Health inspection·January 31, 2024

F609 Reporting of Allegation Violations Section 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Section 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. Section 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. The following citation was written as a result of an unannounced visit to the facility on 1/19/24 for a Standard Abbreviated Survey. As a result of the investigation, The California Department of Public Health (CDPH) determined that the facility failed to report and investigate two incidents of allegation of abuse for one of three sampled residents (Resident 1) as required by the regulations. This failure resulted in a delay in the abuse investigation process and decreased the facility's potential to protect residents from physical and psychosocial harm. Findings: A review of the admission record indicated Resident 1 was admitted in 2022 with multiple diagnoses which included anxiety disorder. Her Minimum Data Set (MDS, an assessment tool) dated 10/21/23, indicated Resident 1 had moderate memory impairment. During a concurrent observation and interview on 1/19/24 at 10:20 a.m., in another resident's room, Resident 1 was on her wheelchair and stated that 3-4 weeks ago, Resident 2 hit her with his arm on her chest in the hallway. She stated the maintenance guy was there and he saw the incident. Resident 1 stated, she filed a grievance regarding the incident, and she was later informed that it was already closed. During an interview on 1/19/24 at 11:12 a.m., the Environmental Supervisor (ES) stated, he did not see any physical altercation between the two residents. The ES stated the residents were in the hallway in each other's way when he heard Resident 2 cursing at Resident 1. The ES further stated, he could not remember what curse words Resident 2 had used towards Resident 1. He stated, he did not report the incident to anybody because the AD was there. The ES stated he thought the activity director reported the incident. During an interview on 1/19/24 at 11:22 a.m., the AD stated, she did not witness any incident of physical altercation between the two residents. The AD stated, Resident 1 went to her and told her she was really upset because she (Resident 1) and Resident 2 got into an argument and that Resident 2 put his hand on her. The AD stated she brought this incident to the attention of the Social Service Director (SSD). The AD stated, she did not document anything but informed the SSD. During an interview on 1/19/24 at 11:35 a.m., the SSD stated, she does not remember the exact details of the incident. The SSD stated, Resident 1 informed her that Resident 2 was very loud in the activities room. The SSD further stated, she was not informed that there was a physical and verbal altercation between the two residents. During an interview on 1/19/24 at 12:05 p.m., the Director of Nursing (DON) stated, she was not aware of the incident between Resident 1 and Resident 2. The DON stated she should have been informed of the incident and it should have been reported to the State Agency (SA). She further stated, everyone was a mandated reporter. During a follow up interview on 1/19/24 at 12:29 p.m., Resident 1 reported there was another incident in the dining room a few weeks ago. Resident 1 stated, "he (Resident 2) started calling me a fat pig in front of everybody it was embarrassing...it was in front of everybody...everybody heard that it was directed to me. I was upset and embarrassed..." Resident 1 further stated, there were three staff in the room and another resident (Resident 3) heard it. During an interview on 1/19/24 at 12:33 p.m., Resident 3 was in her room sitting on her wheelchair. Resident 3 stated, the incident between Resident 1 and Resident 2 happened, "a while ago around the first part of November," and she could not recall the exact date. They were in the activity room and were getting ready to eat lunch. Resident 3 stated, Resident 2 started shouting at Resident 1 when Resident 1 asked Resident 2 to stop talking because he was being loud. Resident 3 reported that Resident 2 called Resident 1, " a fat pig and told her she looked like she was 9 months pregnant ...he was shouting at her it was in the dining room." She stated, when the staff heard the shouting, they all came running and separated them. The staff put Resident 2 in one area and the administrator talked to Resident 1 because she was crying and was really upset. There were several residents there. Resident 3 further stated, "She [Resident 1] cried so hard ...He's [Resident 2] always loud and arrogant." During an interview on 1/19/24 at 1:00 p.m., the Administrator (ADM) stated, there was an incident in the activity room a few weeks ago, but he could not remember exactly when it happened. The ADM stated, he was talking to somebody in his office, and he heard the arguing in the activity room. The ADM stated, Resident 2 was singing, and Resident 1 made a comment on his singing. Resident 2 then started yelling at Resident 1 and they started arguing. He stated, Resident 1 was upset when he spoke to her in the activity room. The ADM acknowledged there was no documentation of the incident and that it was not investigated or reported to the SA or to the Ombudsman. A review of the Facility's "Abuse and Neglect" policy created 11/18/21 indicated, "The facility will report all allegations of abuse...as required by law and regulations, to the appropriate agencies...The facility promptly reports and thoroughly investigates allegations of resident abuse..." Therefore, the facility failed to report and investigate two incidents of allegation of abuse for one of three sampled residents (Resident 1) as required by the regulations. This violation had a direct relationship to the health, safety, or security of long-term care facility residents.