Health inspection·May 20, 2025

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. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. 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 4/7/2025, the California Department of Public Health (CDPH) received a facility reported allegation of staff-to-resident abuse. On 4/10/2025 at 11:00 a.m., the CDPH conducted an unannounced visit to the facility to investigate the allegation. During the onsite investigation, Resident 2’s Family Member (FM) 1, reported that on 4/5/2025, she witnessed Certified Nurse Assistant (CNA) 2 roughly grab Resident 2’s arm and reported to Registered Nurse (RN) 1. The allegation was not reported to the CDPH. The facility failed to: 1. Ensure a staff to resident abuse allegation was reported to the CDPH. As a result, there was a delay in the investigation by the CDPH. Resident 2 was an 82- year-old female, admitted to the facility on 3/24/2025 with diagnoses that included chronic respiratory failure with hypoxia (a chronic lung disease causing difficulty in breathing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness on one side of the body), muscle wasting and atrophy (muscle shrinking), difficulty in walking, and a history of falling. A review of Resident 2’s Minimum Data Set ([MDS], a resident assessment tool), dated 4/6/2025, indicated Resident 2’s cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 2 was dependent (helper does all the effort) on staff, performing toileting hygiene, sitting to lying, and perform chair or bed-to-chair transfers. During an interview on 4/10/2025 at 2:02 p.m. with Family Member (FM) 1, FM 1 stated on 4/5/2025, around 6:00 p.m., she witnessed CNA 2 roughly grab Resident 2’s arm. FM 1 stated she was upset and reported the incident to RN 1, immediately. During an interview on 4/10/2025 at 3:54 p.m. with RN 1, RN 1 stated his role was to report any allegation of abuse to the Administrator (ADM), the Director of Nursing (DON) and the CDPH. RN 1 stated on 4/5/2025, FM 1 reported to him that CNA 2 was “rough handling” Resident 2. RN 1 stated he did not report the allegation because he was busy and forgot during the shift. RN 1 stated it was important to report any allegations of abuse to ensure it did not happen again to any other residents. During an interview on 4/14/2025 at 2:11pm with the DON, the DON stated the expectation of the staff to report any allegation of abuse to the ADM, the DON, and the CDPH to ensure the abuse did not occur again. The DON stated on 4/5/2025, she was not aware of the incident between Resident 2 and CNA 2 and therefore did not report to the CDPH. During an interview on 4/14/2025 at 3:19 p.m. with the ADM, the ADM stated he did not report the incident between CNA 2 and Resident 2 because he was not notified of the allegation. A review of the facility’s Policy and Procedure (P&P), titled, “Abuse and Neglect Prevention Management,” revised 2/2018 indicated the following: 1. The facility will ensure alleged violations abuse, are immediately reported to the Administrator and Director of Nursing Services; with subsequent mandatory reporting in accordance with state law, through established procedures (including law enforcement, the state survey and certification agency, Ombudsman, Licensing Boards and Registries, and other agencies as required.) 2. Allegations involving abuse are reported no later than two (2) hours after the allegation is made. The facility failed to: 1.Ensure a staff to resident abuse allegation was reported to the CDPH. 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 2 and all residents in the facility.