Health inspection·August 13, 2025

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. 42 CFR § 483.12 Freedom from Abuse, Neglect, and Exploitation (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. HSC 1418.91(a) (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. On 6/27/2025, the California Department of Public Health (CDPH) received a facility reported incident (FRI) regarding an allegation reported by Resident 2 of Responsible Party (RP) 1 yelling and screaming at him, causing him to sustain distress and intimidation. On 7/3/2025, the CDPH conducted an unannounced visit to the facility to conduct an investigation. The facility failed to notify the CDPH of: 1. A verbal abuse incident when Licensed Vocational Nurse (LVN) 1 observed Responsible Party (RP) 1 yelling at Resident 2 on 6/13/2025. 2. An allegation of abuse, on 6/26/2025, after Resident 2 reported to the Social Services Director (SSD) that he felt distressed after RP 1 yelled and screamed at him on 6/13/2025. As a result, there was a delay in the investigation by the CDPH, and Resident 2 and other residents were placed at risk for further abuse. Resident 2 was an 88-year-old male admitted to the facility on 5/15/2025 with diagnoses including muscle wasting and atrophy (thinning of muscle mass), lack of coordination, and generalized muscle weakness. A review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 5/28/2025, indicated Resident 2 did not have cognitive (ability to think and reason) impairments. The MDS indicated Resident 2 required substantial to maximal assistance from staff with all mobility while in and out of bed. 1. A review of Resident 2's progress note dated 6/13/2025 at 3:13 PM, indicated on 6/13/2025, a verbal exchange, lasting approximately ten minutes, occurred between Resident 2 and RP 1. The progress note indicated RP 1 yelled at Resident 2 during the exchange. During an interview on 7/3/2025 at 12:09 PM, LVN 1 stated verbal abuse was a type of abuse. LVN 1 stated after the incident with RP 1, Resident 2 was upset and sadder than usual. LVN 1 stated Resident 2 told her he felt intimidated by RP 1. During a concurrent interview and record review, on 7/3/2025 at 12:18 PM, with LVN 1, Resident 2's progress note dated 6/13/2025, was reviewed. LVN 1 stated she wrote the progress note indicating RP 1 yelled at Resident 2. LVN 1 stated on 6/13/2025 (time unknown), she observed RP 1 yell at Resident 2 and noticed a change in Resident 2's demeanor following the incident. LVN 1 stated Resident 2 reported he felt intimidated. LVN 1 stated she reported the incident to Registered Nurse (RN) 1 but did not report the incident to any outside agencies, including the CDPH. During an interview on 7/3/2025 at 12:47 PM, with RN 1, RN 1 stated LVN 1 informed her of the incident that occurred between Resident 2 and RP 1 on 6/13/2025. RN 1 stated she was not responsible for reporting the incident because she was not the staff who directly observed the incident. RN 1 stated that once she was made aware of the incident, she did not follow up further or assess Resident 2 for any harm or distress related to the incident. During an interview on 7/3/2025 at 1:55 PM, the Director of Staff Development (DSD) stated all staff were mandated reporters and required to report suspected abuse even if they did not directly witness it themselves. During a concurrent interview and record review, on 7/8/2025 at 2:01 PM, with the DON, the facility's policy and procedure (P&P) titled "Abuse and Neglect Prevention Management," revised 2/2018, was reviewed. The P&P indicated it was the facility's policy to ensure residents were safe and free from abuse. The DON stated the P&P indicated all staff were mandated reporters and that reporting of alleged abuse was to be completed according to state and federal guidance. The DON stated the incident that occurred between Resident 2 and RP 1 on 6/13/2025 met the definitions of possible mental and/or verbal abuse. The DON stated the incident should have been reported within two hours to the CDPH and other required agencies. The DON stated RN 1 and LVN 1 were both responsible for reporting. 2. During a review of Resident 2's Interdisciplinary Team (IDT) Care Conference Note, dated 6/26/2025, the note indicated Resident 2 stated any minor disagreement with RP 1 resulted in RP 1 yelling and screaming at him. The note indicated the Social Services Director (SSD) attended the IDT care conference. During an interview on 7/3/2025 at 2:50 PM, the SSD stated she suspected RP 1 was abusing Resident 2 following the information reported by Resident 2 during IDT care conference on 6/26/2025. The SSD stated she did not report the suspected abuse until 6/27/2025. The SSD stated she was waiting for guidance from the Ombudsman (a public official who advocates for residents of nursing homes and other long-term care facilities) on whether to report. The SSD stated she placed an initial call to the Ombudsman on 6/26/2025 but did not hear back from the Ombudsman until 6/27/2025. The SSD stated she was taught by the former SSD to get guidance from the Ombudsman prior to reporting suspected abuse. During a concurrent interview and record review, on 7/3/2025 at 2:56 PM, with the SSD, the facility's P&P titled "Abuse and Neglect Prevention Management," revised 2/2018, was reviewed. The SSD stated the P&P did not indicate the Ombudsman was required to provide guidance on abuse reporting. The SSD stated the P&P indicated suspected abuse was to be reported right away. The SSD stated timely reporting was important to ensure the abuse was addressed and to prevent any unwanted adverse effects on the resident's wellbeing resulting from the abuse. During an interview on 7/8/2025 at 2:26 PM, the Administrator in Training (AIT) stated RP 1 yelling at Resident 2 was possible mental abuse. The AIT stated he was acting as the facility's abuse coordinator, and stated he was not made aware of the incident that occurred between Resident 2 and RP 1 on 6/13/2025. The AIT stated the incident was not reported and should have been reported because RP 1 was causing distress to Resident 2. The AIT stated anyone with knowledge of the incident that occurred on 6/13/2025 should have reported it. During an interview on 7/8/2025 at 2:48 PM, with the AIT, the AIT stated he was not sure why the suspected abuse was reported late. The AIT stated the incident should have been reported on 6/26/2025, within two hours of the meeting with Resident 2. The facility failed to notify the CDPH of: 1. A verbal abuse incident when Licensed Vocational Nurse (LVN) 1 observed Responsible Party (RP) 1 yelling at Resident 2 on 6/13/2025. 2. An allegation of abuse, on 6/26/2025, after Resident 2 reported to the Social Services Director (SSD) that he felt distressed after RP 1 yelled and screamed at him on 6/13/2025. As a result, there was a delay in the investigation by the CDPH, and Resident 2 and other residents were placed at risk for further abuse. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.