Health inspection·June 5, 2025

Health and Safety Code Section 1418.91(a)(b).  (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. The Department determined during the investigation; the facility failed to report an allegation of abuse to the Department after several employees brought it to the attention of the former Operations Manager. On 3/25/25 at 10 a.m., an unannounced visit was conducted at the facility to investigate an anonymous complaint regarding an allegation of resident abuse. The allegation indicated; a female Certified Nurse’s Assistant (CNA) had an inappropriate relationship with a resident at the facility from approximately August 2024 to October 2024. Resident 1 was a 25-year-old male, admitted to the facility on 10/4/24 with diagnoses that included, chronic osteomyelitis with draining sinus, right femur, localized swelling mass and lump lower right limb, cutaneous abscess of limb, difficulty in walking, acquired absence of right hand, lack of coordination and anemia. Resident 1 was admitted for IV antibiotic administration through a PICC line on the left upper arm. The resident was alert and oriented x 4 and ambulatory. The facility’s policy and procedure (P&P) titled, “Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating,” dated September 2022 indicated, 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. During an interview on 3/19/25 at 3:56 p.m. with the Ventura County Ombudsman (VCO), VCO verbalized they have no knowledge of any abuse allegations at the facility, or their office being notified of any allegations. During an interview on 3/25/25 at 11:35 a.m. with licensed nurse (LN) 3, LN 3 verbalized they heard rumors of the abuse, reported it to the former Operations Manager (FOM). The FOM requested LN 3 write a statement regarding the alleged abuse. LN 3 provided a written statement and did not report the alleged abuse further. During an interview on 3/25/25 at 1:10 p.m. with Human Resources (HR), HR verbalized FOM knew about the allegations December 2024, an investigation was conducted. The employee was terminated on December 23, 2024. Evidence of text messages and information gathered from a phone were utilized to terminate the employee. HR further verbalized thought the FOM was to notify the CDPH. During an interview on 3/25/25 at 1:30 p.m. with Director of Staff Development (DSD), DSD verbalized the alleged abuse information was given to the FOM, and believed the FOM was the one to notify police, CDPH or ombudsman and was not able to explain policy and procedure for reporting abuse to surveyor. During an interview on 3/25/25 at 1:50 p.m. with the facility receptionist (REC), REC verbalized had heard rumors of the alleged sexual misconduct between the staff member and the resident. REC further verbalized informed the FOM and gave a statement. REC did not notify anyone else regarding the incident. During a concurrent interview and record review on 3/25/25 at 2:10 p.m. with Director of Nursing (DON) and Operations Manager (OM), the facility’s policy and procedure (P&P) titled, “Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating,” dated September 2022 was reviewed. The P&P indicated the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies. The OM confirmed the P&P was not followed by staff. The DON confirmed the suspected abuse was not reported to the appropriate agencies. The facility failed to report an allegation of abuse to the Department after several employees brought it to the attention of the former Operations Manager. This resulted in delayed investigations by CDPH, the police department and other agencies. The parties involved were unable to be interviewed due to the delay and pertinent information was unavailable. This facility failure is a violation of the Health and Safety Code (H&SC) 1418.91 (a)(b) which mandates facilities to report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours.