Health inspection·December 12, 2024

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 for ensuring the reporting of an allegation of abuse for one of three sampled residents (Resident 1). Resident 1 alleged being physically abused (intentional act of causing injury or trauma to a person through bodily contact) by an employee (name not indicated), but the facility did not respond in investigating or reporting such allegation to the California Department of Public Health (CDPH - licensing and certification division). This deficient practice delayed the investigative process and placed Resident 1 at an increased risk for further distress such as physical harm, emotional pain, and further trauma associated with the allegation of abuse. Findings During a review of Resident 1's Record of Admission, the Record of admission indicated an admit date of 1/6/2024 with diagnoses including chronic respiratory failure (a long-term condition that prevents the body from exchanging oxygen and carbon dioxide properly), traumatic hemorrhage of cerebrum (a collection of blood in the brain due to traumatic injury to the head), and diabetes insipidus (a disorder affecting the body's ability to regulate water balance, leading to excessive thirst and urination). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 11/10/2024 indicated that Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making tasks were intact. During an interview with the Director of Staff Development (DSD) on 12/12/2024 at 2:14 p.m., the DSD stated that all staff are mandated (officially required) reporters for abuse. The DSD further stated that reporting of abuse is to be done immediately, or no later than two (2) hours to the local police, Long-term Care Ombudsman (an appointed official that investigates, reports, and helps settle complaints), and to CDPH. DSD indicated the importance of reporting to the investigative agencies is so the agencies can come and do a thorough investigation of the allegation. During a concurrent interview and record review with Registered Nurse 1 (RN 1) on 12/12/2024 at 3:40 p.m., Resident 1's Nursing Progress Notes dated 11/25/2024 at 6:54 p.m. were reviewed. The progress notes indicated Resident 1 alleged being hit by staff (name not indicated) two times on the jaw. The progress notes indicated that the Abuse coordinator was informed of the allegation of abuse. RN 1 stated that types of abuse include physical abuse. RN 1 stated the importance of reporting allegations of abuse is To investigate it, to ensure safety for the resident. If it is not reported, it can Page 1 of 2 056407 056407 12/12/2024 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0609 happen again, so it needs to be addressed so that it does not happen again. Level of Harm - Minimal harm or potential for actual harm During an interview and record review with the Administrator (ADM) on 12/12/2024 at 4:11 p.m., Resident 1's progress notes dated 11/25/2024 at 6:54 p.m. were reviewed. The progress notes indicated the allegation of abuse and information of the allegation of abuse was provided to the abuse coordinator. The ADM stated not being the abuse coordinator (the [NAME] President of Operations is the abuse coordinator) for the facility. The ADM stated this was the first time hearing about Resident 1's allegation of abuse and was not able to provide the facility's investigation report for the allegation or proof of attempts to contact the outside investigative agencies. Residents Affected - Few During a review of the facility-provided policy and procedure titled, Reporting of Alleged Abuse, Neglect and Involuntary Seclusion, with last revised date of 8/16/2022, indicated, Alleged Violation: Is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated yet and if verified, could be non-compliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of residential property. The policy stated that should any employee of the facility be apprised or witness an allegation of abuse as defined in this policy, the employee is charged with the responsibility of reporting the alleged incident immediately. All Licensed employees are considered Mandated Reporters; however, the facility requires that all employees report such information. A thorough investigation will be conducted to ascertain all the events that allegedly occurred. A final written report will be submitted to Department of Health Services within 5 business days. The investigation will be timely and will be given priority. Any authorities that need to be contacted; e.g., Police Department, Ombudsman will be contacted within 24 hours. The Department of Health will be contacted within 2 hours of the initial report. This notification will be the responsibility of the [NAME] President of Operations (Abuse Coordinator), the Administrator, or Director of Nursing/Assistant Director of Nursing. 056407 Page 2 of 2