F0609

D

Failure to Report Resident-on-Resident Abuse Allegation to CDPH

Los Angeles, California Survey Completed on 01-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report an allegation of resident-on-resident physical abuse to the California Department of Public Health (CDPH). One resident (Resident 4), who was admitted with diabetes mellitus and hypertension, had documentation in a History and Physical dated 12/12/2025 indicating a lack of capacity to understand and make decisions, while a Minimum Data Set (MDS) dated 12/14/2025 indicated the resident was able to understand and be understood by others and required varying levels of assistance with activities of daily living and mobility. Despite these documented needs and cognitive findings, there was no Change of Condition (COC) entry or progress note from 12/11/2025 to 12/16/2025 reflecting any allegation that another resident had been hitting this resident, nor any indication that such an allegation was reported to CDPH.

During an interview on 12/16/2025 at 11:00 a.m. at nurse’s station 1, Resident 4 stated that another resident (Resident 5) had been hitting her in the stomach since her admission to the facility, and she repeated this allegation. Licensed Vocational Nurse (LVN 2) and the Assistant Administrator (AADM) were present during this interview, and LVN 2 reported Resident 4’s statement to the AADM at that time. However, the clinical record for Resident 4 did not contain documentation of this allegation as a COC or in progress notes, and there was no documentation that the allegation was reported to CDPH as required.

Resident 5, who was also admitted with diabetes mellitus and hypertension and had an H&P dated 10/2/2025 indicating capacity to understand and make decisions, had an MDS showing that she was usually able to understand and be understood and required assistance with multiple activities of daily living and transfers. A review of Resident 5’s clinical records from 12/11/2025 to 12/16/2025 showed no COC or progress note documenting any allegation that she had hit Resident 4, and no indication that such an allegation was reported to CDPH. In a subsequent interview on 12/31/2025 at 1:00 p.m., the AADM stated that on 12/16/2025 at 11:30 a.m., LVN 2 had reported the allegation that Resident 5 had been hitting Resident 4 in the stomach since admission, and acknowledged that he did not report the incident to CDPH, despite facility policy and federal law requiring that all abuse allegations be reported to CDPH, the Ombudsman, and the police department. The facility’s policy titled “Reporting Guidance & Timelines for Abuse & injuries of Unknown Origin,” dated 6/2022, states that alleged violations related to abuse are to be reported immediately using the SOC 341 form.