Health inspection·February 26, 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. (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. 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 on 2/5/2025 at 10:30 AM to investigate a facility reported incident (FRI) regarding an allegation of a facility staff hurting Resident 1 when turning the resident. The facility failed to report an allegation of abuse (any intentional or unintentional actions that cause harm or distress to a patient or person in their care) within two hours to local police department, state survey agency (CDPH) and ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) after the allegation of physical abuse (inflicting physical injury such as hitting and slapping) was made by Resident 1. This resulted in delayed reporting which could have resulted in ongoing abuse, leading to worsening physical, emotional, or psychological (mental or emotional) harm for Resident 1. A review of Resident 1’s Admission Record dated 2/5/2025, indicated Resident 1, a 65-year-old-male, was admitted to the facility on 12/4/2024 with diagnosis of functional quadriplegia (inability to move due to severe disability frailty caused by another medical condition without physical injury or damage to the spinal cord). A review of Resident 1’s Minimum Data Set: (MDS- resident assessment tool) dated 1/7/2025, it indicated Resident 1 had intact cognition (ability to think, remember, reason and make decisions). The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on staff for toileting, dressing, transfer to and from a bed to a chair, and required maximal assistance (helper does more than half the effort to lift or hold trunk or limbs and provides more than half the effort) to roll left and right. A review of Resident 1’s Order Summary dated 1/31/2025 at 1:35 PM, indicated Resident 1 had a physician’s order for “X RAY (Radiograph - type of medical imaging that creates pictures of bones and soft tissue) of left hand for further evaluation due to complaint of pain”. During a concurrent observation and interview on 2/5/2025 at 10:25 AM with Resident 1, in Resident 1’s room, Resident 1 stated he did not remember the incident very well because he was asleep but believed there were two males and one female who tried to pull him up in bed using the bed sheets but was done very aggressively (unable to recall date). Resident 1 stated staff (unable to recall who) told him to grab his headboard, so he complied and that was when he hurt his hand because his hand was smashed in between the wall and the headboard. Resident 1 did not have a headboard at the time of observation and interview. Resident 1 stated he refused the XRAY ordered by the physician because his left hand was feeling better, and he wanted to talk to his family and go to his primary physician to get recommendations on what to do next. During an interview on 2/5/2025 at 11:09 AM with Social Services Worker (SSW), SSW stated on 1/31/2025 at 10 AM, he received report from the charge nurse (CN) via a communication page on the electronic health system (EHS) that Resident 1 had reported an incident of alleged abuse on 1/31/2025 at around 2:30 AM against Certified Nursing Assistant 1 (CNA1) when CNA 1 was alleged to hit Resident 1’s hand between the wall and the headboard. SSW stated he initiated an investigation by interviewing Resident 1 regarding the alleged abuse and reported the allegation made by Resident 1 to the Administrator, state survey agency, police department, and Ombudsman on 1/31/2025 at 10 AM (eight hours after the alleged abuse was initially reported by Resident 1). During an interview on 2/5/2025 at 11:41 AM with CNA1, CNA1 stated on 1/31/2025 at 1:30 AM, Resident 1 accused CNA1 of hurting the resident when CNA1 assisted the resident to reposition on the resident’s left side while lying in bed. During an interview with the Director of Nursing (DON) on 2/5/2025 at 12 PM, the DON stated the CN had been working at the facility for a long time, had received in service about abuse reporting, and should have notified the Administrator immediately within two (2) hours from when the allegation of abuse was made by Resident 1. During an interview on 2/5/2025 at 12:36 PM with the Administrator, Administrator stated she was the Abuse Coordinator for the facility and was aware that staff was to report any alleged abuse to the authorities such as local police department, state survey agency and ombudsman within two hours of the allegation of abuse was made. The Administrator stated the CN should have done the SOC 341 (a form that documents the information given by the reporting party on the suspected incident of abuse or neglect of an elder or dependent adult), call Ombudsman, notify law enforcement (local police department), and state agency (state survey agency) within two hours when Resident 1 alleged CNA 1 of abuse. The Administrator stated she was notified regarding the alleged abuse on 1/31/2025 at around 10 AM by the SSW which was past the two-hour time frame for reporting an abuse. A review of the facility’s policy and procedure titled “Abuse Policy” dated October 2022, the policy indicated all alleged violations involving abuse are reported immediately to the administrator and must also be reported by the facility to officials in accordance with state law, including to the state survey agency and adult protective services immediately, but no later than two (2) hours if the alleged violation involves abuse or results in bodily injury. The facility failed to report an allegation of abuse within two hours to local police department, state survey agency and ombudsman after the allegation of physical abuse was made by Resident 1. This resulted in delayed reporting which could have resulted in ongoing abuse, leading to worsening physical, emotional, or psychological harm for Resident 1. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.