Health inspection·February 27, 2025

California Health & Safety Code, 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) Failure to comply with the requirements of this section shall be a Class B Citation. California Code, Welfare and Institutions Code - WIC Section 15630 (b)(1) A mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that they have experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an internet report shall be made through the confidential internet reporting tool established in Section 15658, within two working days. California Code of Regulations Title 42 Section 483.12(c)(1) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. The following citation is written because of a facility reported incident (FRI) # CA00940818. An un-announced visit was made to the facility on 1/17/25 to investigate a FRI received on 1/16/25 at 10:15 a.m. regarding an incident of alleged physical and verbal abuse on January 9, 2025. It was determined that the facility failed to report the alleged incident of physical and verbal abuse that occurred involving an employee and Patient 1 when the facility received the allegation report of abuse on 1/9/25. Three facility staff members who were mandated reporters had knowledge of an abuse allegation on 1/9/25 and failed to report to the administrator of the facility. Therefore, the facility failed to report immediately, not later than 24 hours all incidents of an alleged violation involving physical and verbal abuse when an employee allegedly cursed and slapped Patient 1's hand. This failure decreased the facility's potential to protect and provide residents with a safe environment. Patient 1 was admitted in late 2024 with diagnoses including encephalopathy (brain dysfunction) and dementia (a progressive state of decline in mental abilities). A review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/23/24, indicated, Patient 1 had severe memory decline. A review of a facility document, dated 1/15/25 and received by the Department on 1/16/25, indicated an allegation of suspected dependent adult/elder abuse occurred related to a verbal and physical abuse between an employee and Patient 1. During an interview, on 1/17/25 at 12:49 p.m., Licensed Nurse 1 (LN 1) confirmed that the allegation was reported to her on 1/9/25 from Registry staff 2 and she did not report it timely to the Administrator who was the Abuse Prevention Coordinator (APC). During an interview, on 1/17/25 at 1:33 p.m., Certified Nursing Assistant 1 (CNA 1) confirmed that she heard the allegation of abuse from Registry 2 on 1/9/25 at the nurse's station and acknowledged that it was not reported to the APC. During an interview on 1/17/25 at 2:18 p.m., CNA 2 confirmed that she heard the allegation of abuse from Registry 2 on 1/9/25 and confirmed that it was not reported to the APC. During an interview, on 1/17/25 at 4:23 p.m., Director of Nursing (DON) stated it was the facility's policy to report an allegation of abuse to the Department within 2 hours. The DON confirmed the 1/9/25 alleged incident had not been reported to the Department until 1/15/25, which was 6 days when the facility was informed of the alleged incident on 1/9/25. The Department (CDPH) was notified of the alleged abuse incident on 1/15/25 at 5:36 p.m. A review of the facility's policy and procedure titled "Abuse Reporting and Investigation," dated 1/10/24, the policy indicated "To promptly report ALL allegations of abuse as required by law and regulations to the appropriate agencies...All allegations of abuse, neglect, mistreatment...shall be reported to the APC." The policy further indicated that reports of abuse would be made within two hours to the Department. Therefore, the facility failed to report immediately, not later than 24 hours all incidents of an alleged violation involving physical and verbal abuse when an employee allegedly hit Patient 1. This failure decreased the facility's potential to protect and provide residents with a safe environment. This violation had a direct or immediate relationship to the health, safety, or security of Patient 1.