Health inspection·September 10, 2025

22 CCR § 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (A) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. 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. 22 CR § 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. 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. An unannounced visit was conducted by California Department of Public Health (CDPH) on 8/5/2025 to investigate a complaint regarding an allegation of abuse Resident 1. The facility failed to report an alleged incident of staff to resident abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for Resident 1 within 2 hours to the state survey agency, adult protective services, law enforcement and the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) according to federal and state regulations and facility policy. This deficient practice resulted in the delay of onsite inspections and investigations which could potentially lead to Resident 1 experience of ongoing abuse from facility staff and/or other residents. During a review of Resident 1’s Admission Record, the Admission Record indicated Resident 1 a 66 years old male was admitted to the facility on 2/5/2025 and readmitted to the facility on 7/16/2025 with diagnoses that included End Stage Renal Disease (ESRD- irreversible kidney failure), dependence on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed), diabetes mellitus (DM- body doesn’t produce enough insulin or can’t effectively use the insulin it produced leading to high blood sugar levels), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life) and peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 1’s “Minimum Data Set (MDS – a resident assessment tool),” dated 7/22/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 1 was dependent (helper does all effort needed to complete activity) for toileting, showering/bathing, partial/moderate assistance (helper does less than half the effort needed to complete the activity) with eating and substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with oral hygiene. During a review of Resident 1’s “Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form,” dated 8/4/2025, timed 12:50 PM, the SBAR Communication Form indicated facility SSD was made aware of an allegation of physical abuse from Resident 1, stating he was punched and hit in the head with a broom.  During a review of Resident 1’s “Social Services Progress Note,” dated 8/4/2025, timed 13:10 PM, the Progress Note indicated Social Services Director (SSD) received a call from social worker at the dialysis center that Resident 1 informed dialysis staff he (Resident 1) was being physically abused by facility staff. During a review of Resident 1’s “Alleged Physical Abuse” care plan (a document that outlines the facility’s plan to provide personalized care to a resident based on the resident’s needs), dated 8/4/2025, the care plan indicated that one of the interventions is for staff to report abuse to appropriate agencies. During an interview on 8/5/2025 at 12:47 PM with Resident 1, Resident 1 stated he was hit by facility staff on the head with a broom on Sunday (8/3/2025). During an interview on 8/5/2025 at 2:08 PM with the Director of Nursing (DON), the DON stated being made aware of Resident 1’s alleged abuse incident on 8/4/2025 after Resident 1 returned to the facility from dialysis. The DON stated facility staff completed a change of condition (COC) form, but the staff did not report the alleged abuse incident to CDPH, state agency, because the facility needed to complete an investigation first to verify if the abuse occurred. The DON stated the facility should have reported Resident 1’s allegation of abuse within two (2) hours of learning of the alleged abuse incident to the ombudsman (an advocate for residents of nursing homes, local police and CDPH because it is mandatory for facility to report if it is alleged and/or confirmed. During a concurrent interview and record review on 8/5/2025 at 3:51 PM with the Administrator, the facility’s policy and procedure (P&P) titled “Abuse Prevention and prohibition Program,” revised 8/1/2023, the P&P indicated: a.     The P&P purpose is to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. b.     Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and the California Elder Abuse and Dependent Adult Civil Protection Act to report known or suspected instances of abuse of elder or dependent adults. c.     The facility will report allegations of abuse, neglect, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime. Immediately, but no later than 2 hours after forming the suspicion- if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the ombudsman. The Administrator stated according to the facility’s policy, state and federal regulations, the facility should have reported this alleged incident of abuse for Resident 1 to the appropriate agencies within 2 hours of incident. Administrator also stated, it is important to report alleged and confirmed allegations of abuse to ensure Residents feel safe and secure, to prevent any other instances of abuse and to have a third party that is not affiliated with the facility investigate allegations. The facility failed to report an alleged incident of staff to resident abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for Resident 1 within 2 hours to the state survey agency, adult protective services, law enforcement and the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) according to federal and state regulations and facility policy. This deficient practice resulted in the delay of onsite inspections and investigations which could potentially lead to Resident 1 experience of ongoing abuse from facility staff and/or other residents. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1.