Health inspection·April 17, 2025

F609 42 CFR §483.12(b) The facility must develop and implement written policies and procedures that: (b)(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. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. 42 CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 42 CFR §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)(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. 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. An unannounced visit was conducted by California Department of Public Health (CDPH) on 3/7/2025 to investigate a complaint regarding an allegation of sexual abuse (the act of engaging in sexual activity with someone without their consent, or by using force or coercion) about that on 3/5/2025, Resident 1 stated Resident 1 was sexually assaulted (any type of sexual contact without consent) by a resident in the other facility (Facility 2). The facility failed to report an allegation of alleged sexual abuse (the act of engaging in sexual activity with someone without their consent, or by using force or coercion) for Residents 1 within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), ombudsman (OMB) (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement when OMB and local law enforcement went to the facility to investigate the allegation of sexual abuse made by Resident 1 on 3/5/2025. As a result, this deficient practice had the potential to compromise or impede the protection of Resident 1, which could affect resident's physical, emotional, and mental wellbeing. A review of Resident 1's Admission Record, the Admission Record indicated Resident 1, a 60-year-old-female, was admitted to the facility on 2/21/2025 with diagnoses of diabetes mellitus type 1 (DM type 1, is a life-long autoimmune disease that prevents the pancreas from making insulin), schizoaffective disorders a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder), and anxiety disorders (a group of mental health conditions that cause excessive fear and worry). A review of Resident 1's Minimum Data Set (MDS - resident assessment tool), dated 2/28/2024, the MDS indicated Resident 1 had modified independence (some difficulty in new situations only) of cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 1 needed supervision or 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) in shower/ bathe self, lower body dressing, and putting on/taking off footwear, lying and sitting on the side of the bed, sit to stand position, toilet transfer and tub/shower transfer. During an interview with Licensed Vocational Nurse (LVN) on 3/7/2025 at 10:33 AM, LVN stated she is a mandated reporter, she must report any abuse incident or allegation of abuse to the ADM as soon as possible, she can also call police, ombudsman to report the abuse. LVN stated there is a form of SOC 341 (form used by Californian to report suspected dependent adult or elder abuse) that needs to be filled out in case of any abuse and suspected abuse happened to residents. During an interview with the Director of Nursing (DON) on 3/7/2025 at 10:43 AM, the DON stated facility staff need to report to the Administrator (ADM) for any abuse or allegation of abuse within two- hour time frame. During an interview with the Administrator (ADM) on 3/7/2025 at 12:28 PM, ADM stated sexual abuse allegation happened to Resident 1 according to the resident back in December 2024 when Resident 1 is still residing at Facility 2. ADM stated OMB came to the facility on 3/5/2025 and OMB called the police for Resident 1 after OMB listened to Resident 1's story and the resident made the sexual abuse allegation. ADM stated, police came to the facility for Resident 1 on 3/5/2025 to investigate the allegation of sexual abuse and the police also went to Facility 2 and did the investigation over at Facility 2 with the OMB. ADM stated she did not start any investigation and reported to SA when the facility was made aware that Resident 1 made an allegation for sexual abuse on 3/5/2025. ADM also stated she will start the investigation right away and report it to the agencies only if there is a real abuse case. During an interview with Director of Staff Development (DSD) on 3/7/2025 at 12:48 PM, DSD stated staffs are mandated reporters and the facility need to report any abuse incident or allegation of abuse within two hours to SA, ombudsman and local law enforcement. A review of the facility's Policy and Procedure (P&P) titled, "Abuse Investigation and Reporting," undated, the P&P indicated all alleged violations involving abuse will be reported by the facility administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency (SA) 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 The P&P also indicated an alleged violation of abuse 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. A review of the facility's Policy and Procedure (P&P) titled, "Abuse, Neglect (fail to care for properly), Exploitation (treating someone unfairly in order to benefit from their work) and Misappropriation (unauthorized use of another's name. likeness, identity, property without permission resulting to harm to that person)- Reporting and Investigating," undated, the P&P indicated if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The P&P indicated the Administrator or the individual making the allegation immediately reports his or her suspicion 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 of Record d. Adult Protective Services e. Law enforcement officials The P&P also indicated, "Immediately" is defined as within 2 hours of an allegation involving abuse or result in serious bodily injury. The facility failed to report an allegation of alleged sexual abuse for Residents 1 within 2-hour timeframe to the SA, OMB, and local law enforcement when OMB and local law enforcement went to the facility to investigate the allegation of sexual abuse made by Resident 1 on 3/5/2025. As a result, this deficient practice had the potential to compromise or impede the protection of Resident 1, which could affect resident's physical, emotional, and mental wellbeing. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.