Health inspection·June 6, 2025

F607 42 CFR §483.12(b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, (4) Establish coordination with the QAPI program required under §483.75. (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. (ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. (iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act. 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. 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. (c) Each facility shall establish at least the following: (6) Procedures for reporting unusual occurrences. 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 Patient’s 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. An unannounced visit was conducted by California Department of Public Health (CDPH) on 4/22/2025 at 10:40 AM to investigate a complaint regarding an allegation that one resident physically assaulted another resident. The facility failed to follow their Policy and Procedure (P&P) titled “Abuse (misusing something, especially mistreating a person or harming them physically) Investigation and Reporting” for Resident 1 by: 1. Failing to report to the State Agency (SA where state law provides for jurisdiction in long-term care facilities), ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities) and local enforcement within 2 hours after Resident 1 reported an allegation of physical abuse to Registered Nurse 1 (RN 1) on 4/22/2025 at 10 AM that Resident 2 jumped on top of Resident 1 and hit Resident 1’s head. 2. Failing to separate Resident 1 and 2 immediately after the incident was reported on 4/22/2025 at 10 AM. As a result, Resident 2 jumped on Resident 1 and hit Resident 1 on the head on 4/22/2025 at approximately 10 AM. These deficient practices resulted in Resident 1 being subjected to physical abuse and related trauma, and further placed Resident 1 and other residents at risk of further abuse. A review of Resident 1’s Admission Record, the Admission Record indicated Resident 1, an 89-year-old-male, was admitted to the facility on 3/10/2025 with the following diagnoses of muscle weakness and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 4/8/2025, the MDS indicated the resident was independent in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene and upper body dressing but requires substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. A review of Resident 2’s Admission Record, the Admission Record indicated Resident 2, a 70-year-old-male, was admitted to the facility on 1/16/2025 with the following diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought) and insomnia (trouble falling asleep or staying asleep). A review of Resident 2’s MDS, dated 4/25/2025, the MDS indicated that the resident is independent in cognitive skills for daily decision making. The MDS also indicated the resident required supervision/touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with toileting hygiene, upper body dressing and personal hygiene but required partial/moderate assistance with shower/bathe self, lower body dressing and putting on/taking off footwear. During an interview on 4/22/2025 at 2 PM, Resident 1 stated Resident 2 tried to jump on him and tried hit his head (unable to recall when). During an interview on 4/22/2025 at 2:33 PM, RN 1 stated, on 4/22/2025 at 10 AM, Resident 1 reported that Resident 2 tried to jump on Resident 1 and tried to hit Resident 1’s head. During a concurrent observation in Resident 1 and 2’s room (Room A) and interview on 4/22/2025 at 3:20 PM, Resident 1 and Resident 2 were observed in the same room. Resident 1 stated he was uncomfortable being roommates with Resident 2 after Resident 2 tried to jump on Resident 1 at 10 AM. During an interview with Resident 2 on 4/22/2025, at 3:45 PM, Resident 2 denied jumping on Resident 1. Resident 2 also stated, he did not try to jump over nor try to hit Resident 1 in the head. During an interview on 4/22/2025 at 3:30 PM, the Director of Nursing (DON) stated, RN 1 should have reported the allegation of physical abuse by Resident 2 within 2 hours after Resident 1 reported the allegation of physical abuse. The DON also stated Resident 2 trying to jump on Resident 1 and trying to hit Resident 1’s head is considered a physical abuse whether it was witnessed or just an allegation of abuse. it should have been reported within two hours of the incident or allegation, investigated and both residents should have been separated immediately and changed the rooms, so they are not roommates. During a concurrent record review of the facility’s Policy and Procedure (P&P) titled “Abuse Investigation and Reporting,” revised 3/2024, and interview on 4/23/2025 at 12:30 PM, the P&P indicated all other instances of resident abuse will be reported by the facility administrator, or his/ her designee immediately or as soon as practicable but not later than two hours after the incident occurred or the allegation was made to the ombudsman, law enforcement and SA. The DON stated it should have been reported to SA, ombudsman and law enforcement but was not reported and/or investigated within 2 hours from the allegation was made. The DON also stated she was only made aware about the allegation of physical abuse by Resident 2 to Resident 1 around 3:30 PM. The DON also stated Residents 1 and 2 should have been separated to prevent further abuse, but the residents were not separated until 4/22/2025 at 3:45 PM (5 hours and 45 minutes). A review of the facility’s P&P titled “Abuse Prevention Program” dated 3/1/2024, indicated as part of the resident abuse prevention, the administration will protect the residents from abuse and protect resident during abuse investigations. The facility failed to follow their Policy and Procedure titled “Abuse Investigation and Reporting” for Resident 1 by: 1. Failing to report to the State Agency, ombudsman and local enforcement within 2 hours after Resident 1 reported an allegation of physical abuse to Registered Nurse 1 on 4/22/2025 at 10 AM that Resident 2 jumped on top of Resident 1 and hit Resident 1’s head. 2. Failing to separate Resident 1 and 2 immediately after the incident was reported on 4/22/2025 at 10 AM. These deficient practices resulted in placing Resident 1 and other residents at risk of further abuse. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.