Health inspection·July 25, 2025

F609 §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. T22 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. An unannounced visit was conducted by California Department of Public Health (CDPH) on 6/9/2025 to investigate a facility reported incident (FRI) regarding an allegation of resident-to-resident abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish). The facility failed to report an allegation of verbal abuse to the state agency (CDPH, California Department of Public Health), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement (Police Department) within 2 hours. This violation had the potential to result in unidentified abuse in the facility that could have led to a physical abuse between Residents 1 and 2. A review of Resident 1's Admission Record indicated the resident was a 78 year old male initially admitted to the facility on 5/7/2025 with diagnoses of nontraumatic (not caused by trauma or injury to the body) intracerebral hemorrhage (ICH; also known as hemorrhagic stroke is a medical emergency where bleeding occurs within the brain tissue) in brain stem (the lower part of the brain that connects to the spinal cord [a tube of tissue that carries nerve signals from the brain to the rest of the body]) and type 2 diabetes mellitus (DM2; a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic chronic kidney disease (damage to the kidneys caused by long-standing high sugar levels leading to impaired kidney function and potentially kidney failure). A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/14/2025, indicated Resident 1 was severely impaired (difficulty with or unable to make decisions, learn remember things) with cognitive (ability to think, remember and reason) skills for daily decision making. Resident 1 needed substantial/maximal assistance (helper does more than half the effort) with walking 10 feet. Resident 1 needed partial/moderate assistance (helper does less than half the effort) with transfers (how resident moves to and from bed, chair, wheelchair, standing position), personal hygiene, putting on/taking off footwear, upper and lower body dressing (the ability to dress and undress above and below the waist) and needed setup or clean-up assistance (helper sets up or cleans up, resident completes activity) with eating. A review of Resident 1's Situation, Background, Assessment and Recommendation (SBAR; a communication tool used by healthcare workers when there is a change of condition among the residents) documentation dated 6/5/2025, indicated it was reported to the Director of Nursing (DON) that on 6/1/2025 an alleged verbal altercation happened between Resident 1 and roommate, Resident 2. 2. A review of Resident 2's Admission Record, indicated the resident was a 64 year old male initially admitted to the facility on 5/29/2025 with diagnoses of encephalopathy (a condition where the brain does not function properly) and psychosis (a mental health condition characterized by a loss of touch with reality) not due to a substance or known psychological (relating to the mind and mental processes) condition. A review of Resident 2's MDS, dated 6/4/2025, the MDS indicated the resident was severely impaired with cognitive skills for daily decision making. Resident 2 needed setup or clean-up assistance with personal hygiene and eating and was independent (resident completes the activity by themselves with no assistance from a helper) with walking 150, 50 and 10 feet, transfers, upper and lower body dressing, and putting on/taking off footwear. A review of Resident 2's Licensed Nurse Progress Note, dated 6/1/2025, Resident 2's Licensed Nurse Progress Note indicated Resident 2 was assigned to a new room due to an attempted altercation with his roommate, Resident 1. During an interview on 6/12/2025 at 8:40 AM with the Director of Nursing (DON), the DON stated she was informed about the situation that happened on 6/1/2025 between Resident 1 and 2 by the new Administrator (ADM) on 6/5/2025 and created the SBAR documentation but was not present on 6/1/2025 when the alleged altercation occurred. During an interview on 6/12/2025 at 10:45 AM with the ADM, ADM stated the altercation between Residents 1 and 2 should have been reported on 6/1/2025 within 2 hours to CDPH, the ombudsman and the police. ADM stated they were not able to report the incident to the three (3) entities until 6/5/2025 when they were made aware in a meeting by the MDS Coordinator who found the information after auditing Resident 2's progress notes. ADM further stated the incident was reported late and should have been reported on 6/1/2025 to prevent abuse in the future and that the facility needs to not only have a system of abuse prevention and reporting but also needs to assess residents for any behaviors so that they can be addressed. During a review of the facility's policy and procedure (P&P) titled "Abuse Investigation and Reporting" dated March 2025, the P&P indicated, "All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse') shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported." The P&P also indicated: a. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and b. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: Two (2) hours if the alleged violation involves abuse of any kind. The facility failed to report an allegation of verbal 2abuse to the state agency, the state ombudsman, and local law enforcement within 2 hours. This violation had the potential to result in unidentified abuse in the facility that could have led to a physical abuse between Residents 1 and 2. This violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Residents 1 and 2.