Health inspection·March 16, 2023

California Health and Safety Code 1418.91 (a)(b)-Failure to Report (a) A long-term 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 of a complaint the facility failed to report an allegation of abuse/neglect for one resident (Resident 1) to the Department immediately or within 24 hours when a licensed staff (LN2) reported to the facility's Director of Nursing (DON) and Director of Staff Development (DSD) regarding a Certified Nursing Assistants' (CNA) neglect to follow up on Resident 1 at night resulting in the resident falling out of bed. Resident 1 was found on the floor (unwitnessed fall) with bruises and skin tears on the left forearm and legs on 7/21/22 at 5:30 am. During a review of a complaint filed against the facility dated 7/21/22, the complaint indicated the facility had been neglecting a resident (Resident 1) and an incident occurred on 7/21/22 around 5:30 am. The complaint further indicated, the DON and DSD had been neglecting the resident and retaliating against anyone who reports about the condition of Resident 1. Attached to the complaint were various pictures of Resident 1 on the floor with bruises (skin discoloration) on arms and legs and clothed with an upper garment and a disposable undergarment on. A review of the clinical record for Resident 1 on 9/7/22 at 4:50 pm, indicated on 7/21/22, night shift (11 pm to 7 am 5:30 am) the resident was found on the floor, (unwitnessed fall) with skin tears on the left forearm and legs. During an interview on 8/10/22 at 3:40 PM, the Director of Nursing (DON) indicated having no knowledge of any allegation of abuse that occurred on 7/21/22. The DON denied anyone (staff) reporting an allegation of abuse on 7/21/22 and if there was any, the facility will investigate and report. The DON further indicated any nurse who witnesses any form of abuse against residents and others should report right away. During an interview on 9/7/22 at 4:25 pm via phone with a Licensed Nurse (LN2), LN2 indicated reporting to the DON and DSD on the morning of 7/21/22 about Resident 1 being found on the floor with skin tears and skin bruising on the left forearm and legs. LN2 further indicated both the DON and DSD did nothing to address LN2's notification of night shifts certified nursing assistant (CNA) neglecting to check on Resident 1 who had history of falls ended up falling off the bed on 7/21/22 at 5:30 am. LN2 further indicated texting the DON of LN2's concerns regarding CNA not following up on the resident at night causing him to fall off the bed. Review of the facility's policy and procedure titled "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" dated April 2021 indicated, "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 the facility management. Findings of all investigation are documented and reported." During a review of the Department's record of facilities reported incidents from 7/21/22 to 9/7/22 indicated, the facility has not submitted any report regarding Resident 1's incident on 7/21/22 of falling with skin bruising and skin tears on the forearm and legs. Further review of the Department's record for facility reported incidents indicated, the facility submitted a report to the State Agency on 9/14/22 (more than 45 days after the DON was made aware by LN2) of the fall incident of Resident 1 on 7/21/22 with skin bruising and skin tears to the left forearm and legs. This facility's 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.