Health inspection·July 25, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00964212 A Class B citation was written. Regulatory Violations: F609 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. § 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 6/10/2025, the California Department of Public Health (State Agency) made an unannounced visit to the facility to investigate an allegation of resident neglect. The facility failed to follow its policy and procedures (P&P) by failing to report an employee-to-resident abuse within 2 hours of occurrence to law enforcement, the State Agency, and Ombudsman for Resident 3. As a result, there was a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further abuse for Resident 3. During a review of Resident 2's "Admission Record", dated 6/11/25 indicated, Resident 2, a 86 years-old female was admitted to the facility on 1/18/25 with diagnoses including hypertension (HTN-high blood pressure), insomnia (inability to sleep), hyperlipidemia (HLD - a condition characterized by elevated levels of lipids (fats) in the bloodstream), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and abnormalities of gait and mobility. During a review of Resident 2's "History and Physical" (H&P), dated 1/20/25 indicated, Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 3/25/25, indicated, Resident 2 had intact cognition (ability to think, understand and make daily decisions). The same MDS further indicated Resident 2 required setup or cleaning assistance to supervision from staff for eating, personal hygiene, toileting, bathing, dressing and bed mobility. During a review of Resident 3's "Admission Record", dated 6/11/25 indicated, Resident 3, a 97 years-old male was admitted to the facility on 1/10/25 with diagnoses including chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breath), heart failure (a condition where the heart can't pump enough blood to meet the body's needs), chronic kidney disease (CKD-a condition where the kidneys are damaged and cannot filter blood as well as they should) muscle weakness, and lack of coordination. During a review of Resident 3's H&P, dated 1/13/25 indicated, Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's MDS, dated 4/16/25, indicated, Resident 3 had severe cognitive (ability to think, understand and make daily decisions) impairment. The same MDS further indicated Resident 3 required substantial/maximal to total dependance on staff for eating, personal hygiene, toileting, bathing, dressing and bed mobility. During a review of Resident 2's grievance, undated, indicated Resident 2 filed the grievance on behalf of Resident 3 for an incident of alleged employee-to-resident abuse on 3/28/25 at 8:30 pm indicating "Despite... refusal... CNA alleged proceeded forcefully... leading to the resident's... yelling and screaming in resistance." During a concurrent interview and record review on 6/10/25 at 3:02 pm with Social Services Director (SSD), Resident 2's grievance was reviewed. The SSD stated the Resident who filed the grievance (Resident 2) thought Resident 3 was being abused by the CNA, we investigated it, and it was a miscommunication, we apologized to the resident. The Administrator was made aware of the incident, and he should have done the process (for reporting abuse) on his side. During a concurrent interview and record review on 6/11/25 at 12:45 pm with Director of Nursing (DON) Resident 2's grievance was reviewed. The DON stated there was no physical problem, so we did not report it, but as it is written it in the grievance - if there are allegations of abuse we have to report it. During an interview with Administrator (ADM) on 6/24/25 at 10:16 am, the ADM stated he was made aware the same or next day of the incident, but that it was not communicated to him with the words "forcefully" as written in the grievance, otherwise they would have reported it. During a review of the facility's P&P titled, "Abuse and Neglect Prohibition Policy", reviewed June 2024, indicated, "It is the facility's policy to prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all residents through the following... Identification of possible incidents or allegation which need investigation... Reporting of incidents, investigations, and the facility's response to the results the results of their investigations... Reporting of incidents, investigations, and facility's response to the investigation... Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect, or exploitation the Administrator or designed will perform the following... All alleged violations - Immediately but not later than... 2 hours- if the alleged violation involves abuse... Report the incident to the local Ombudsman or the local law enforcement agency by telephone as soon as possible, and... The Licensing and Certification Program District Office". The facility failed to follow its P&P by failing to report an employee-to-resident abuse within 2 hours of occurrence to law enforcement, the State Agency, and Ombudsman for Resident 3. As a result, there was a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further abuse for Resident 3. The above violation had a direct relationship to the health, safety, and security of Resident 3.