Health inspection·May 1, 2025

REGULATION VIOLATION(S) 1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to report incidents of alleged employee-to-resident abuse/neglect/mistreatment to the Department within 24-hours, when the Administrator did not report alleged employee-to-resident altercations between Unlicensed Staff B and Resident 1 and other residents to whom Unlicensed Staff B was assigned. Unlicensed Staff A, who received resident complaints regarding Unlicensed Staff B's behavior, sent a group text message on 1/2/23, to the Administrator, Director of Nursing (DON), Director of Staff Development (DSD), and a Charge Nurse of residents' allegations of mistreatment. This failure had the potential to decrease the Department's ability to ensure a complete investigation was done and interventions were started to protect all residents so there was no recurrence of abusive behavior. During an interview on 3/6/23, at 11:25 a.m., the DSD stated residents reported to Unlicensed Staff A the following morning, 1/2/23, about Unlicensed Staff B's, who had been assigned residents in the Yellow Hallway and worked on the PM and Night shift the previous day, 1/1/23, inappropriate behavior/treatment/communication. The DSD stated Unlicensed Staff A told her, the Administrator, and the DON about the alleged altercations regarding Unlicensed Staff B's treatment toward residents through a group text on 1/2/23. The DSD stated she did not recall if the alleged altercations were investigated. The DSD stated she knew the Registry (staffing agency) was called and was made aware of the residents' complaints about Unlicensed Staff B's behavior, and the facility did not want Unlicensed Staff B working at the facility anymore. During an interview on 3/6/23 at 12:05 p.m., Unlicensed Staff A stated she worked the AM shift on 1/2/23, and followed Unlicensed Staff B, who had worked the PM shift and the Night shift on 1/1/23. Unlicensed Staff A stated she and Unlicensed Staff B were assigned to residents in the Yellow Hallway. Unlicensed Staff A stated the Yellow Hallway was mainly [physical] rehab/short-term residents and residents with high acuities (residents who needed special supervision while recovering from a serious illness or injury). Unlicensed Staff A stated, when she started her shift on 1/2/23 at 6:30 a.m., Unlicensed Staff B had already taken off, so she had not received a report from Unlicensed Staff B. Unlicensed Staff A stated the residents on the Yellow Hallway could be very demanding and were often on their call light requesting their pain medication. Unlicensed Staff A stated the residents who were alert/cognitive and those who were easy going, complained to Unlicensed Staff A that Unlicensed Staff B, "was the worst CNA (Certified Nursing Assistant) ever." Unlicensed Staff A stated the residents said when they would ask for the bedpan, Unlicensed Staff B told residents to get their bedpan themselves. Unlicensed Staff A stated residents said Unlicensed Staff B cursed at the residents, and when a resident would ask for assistance to the bathroom, Unlicensed Staff B would tell the resident to get up and go by themselves. Unlicensed Staff A stated residents told her Unlicensed Staff B would move their call light so they could not reach the call light to call for assistance. Upon request to identify the residents for an interview, it was noted that these residents were already discharged from the facility. Unlicensed Staff A stated she reported the allegations of employee-to-resident abuse/neglect/mistreatment to her charge nurse, and she sent a group text message to the Administrator, the DON and the DSD, the same morning the residents complained to her, 1/2/23, regarding Unlicensed Staff B's care/treatment toward the residents. During an interview on 3/6/23 at 1:10 p.m., the Administrator was asked if he had investigated the complaint about Unlicensed Staff B's alleged altercations of behavior/treatment/care toward the residents assigned to her on the PM and Night shift, 1/1/23. The Administrator stated he had received a text message, but all he understood was Unlicensed Staff B had been rude to residents. During an interview on 3/6/23 at 2:05 p.m., the Administrator stated he had not heard about all the various complaints the residents had stated to Unlicensed Staff A on 1/2/23. The Administrator stated the allegations of abuse/neglect were news to him. The Administrator stated he thought the issue was a personality clash between Unlicensed Staff B and the other CNAs who worked at the facility. The Administrator stated he thought the CNAs did not like working with Unlicensed Staff B. The Administrator stated the Registry Coordinator was notified about Unlicensed Staff B's rude behavior. The Administrator stated Unlicensed Staff B was banned from working at the facility and was taken off any scheduled shifts right away. The Administrator stated no resident had complained to him about Unlicensed Staff B, only staff members had. When the Administrator was asked if he received a text message from Unlicensed Staff A regarding Unlicensed Staff B being rude to residents, he said, "Yes." The Administrator stated he was the head of investigating an allegation of abuse/neglect and reporting the allegation of abuse/neglect to the Police, CDPH (California Department of Public Health), and the Ombudsman's office. The Administrator stated he only heard Unlicensed Staff B had been rude to residents. The Administrator stated he never spoke to Unlicensed Staff B regarding the allegations reported by Unlicensed Staff A. During an interview on 3/6/23 at 2:15 p.m. the DON, (Director of Nursing) stated she thought the Administrator had taken care of the investigation regarding Unlicensed Staff B being rude to the residents. The DON stated she called the Registry about not wanting Unlicensed Staff B to work at the facility anymore. The facility policy/procedure titled, "Abuse and Neglect - Clinical Protocol," revised 3/2018, indicated: "Definitions - 1. 'Abuse' is defined at §483.5 as 'the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 2. 'Neglect,' is defined at §483.5, means 'the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress ... Treatment/Management: 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. 2. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations ..." The facility policy/procedure title, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," revised 9/2022, indicated: "Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation: Reporting Allegations to the Administrator and Authorities: 1. 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. 2. 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, d. Adult protective services (where state law provides jurisdiction in long-term care), e. Law enforcement officials, f. The resident's attending physician; and g. The facility Medical Director. 3. 'Immediately' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 4.Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone ..." Therefore, the facility failed to notify the Department within 24 hours of an alleged incident of abuse resulting in an automatic B violation. The violation of the regulation had a direct relationship to the health, safety or security of residents.