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 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. 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 the California Department of Public Health (CDPH) on 8/6/2025 to investigate a complaint regarding an allegation of abuse Resident 1. The facility failed to report an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) on 8/4/2025 for Residents 1 within two (2) hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement.   This deficient practice of falling to report and investigation Resident 1’s allegation of abuse means the facility cannot verify to CDPH that Resident 1 was free from abuse and cannot demonstrate that this requirement was upheld. The facility’s failure to perform due diligence had the potential to compromise or impede the protection of Resident 1, which could affect Resident 1’s emotional and mental wellbeing by ongoing distress at the thought of future abuse. During a review of Resident 1’s Admission Record, the admission record indicated Resident 1, an 80 year old female was admitted to the facility on 7/22/2025. Resident 1’s diagnoses included right hip fracture (a partial or complete break in the upper part of the thigh bone [femur] where it meets the pelvic bone), right hip hemiarthroplasty (a surgical procedure that replaces the femoral head of the hip with metal component), history of falling, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and insomnia (trouble falling asleep or staying asleep)   During a review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool), dated 7/26/2025, the MDS indicated Resident 1 had intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 required  supervision or touching assistance (helper provides verbal cues and/or touching/ steadying and/or contact guard assistance as resident completes activity) in toileting hygiene, lower body dressing, putting on and taking off footwear, roll left and right, sit to lying, sit to stand, chair/ bed-to-chair transfer, toilet transfer, walk 10, and 50 feet.   During an observation and interview on 8/6/2025 at 6:42 AM, Resident 1 was observed sitting on her bed.  Resident 1 stated someone came to her room, came close to her and stared at her on Saturday (8/2/2025) at 6:30 AM. The curtain was surrounding her bed, then one man came in and she was completely nude, and the man saw her nude. Resident 1 stated she should have called the police. Resident 1 was very upset and clenched her fists while telling the story.   During an interview on 8/6/2025 at 6:54 AM, with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 stated a man came into her room and looked at her while she was naked. CNA 1 stated the facility should have reported the allegation within 2 hours because we had to make sure that nothing happened to her, nobody abused the resident. CNA 1 further stated the facility needed to verify the residents’ statements because the resident can be psychologically affected by the incident.   During an interview on 8/6/2025 at 7:08 AM, with Licensed Vocational Nurse 2 (LVN2), LVN 2 stated, “on Monday night (8/4/2025) Resident 1 said somebody came inside her room and she was naked, and a man looked at her. It was endorsed to me by the previous shift that night. If something was mentioned like that, it should be reported right away to the Registered Nurse Supervisor (RNS) and to the Abuse coordinator.  It can be traumatizing to Resident 1. She can suffer and can affect her well-being.”   During an interview on 8/6/2025 at 7:19 AM, with LVN 2, LVN 2 stated, “there was no abuse monitoring that was done on my shift. I did not report allegations of abuse. Resident 1 can continue feeling scared, feeling not safe in the facility. I am not sure if the previous shift reported abuse. I thought they did the report, because when they endorsed it to me, I thought it was being handled.”   During an interview on 8/6/2025 at 7:54 AM with Director of Nursing (DON), DON stated, “Resident 1 went to her appointment on Monday 8/4/2025. We received a call from the medical office. Resident 1 told the Doctor that she does not want to go back to the facility because a man was staring at her in her room. Resident 1 stating a man was staring at her while she was naked Saturday morning (8/2/2025). I did not report it to the survey agency, police department and ombudsman.”   During a concurrent interview and record review on 8/6/2025 at 8:08 with Administrator (ADM), the facility’s policy and procedure (P&P) titled, “Elder/ Dependent Adult Abuse, “revised 3/22/2024 was reviewed. The P&P indicated the facility will report any reasonable suspicion of a crime against a resident and all alleged violations involving abuse. ADM stated, “we did not report it because there was no physical interaction with Resident 1. We did not report the incident to the CDPH, police and Ombudsman. We should have reported it within 2 hours when we were made aware on Monday (8/4/2025).”   During a concurrent interview and record review on 8/6/2025 at 8:17 AM with DON, the facility’s P&P titled, “Elder/ Dependent Adult Abuse, “revised 3/22/2024 was reviewed. The P&P indicated 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. DON stated, “we did not report to the CDPH, police and Ombudsman. During my interview with Resident 1, she was telling stories, and I cannot say which one is real. we did not monitor Resident 1 for abuse allegation and no care plan for abuse allegation.”   During an interview on 8/6/2025 at 10:38 AM with LVN 1, LVN 1 stated, on Monday (8/4/2025) Resident 1 went to her appointment and did not want to go back to the facility. LVN 1 stated Resident 1 alleged somebody went to Resident 1’s room and was naked and that a male staff went close to her. LVN 1 stated she informed RNS of Resident 1’s allegation.   During an interview on 8/6/2025 at 10:45 AM with LVN 1, LVN 1 stated, Resident 1 was saying, she was naked, and somebody walked in her room and stared at her. LVN 1 stated the allegation is a suspicion of abuse because we are not sure, but we should have reported it right away. LVN 1 further stated facility staff should always report abuse to protect the residents’ rights.   During an interview on 8/6/2025 at 11:50 AM with RNS 1, RNS 1 stated, she was aware of the abuse allegation from the appointment last Monday (8/4/2025). She further stated Resident 1 refused to go back to the facility and did not want any male staff in her room. She further stated the resident wanted to call the police, and she wanted to go home at that time.   During an interview on 8/6/2025 at 11:58 AM with RNS 1, RNS 1 stated, if suspected allegation of abuse was not reported, the resident might be neglected because the issue was not addressed. RNS further stated the facility should report to make sure we can protect Resident’s Rights. She will not be monitored for allegation of abuse.   During a review of the facility’s Policy and Procedure (P&P) titled, “Elder/ Dependent Adult Abuse, “revised 3/22/2024, the P&P indicated the facility will report any reasonable suspicion of a crime against a resident and all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property. The P&P also indicated, 5.      The facility will annually notify covered individuals of their obligations to comply with requirements to ensure reporting of crimes. Each covered individual will: a.      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.      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. 10.    Reporting/Response a. A mandated reporter who, in his or her professional capacity, or within the scope of his employment, has observed or has knowledge of an incident that reasonably appears to be abuse or is told by an cider or dependent adult they have experienced behavior, including an act or omission, constituting abuse or reasonably suspects that abuse, will report known or suspected instance of abuse and any reasonable suspicion of a crime to the Administrator. The facility failed to report an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) on 8/4/2025 for Residents 1 within two (2) hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement.   This deficient practice had the potential to compromise or impede the protection of Resident 1, which could affect the resident’s emotional and mental wellbeing. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1.