Other·April 18, 2023

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. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 3/23/27 an unannounced visit was conducted at the facility to investigate an allegation of abuse reported to the Department. The facility failed to report an allegation of abuse immediately or within twenty-four hours after the facility administrator was made aware of the allegation. Resident 1 was admitted to the facility in early 2023 with diagnoses which included recent surgery with bone fusion in her lower abdomen, difficulty walking, anxiety, constipation. Resident 1 was her own responsible party. During an interview on 3/23/23, at 3:57 p.m., with the facility Administrator (ADM) and Director of Nursing (DON), the ADM indicated he received a call from Resident 1 on 3/21/23 with a complaint that a male nurse touched her legs. The touch was unwanted and made her feel uncomfortable. The ADM informed Resident 1 he would investigate. ADM acknowledged that he did not report the allegation to state agencies. He stated, "We did our internal investigation to figure out what was going on." During an interview on 3/27/23, at 10:19 a.m., with Resident 1, Resident 1 indicated on 3/17/23 during the night a male nurse came into her room. She stated she had emailed the ADM about the incident and called the facility after she discharged. During an interview on 3/27/23, at 1:37 p.m., with the Social Service Director (SSD), the SSD indicated Resident 1 called the facility on 3/21/23 wanting to "talk to someone higher up...wanted to talk to [ADM first name]...she used his first name." During an interview on 3/27/23, at 1:51 p.m., with ADM, the ADM confirmed he did not submit a report on 3/21/23 after Resident 1 called but did submit a report to California Department of Public Health (CDPH) on 3/23/23. On 3/23/23 the Department received a report from the facility with alleged abuse as noted above. During a review of the facility's policy and procedure (P&P) titled, "Abuse Investigation and Reporting" dated July 2017, the P&P indicated, "...Reports of resident abuse...mistreatment...shall be promptly reported to local, state, and federal agencies...An alleged violation of abuse, neglect, exploitation...will be reported immediately, but not later than...two hours if the alleged violation involves abuse." In violation of the above cited standards, the facility failed to report immediately, but not later than two hours after an allegation is made. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.