Health inspection·May 14, 2025

The following reflects the findings of the California Department of Public Health during the investigation of the complaint number: CA00953609. A Class B citation was written. Regulatory Violations: §483.12: Freedom from Abuse, Neglect, and Exploitation: §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)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §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. Title 22 § 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. On 4/7/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident-to-resident altercation. The facility failed to follow and implement their abuse policy for Resident 1. On 3/15/25, Resident 1 alleged that Resident 2 “hit” Resident 1 on the left shoulder. Resident 1 stated, Resident 2 “hit” her on the left shoulder and as a result, Resident 1 stated she had pain on the left arm and unable to stretch her left arm. The facility failed to report Resident 1’s allegation of abuse to the state survey agency within two hours of knowing about Resident 1’s allegation. This deficient practice had the potential for delay in investigation and determined if Resident 1 and Resident 2 felt safe. 1.During a review of the Admission Record indicated the facility admitted Resident 1, a 76-year-old female on 12/23/24 and re-admitted on 3/8/25 with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and depression. During a review of Resident 1’s care plan initiated on 12/25/24 indicated Resident 1 and/or responsible party have been made aware that the facility has stable systems to identify not only abuse but also those practices and omissions that lead to abuse, neglect and misappropriation of property. The care plan goal indicated the facility will promptly identify and take appropriate measures to protect residents from abuse. The care plan interventions included follow all reporting guidelines as required related to abuse reporting and inform the resident and/or responsible party of the facility policy for reporting abuse. During a review of Resident 1’s Change of Condition (COC) dated 3/15/25 at 4:30 p.m. indicated on 3/15/25 at 10:30 a.m., the occupational therapist (OT) informed the registered nurse supervisor (RNS 1) that while Resident 1 and Resident 2 were in the rehabilitation room, Resident 2 called the attention of Resident 1 by “tapping” Resident 1’s left shoulder. The COC indicated the OT told Resident 2 to call Resident 1 by Resident 1’s name instead of “tapping” Resident 1’s shoulder. The same COC indicated on 3/15/25 at 4:30 p.m., Resident 1 “complained of pain in her shoulder that she claimed where another resident (Resident 2) tapped her”. RNS 1 assessed Resident 1 and found no bruising or discoloration. Resident 1’s range of motion (ROM, the extent to which a part of the body can be moved around a joint or a fixed point) was intact. Resident 1 was given Tylenol 650 milligrams (mg. - metric unit of measurement, used for medication dosage and/or amount) for pain and warm compress was applied to the left shoulder. Resident 1’s nurse practitioner (NP,) was notified and gave order for x-ray of the left shoulder. At 6:30 p.m., Resident 1’s NP gave a telephone order that included to apply Voltaren Gel (medicated gel applied to the skin for relief from muscle and joint pain) three times a day to Resident 1’s left shoulder. During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 3/29/25, indicated Resident 1 was cognitively intact. Resident 1 needed moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe, upper/lower body dressing, putting on/taking off footwear and supervision with eating, oral and personal hygiene. 2.During a review the Admission Record indicated the facility admitted Resident 2, a 68 years-old on 3/9/22 and re-admitted on 11/27/24 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of the MDS dated 3/27/25 indicated Resident 2 had moderately impaired cognitive skills. Resident 2 needed supervision with oral/toileting hygiene, shower/bather self, upper/lower body dressing, putting on/taking off footwear, personal hygiene and set up with eating. During an interview on 4/7/25 at 9:10 a.m., Resident 1 (certified nursing assistant [CNA 1] interpreting, stated she was in the rehabilitation room doing exercise when Resident 2 came and “hit me” in the left shoulder. Resident 1 stated after Resident 2 hit her on the left shoulder, Resident 1 stated she had pain nine out of 10 pain scale (measure of pain, zero -no pain, one to three - mild pain, four to six - moderate pain seven to nine severe pain and 10 – very severe pain) on the left shoulder and unable to stretch her left arm. Resident 1 stated she felt safe. During an interview on 4/7/25 at 9:43 a.m., Resident 2 did not respond to simple questions. During an interview on 4/7/25 at 9:54 a.m., the assistant director of staff development (DSD) stated for any allegations of abuse the administrator had to be notified and report the allegation to the state survey agency no more than two hours of knowing the allegation. During an interview on 4/7/25 at 11:33 a.m., the OT stated Resident 1 was sitting on the exercise bicycle when Resident 2 “tapped” Resident 1 on the shoulder. OT stated Resident 1 was annoyed and OT pulled Resident 2. OT stated he informed Resident 2 to call Resident 1 by Resident 1’s name instead of “tapping” Resident 1. OT stated no abuse and there was no yelling that occurred. During a telephone interview on 4/7/25 at 11:40 a.m., RNS 1 stated on 3/15/25, the OT informed RNS 1 that Resident 2 was annoying Resident 1 in the rehabilitation room. RNS 1 stated she went to the rehabilitation room and informed Resident 2 to call Resident 1 by her name instead of tapping Resident 1’s shoulder. RNS 1 stated, later during the day, Resident 1 approached RNS 1 and informed RNS 1 that Resident 1 was having pain on the left shoulder after Resident 2 “tapped” Resident 1 on the left shoulder. RNS 1 stated she assessed Resident 1 and found no bruising and discoloration but complained of pain in the left shoulder. RNS 1 stated she gave Resident 1 Tylenol for pain and notified Resident 1’s NP. The NP gave an order for x-ray of the left shoulder and apply Voltaren gel to the left shoulder. RNS 1 stated the x-ray result was negative. During an interview on 4/7/25 at 12:25 p.m., with the director of nursing (DON) and administrator (ADM), the DON stated RNS 1 informed her that Resident 1 complained of pain of the left shoulder where Resident 1 claimed that Resident 2 hit her on the left shoulder. DON and ADM stated they did not report the allegation to the state survey agency because the OT witnessed the incident. DON and administrator stated no abuse occurred. During a review of the facility Policy titled “Abuse & Mistreatment of Residents” reviewed on 5/21/24 indicated facility shall ensure reporting of all alleged and substantiated violations to the state agency and all other agencies as required and take all necessary corrective action on the results of the investigation. The same Policy indicated it is the facility’s policy for any mandated reporter working in a facility to report abuse to their supervisor as well as the state agency. The facility failed to follow and implement their abuse policy for Resident 1. On 3/15/25, Resident 1 alleged that Resident 2 “hit” Resident 1 on the left shoulder. Resident 1 stated, Resident 2 “hit” her on the left shoulder and as a result, Resident 1 stated she had pain on the left arm and unable to stretch her left arm. The facility failed to report Resident 1’s allegation of abuse to the state survey agency within two hours of knowing about Resident 1’s allegation. This deficient practice had the potential for delay in investigation and determined if Resident 1 and Resident 2 felt safe. The above violation had a direct relationship to the health, safety, and security of Residents 1 and 2.