Other·May 1, 2026

Code of Federal Regulations, Title 42, Section 483.12(c)(1)(4). 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 of Regulations, Title 22, Section 72315. Nursing Service-Patient Care. 72315(b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind California Code of Regulations, Title 22, Section 72523. Patient Care Policies. 72523(a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. California Code of Regulations, Title 22, Section 72527. Patients' Rights. 72527(a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. On 3/17/2026, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility to investigate a complaint regarding resident abuse and resident rights. The facility failed to report an allegation of abuse for Resident 1 to the Department, to the Ombudsman, and to the local law enforcement within two hours in accordance with the facility’s policy and procedure (P&P) titled, “Abuse, Neglect, and Exploitation,” dated 12/19/2022. As a result, Resident 1’s right was violated, notification of an allegation of abuse to the Department, to the Ombudsman, and to the local law enforcement was delayed, and Resident 1 was placed at risk of being subjected to abuse while in the facility. a. A review of Resident 1’s Admission Record (AR) indicated Resident 1, a 95-year-old female, was admitted to the facility on 1/30/2026 with diagnoses which included hemiplegia and hemiparesis following cerebral infarction and other abnormalities of gait and mobility. A review of Resident 1’s History and Physical, dated 2/2/2026, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool), dated 2/3/2026, indicated Resident 1 was mildly impaired in cognitive skills and required substantial/maximal assistance with toileting hygiene, showering/bathing self, lower body dressing, putting on/taking off footwear, and with moving around in bed. The MDS indicated Resident 1 was dependent on staff for transfers and walking. A review of Resident 1’s Progress Notes (PN), dated 3/3/2026 and timed at 2:57 PM, indicated that the Social Services Director (SSD) requested psychology consultation for Resident 1 on 3/3/2026 because Resident 1 was having a hard time due to Resident 1’s health challenges. b. A review of Resident 4’s AR indicated Resident 4, a 62-year-old female, was admitted to the facility on 2/20/2026 with diagnoses which included metabolic encephalopathy, psychosis, and schizophrenia. A review of Resident 4’s H&P, dated 2/21/2026, indicated Resident 4 did not have the capacity to understand and make decisions. A review of Resident 4’s MDS, dated 2/24/2026, indicated Resident 4 was severely impaired in cognitive skills. The MDS indicated Resident 4 required substantial/maximal assistance with oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and with transfers and walking. A review of Resident 4’s PN, dated 3/2/2026 and timed at 10:38 AM, indicated that Resident 4 was throwing objects at staff, hitting head against wall, and grabbing other residents on 3/2/2026 at 9:45 AM and was sent to General Acute Hospital (GACH) 1 on 3/2/2026 at 10:30 AM for further evaluation. A review of Resident 4’s care plan (CP), initiated on 3/2/2026, indicated Resident 4 was having a behavioral/psychotic episode by yelling out, throwing objects at staff, grabbing other residents and hitting head against wall. A review of Resident 4’s SBAR Communication Form (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 3/2/2026, indicated that Resident 4 was agitated, yelling out, throwing objects at other people, and grabbing others and Resident 4 was sent out to the emergency room for further evaluation. During an interview on 3/17/2026 at 10:46 AM with Resident 1, Resident 1 stated Resident 1 was scared when another resident (Resident 4) suddenly hit and grabbed Resident 1’s left arm in the hallway. Resident 1 stated Resident 1 could not remember the date and time the incident happened. Resident 1 stated someone from the social services department spoke to Resident 1 and requested a psychology consultation for Resident 1. During an interview on 3/17/2026 at 12:42 PM with Physical Therapy Assistant (PTA) 2, PTA 2 stated Resident 4 grabbed Resident 1’s arm in the hallway which scared Resident 1 on 3/2/2026. PTA 2 stated the Social Services Director (SSD) witnessed the incident and Licensed Vocational Nurse (LVN) 1 and a Registered Nurse (unknown) checked on Resident 1. PTA 2 stated Resident 4 grabbing Resident 1’s arm should have been reported as an allegation of physical abuse to the Department, to the Ombudsman, and to local law enforcement within two hours. During an interview on 3/18/2026 at 2:08 PM with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 4 grabbed Resident 1’s arm in the hallway on 3/2/2026. CNA 4 stated abuse or allegations of abuse must be reported to the charge nurse, the administrator and to the Director of Nursing (DON) right away. During a concurrent interview and record review on 3/17/2026 at 3:14 PM with the SSD, Resident 1’s PN, dated 3/3/2026, was reviewed. SSD stated Resident 1 was shaking and tearing after Resident 1 was touched by Resident 4 in the hallway on 3/2/2026. SSD stated SSD requested psychology consultation for Resident 1 on 3/3/2026 due to Resident 1 having a hard time due to “health challenges”. The SSD stated that the SSD should report any abuse and allegation of abuse to the Department, to the Ombudsman, and to local law enforcement within two hours. During an interview on 3/18/2026 at 11:42 AM with LVN 1, LVN 1 stated staff (in general) must report unwanted grabbing as physical abuse to the Department, to the Ombudsman, and to local law enforcement within two hours. During an interview on 3/18/2026 at 12:35 PM with the DON, the DON stated the facility did not report the incident to the Department, to the Ombudsman, and to local law enforcement regarding Resident 4 grabbing Resident 1’s arm which scared Resident 1 in the hallway on 3/2/2026. The DON stated the facility should report any abuse and allegation of abuse to the Department, to the Ombudsman, and to local law enforcement within two hours. During an interview on 3/18/2026 at 1:35 PM with the Administrator, the Administrator stated that the facility did not report the incident to the Department, to the Ombudsman, and to local law enforcement regarding Resident 4 grabbing Resident 1’s arm which scared Resident 1 in the hallway on 3/2/2026. During a review of the facility’s policy and procedure (P&P) titled, “Abuse, Neglect, and Exploitation,” dated 12/19/2022, the P&P indicated, “Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations…Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse,…” The P&P indicated that the facility must ensure “Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. 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 b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury...” The facility failed to report an allegation of abuse for Resident 1 to the Department, to the Ombudsman, and to the local law enforcement within two hours in accordance with the facility’s P&P titled, “Abuse, Neglect, and Exploitation,” dated 12/19/2022. As a result, Resident 1’s right was violated, notification of an allegation of abuse to the Department, the Ombudsman, and to the local law enforcement was delayed, and Resident 1 was placed at risk of being subjected to abuse while in the facility.   The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.   F609 – Pomona Vista Citation 2793732