Health inspection·June 13, 2025

F609 42 CFR §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual’s obligation to comply with the following reporting requirements. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. §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. 22 CCR § 72315. Nursing Service--Patient Care. (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. 22 CCR § 72527. Patients' Rights. (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. (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. 22 CCR § 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. 22 CCR § 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. An unannounced visit was conducted by California Department of Public Health (CDPH) on 5/2/2025 to investigate a complaint and a facility reported incident (FRI) regarding an allegation of visitor to resident abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), which a resident claimed that a visitor grabbed the resident and started to kiss her shoulder and lips in hallway which made the resident feel uncomfortable. The facility failed to report an allegation of sexual abuse (any act of sexual contact that a person suffers, submits to, participates in, or performs as a result of force or violence, threats, fear, or deception or without having legally consented to the act) for Resident 1 within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities) and the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), in accordance with the facility's abuse policy. As a result, this deficient practice had the potential to compromise or impede the protection of Resident 1 from further abuse, which could result in emotional distress for Resident 1. A review of Resident 1’s Admission Record, indicated Resident 1, a 35-year-old-female, was admitted to the facility on 11/14/2024 with diagnoses that included spondylosis (gradual breakdown of the spine and related structures), anxiety disorder (persistent and excessive worry that interferes with daily activities), depression (a common mental health condition characterized by a persistent low mood, loss of interest or pleasure in activities, and other symptoms that can significantly interfere with daily life) and borderline personality disorder (a personality disorder characterized by severe mood swings, impulsive behavior, and difficulty forming stable personal relationships). A review of Resident 1’s Minimum Data Set (MDS, resident assessment screening tool), dated 2/1/2025, indicated the resident had no impairment of cognitive (capable of remembering, learning new things, concentrating, or making decisions that affect everyday life) skills for daily decision making. Resident 1 required supervision (helper provides verbal cues or touching assistance) for upper and lower body dressing and putting on/taking off footwear. Resident 1 required set up or clean up assistance (helper sets up or cleans up) for eating, oral hygiene and personal hygiene. A review of Resident 1’s Care Plan titled, “Resident 1 has episodes of false accusation as evidence by claiming a resident’s visitor touched her arm and tried to kiss her,” dated 4/28/2025, indicated staff interventions were to report to attending physician (MD) if resident exhibits behavior. A review of Resident 1’s Progress Notes, dated 5/1/2025 at 11:55 PM, indicated Resident 1 was offered to see a psychologist (specializes in the study of the mind and behavior) but resident refused. A review of Resident 1’s Progress Notes, dated 5/2/2025 at 6:05 AM, indicated Resident 1 claimed a male visitor inappropriately touched her weeks ago. Progress notes also indicated there were no witnesses and Resident 1 did not verbalize emotional distress. Resident 1 was encouraged to verbalize feelings and concerns. During an interview on 5/2/2025 at 9:54 AM with Resident 1, Resident 1 stated that on 4/24/2025, a resident’s husband tried to forcefully kiss her, and she reported it to Certified Nursing Assistant 1 (CNA1) and Registered Nurse 2 (RN 2) immediately after it happened. During an interview on 5/6/2025 at 6:45 PM with CNA 1, CNA 1 stated that on 4/24/2025, Resident 1 reported to her that a resident’s husband tried to forcefully kiss her. CNA 1 stated she reported it to RN2 and RN 2 reported it to the Administrator. During a concurrent interview and record review on 5/3/2025 at 1:22 PM with the Administrator, the facility’s policy and procedure (P&P) titled, “Reporting and Investigating Abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), Neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress), Exploitation or Misappropriation (unlawful or unauthorized use of another person's money for personal gain or other unauthorized purposes),” dated 9/2022 was reviewed. The P&P indicated that all reports of resident abuse are reported to local, state and federal agencies and thoroughly investigated by facility management. The Administrator or the individual making the allegation immediately reports his/her suspicion to the following persons or agencies: local/state ombudsman, resident’s representative, law enforcement, the resident’s MD (Doctor of Medicine), state licensing/certification agency responsible for surveying the facility (CDPH) and the facility’s medical director ... Immediately is defined as within 2 hours of an allegation involving abuse or result in serious bodily injury. The Administrator stated the reporting policy indicated that an abuse allegation must be reported from 2 hours to 24 hours. The Administrator stated was aware of this abuse allegation on 4/24/25 but it was not reported to CDPH, and ombudsman until 5/1/25. The resident may suffer emotional distress and may continue to be abused if an abuse allegation is not reported promptly. The facility failed to report an allegation of sexual abuse for Resident 1 within 2-hour timeframe to the State Survey Agency and the state ombudsman, in accordance with the facility's abuse policy. As a result, this deficient practice had the potential to compromise or impede the protection of Resident 1 from further abuse, which could result in emotional distress. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.