055728
02/05/2025
Santa Clarita Post-Acute Care Center
23801 Newhall Avenue Newhall, CA 91321
F 0609
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Based on interview and record review, the facility failed to implement its policy and procedure (P&P) for reporting all allegations of abuse immediately within two hours of being made aware for one of three sampled residents (Resident 1). This deficient practice resulted in a delay of notifying the necessary agencies, delay in conducting the facility's investigation and may have placed Resident 1 at risk for further abuse.
Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 1/10/2025 with diagnoses including nondisplaced fracture of lower epiphysis(separation) of left femur (thigh bone - a type of broken bone in the femur), subsequent encounter for closed fracture with routine healing and morbid (severe) obesity due to excess calories. During a review of Resident 1's History & Physical (H&P), dated 1/12/2025, the H & P indicated Resident 1 was obese and can make needs known, but cannot make medical decisions. During a concurrent interview and record review on 2/5/2025 on 4:02 p.m. with the Administrator (Admin), the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 4/2024, was reviewed. The Admin stated the facility did not report to the State Survey Agency (SSA) Resident 1's abuse allegation that a woman was trying to assault him (Resident 1) and attempting to shove power up my bottom while he was under the care of the facility. The Admin stated the facility was not able to conduct an investigation regarding Resident 1's abuse allegation and was not able to submit a written report to the SSA as of this time. The Admin stated it was important to report to the SSA for Resident 1's safety and protection. The Admin stated that the written investigation report must be submitted within five working days after the occurrence of the incident per facility's policy and procedure. During a review of facility's P & P titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 4/2024, indicated, 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. Immediately is defined as within two hours of an allegation involving abuse or result in physical harm serious bodily injury.
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055728
055728
02/05/2025
Santa Clarita Post-Acute Care Center
23801 Newhall Avenue Newhall, CA 91321
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm or potential for actual harm
Based on interview, and record review, the facility failed to thoroughly investigate a sexual abuse (when someone touches another person in a sexual manner without consent) allegation for one of three sampled residents (Resident 1).
Residents Affected - Few This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect Resident 1 from abuse.
Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 1/10/2025 with diagnoses including nondisplaced fracture of lower epiphysis(separation) of left femur (thigh bone - a type of broken bone in the femur), subsequent encounter for closed fracture with routine healing and morbid (severe) obesity due to excess calories. During a review of Resident 1 ' s History & Physical (H&P), dated 1/12/2025, the H & P indicated Resident 1 was obese and can make needs known, but cannot make medical decisions. During a concurrent interview and record review on 2/5/2025 on 4:02 p.m. with the Administrator (Admin), the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, dated 4/2024, was reviewed. The Admin stated the facility did not report to the State Survey Agency (SSA) Resident 1's abuse allegation that a woman was trying to assault him (Resident 1) and attempting to shove power up my bottom while he was under the care of the facility. The Admin stated the facility was not able to conduct an investigation regarding Resident 1's abuse allegation and was not able to submit a written report to the SSA as of this time. The Admin stated it was important to report to the SSA for Resident 1's safety and protection. The Admin stated that the written investigation report must be submitted within five working days after the occurrence of the incident per facility's policy and procedure. During a review of facility ' s P & P titled, Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, dated 4/2024, indicated, 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. Immediately is defined as within two hours of an allegation involving abuse or result in physical harm serious bodily injury.
055728
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