, per the state reporting requirement. 2. Ensure a prompt investigation was initiated when CNA 2 had knowledge Resident 1 alleged that CNA 1 was “rough” during care and used boiling hot water to clean her. This resulted in a delay of an investigation by CDPH and the potential for further abuse to Resident 1 and the other residents. A review of Resident1's Admission Record, indicated Resident 1 was an 83-year-old female, admitted to the facility on 10/10/2024 with diagnoses that included muscle weakness, spinal stenosis (abnormal narrowing of the spinal canal), and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1’s Minimum Data Set ([MDS], a resident assessment tool), dated 1/17/2025, indicated Resident 1’s cognitive skills (ability to think and reason) for daily decision making was severely impaired. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and, or touching as resident completes activity) for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene. A review of Resident 1’s Nursing Progress Notes dated 1/19/2025, indicated Resident 1’s son notified the facility Resident 1 told him a male CNA (CNA 1) was “too rough, hurt” her arm, and cleaned her with hot water last night. A review of the facility’s five-day Investigation Report dated 1/22/2025, indicated CNA 1 asked CNA 2 to translate (in Spanish) for Resident 1 when Resident 1 became agitated. The report indicated Resident 1 told CNA 2 that CNA 1 was “rough” (during care). During an interview on 2/3/2025 at 11:31 a.m. with CNA 1, CNA 1 stated on 1/19/2025 around 4 a.m., during the 11 p.m.- 7 a.m. shift, he asked CNA 2 to translate for him in Spanish and Resident 1 because Resident 1 pushed the call light and was very agitated. CNA 1 stated CNA 2 told him Resident 1 was agitated because she complained the water was too hot when CNA 1 provided perineal care (the cleaning and maintenance of the genital and anal areas) earlier in the shift. CNA 1 stated CNA 2 never told him Resident 1 complained about him being “too rough” with her. CNA 1 stated CNA 2 told him Resident 1 was just “confused”. CNA 1 stated he did not report the incident to LVN 1 because he believed “everything was solved”. During an interview on 2/3/2025 at 11:51 a.m. with CNA 2, CNA 2 stated, on 1/19/2025 around 4 a.m., during the 11 p.m.- 7 a.m. shift, she helped translate for CNA 1 and Resident 1. CNA 2 stated Resident 1 told her CNA 1 was “too rough”. CNA 2 stated Resident 1 also asked for a pain pill because her left arm was hurting after CNA 1 repositioned her. CNA 2 stated she only told LVN 1 that Resident 1 wanted her pain pill, but did not report Resident 1’s complaint about CNA 1. CNA 2 stated she should have told LVN 1 or notified the proper agencies (CPDH, law enforcement, and the ombudsman) about Resident 1’s concern, because it was considered an abuse allegation. CNA 2 stated all staff were considered mandated reporters. CNA 2 stated this delayed the facilities’ ability to investigate timely and there was a potential for further abuse by CNA 1 to Resident 1 or other residents in the facility. During an interview on 2/3/2025 at 12:46 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 1/18/2025 he was assigned to care for Resident 1 for the 11 p.m. to 7 a.m. shift and was not made aware of any incident or allegation of abuse between Resident 1 and CNA 1. LVN 1 stated he would have immediately reported the incident to the abuse coordinator, the police, the ombudsman, CDPH, and would have ensured CNA 1 was sent home. During an interview on 2/3/2025 at 1:12 p.m. with the Administrator (ADM), the ADM stated all facility staff were mandated reporters and did not have to “wait” for him to notify law enforcement, CDPH, and fill out the SOC 341 form (a form that documents the information given by the reporting party on the suspected incident of abuse or neglect of an elder or dependent adult). The ADM stated CNA 2 should have reported the incident right away. The ADM stated this led to a delay in an investigation, and the facility “could have acted on the information to prevent further abuse.” A review of the facility’s Policy and Procedure (P&P), titled, “Abuse and Neglect Prevention Policy” revised 12/2014, indicated the following: 1. When abuse or mistreatment of a resident is suspected staff must immediately notify their supervisor in duty, who, in turn, notifies the abuse prevention coordinator (Administrator) and the Director of Nursing Services. 2. Investigate the alleged incident immediately. 3. Notify the State Department of Public Health, and other regulatory agencies as assigned and according to state reporting requirements. 4. All facility employees were required by law to report any known or suspected abuse immediately upon identifying a concern. The facility failed to: 1. Notify the CDPH within 24 hours, when Resident 1 alleged CNA 1 was “rough” and used boiling hot water to clean her, per the state reporting requirement. 2. Ensure a prompt investigation was initiated when CNA 2 had knowledge Resident 1 alleged that CNA 1 was “rough” during care and used boiling hot water to clean her. This resulted in a delay of an investigation by CDPH and the potential for further abuse to Resident 1 and the other residents. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1 and all residents in the facility.