Health inspection·June 5, 2025

REGULATORY VIOLATIONS:  F609 42 CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(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. §483.12(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. California Code, Welfare and Institutions Code - WIC § 15630 (a) A person who has assumed full or intermittent responsibility for the care or custody of an elder or dependent adult, whether or not they receive compensation, including administrators, supervisors, and any licensed staff of a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care custodian, health practitioner, clergy member, or employee of a county adult protective services agency or a local law enforcement agency, is a mandated reporter. (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. (A) If the suspected or alleged abuse is physical abuse, as defined in Section 15610.63, and the abuse occurred in a long-term care facility, except a state mental health hospital or a state developmental center, the following shall occur: (i) If the suspected abuse results in serious bodily injury, a telephone report shall be made to the local law enforcement agency immediately, but also no later than within two hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse, and a written report shall be made to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse. (ii) If the suspected abuse does not result in serious bodily injury, a telephone report shall be made to the local law enforcement agency within 24 hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse, and a written report shall be made to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within 24 hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse. (iii) When the suspected abuse is allegedly caused by a resident with a physician's diagnosis of dementia, and there is no serious bodily injury, as reasonably determined by the mandated reporter, drawing upon their training or experience, the reporter shall report to the local ombudsman or law enforcement agency by telephone, immediately or as soon as practicably possible, and by written report, within 24 hours. An unannounced visit was conducted by the California Department of Public Health (CDPH) on 4/21/2025 to investigate a Facility Reported Incident (FRI) regarding an allegation of abuse indicating Resident 2 reported that an unnamed nurse punched Resident 2 on the leg on 4/5/2025 at 2:30 PM. The facility failed to report an allegation of physical abuse, for Resident 2 who reported being punched on the leg by an unnamed nurse on 4/5/25, to the CDPH, Ombudsman (a person who investigates, reports on, and helps settle complaints) and local law enforcement immediately or as soon as practicably possible, and by written report, within 24 hours. The facility made the report on 4/7/2025 (2 days after the allegation of abuse) to CDPH, Ombudsman, and local law enforcement As a result, the facility staff violated Resident 2’s rights and placed Resident 2 at risk for further abuse and delayed the investigation for Resident 2’s abuse allegations. A review of Resident 2’s Admission Record (AR), the AR indicated Resident 2, a 43-year-old-male, was admitted to the facility on 1/3/2025 with the diagnoses including but not limited to infection of amputation stump (part of a limb that remains after an amputation surgery) of the right and left lower extremities (thigh, knee, ankle, foot, and toes), anxiety disorder (persistent and excessive worry that interferes with daily activities), and transient cerebral ischemic attack (a blockage of blood flow to the brain). A review of Resident 2’s Minimum Data Set (MDS, a resident assessment and tool), dated 4/5/2025, the MDS indicated Resident 2’s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was intact. The MDS indicated Resident 2 was dependent (helper does all the effort, resident does none of the effort to complete the activity) for toileting hygiene, shower/bathing self, and chair/bed-to-chair transferring. A review of Resident 2’s Change of Condition (COC, tool used by health care professionals when communicating about critical changes in a resident’s status), dated 4/5/2025, the COC indicated on 4/5/2025 at 2:30 PM, Resident 2 stated a nurse punched him in the leg. The COC did not indicate which nurse Resident 2 identified. A review of Licensed Vocational Nurse 4’s (LVN 4) interview statement, dated 4/8/2025, the statement indicated Resident 2 informed LVN 4 that a nurse punched his leg. The statement indicated LVN 4 informed Registered Nurse Supervisor 2 (RNS 2) of the abuse allegation. A review of RNS 2’s interview statement, dated 4/8/2025, RNS 2’s interview statement indicated LVN 4 did not inform RNS 2 that a nurse punched Resident 2’s leg. A review of Resident 2’s care plan, dated 4/9/2025, the care plan indicated Resident 2 was at risk to exhibit psychosocial (combined influence of psychological factors and the surrounding social environment on physical, emotional, and/or mental wellness) and/or emotional distress related to an abuse allegation and Resident 2 alleged a nurse hit his leg. The care plan indicated staff interventions were to provide emotional support as needed based on the resident’s response, encourage resident to verbalize feelings, and give support and reassurance. During an interview on 4/21/2025 at 11:05 AM with the Interim Director of Nursing (IDON), the IDON stated the facility staff did not report Resident 2’s allegation of abuse to CDPH, Ombudsman, and local law enforcement. The IDON stated LVN 4 completed a COC for the abuse allegation on 4/5/2025 at 2:30 PM. The IDON stated LVN 4 should have notified CDPH, Ombudsman, and local law enforcement within two hours of the abuse allegation on 4/5/2025. The IDON stated reporting within the two-hour time frame ensured prompt investigation and prevention of further abuse against Resident 2. The IDON stated the IDON found out about the abuse allegation through a review of the nurses’ notes completed on 4/7/2025 (after two days). The IDON stated the IDON made the report on 4/7/2025 to CDPH, Ombudsman, and local law enforcement. The IDON stated Resident 2’s abuse allegation was not and should have been reported on 4/5/2025 when Resident 2 initially informed LVN 4 of the abuse allegations. During a concurrent interview and record review on 4/23/2025 at 10:12 AM with the IDON of the facility’s policy and procedure (P&P) titled “Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating,” the IDON stated based on the facility’s P&P any allegation of abuse should be reported to CDPH, Ombudsman, and local law enforcement officials immediately and/or within 2 hours of the allegation. A review of the facility’s P&P titled, “Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating,” revised 9/2022, the policy indicated if resident abuse is suspected, the suspicion must be reported immediately to the administrator and to other official according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: - The state licensing/certification agency responsible for surveying/licensing the facility - The local/state ombudsman - Law enforcement officials within two hours of an allegation involving abuse. As a result of the above violations, CDPH determined, the facility failed to report an allegation of physical abuse, for Resident 2 who reported being punched on the leg by an unnamed nurse on 4/5/25, to the CDPH, Ombudsman and local law enforcement immediately or as soon as practicably possible, and by written report, within 24 hours. The facility made the report on 4/7/2025 (2 days after the allegation of abuse was made) to CDPH, Ombudsman, and local law enforcement As a result, the facility staff violated Resident 2’s rights and placed Resident 2 at risk for further abuse and delayed the investigation for Resident 2’s abuse allegations. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.