Health inspection·March 22, 2024

F609 The following reflects the findings of the California Department of Public Health during the investigation of: Entity Reported Incident # CA00885094 Event ID: LDCT11 Representing the Department, HFEN # 44733 State Citation B was written.

F609 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(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. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. On 2/12/2024 at 8:30 a.m., an unannounced visit was conducted at the facility for a recertification survey. The facility failed to follow their abuse policy for one of 24 sampled residents (Resident 52) when staff did not report and investigate Resident 52's allegation of abuse timely. This failure had the potential to compromise Resident 52's safety and delay abuse investigations. Resident 52 was admitted on 1/19/2024 with diagnoses including hemiplegia following cerebral infarction (damage to the brain tissues, also known as a stroke) affecting left nondominated side, mood disorder (a mental health condition), type 2 diabetes (high blood sugar), and chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe). During a review of Resident 52's Minimum Data Set (MDS, an assessment tool) dated 1/22/2024, the MDS indicated she had a brief interview of mental status (BIMS, a structured cognitive test) scoring 03 (severe cognitive impairment). During a review of Resident 52's Nurses Notes dated 1/28/2024 at 2:00 p.m., the note indicated that "around 7:30 a.m., resident went out of her room yelling, 'He raped me, he raped me.' resident was unable to identify any person. resident was more disoriented than baseline, pacing and agitated. when writer asked if someone touched her inappropriately, the resident denied." During a review of Resident 52's Nurses Notes dated from 1/28/2024 to 1/31/2024, the nurses notes indicated Resident 52 was on monitoring for false accusations and mood fluctuation. During a review of Resident 52's clinical record on 2/13/2024, the record revealed there was no care plan developed for the allegation of sexual abuse and no interdisciplinary team (IDT, a group of dedicated healthcare professionals who work together to provide the needed care) note initiated. During an interview and record review on 2/13/2024 at 4:01 p.m. with the Administrator (ADM), she reviewed the nurses notes dated 1/28/2024 and confirmed that there was an allegation of sexual abuse from Resident 52. The ADM stated she was not aware of Resident 52's allegations of abuse on 1/28/2024. The ADM stated she was the facility's abuse coordinator, and the allegation of sexual abuse should have been reported to her on 1/28/2024. During an interview and record review on 2/13/2024 at 4:23 p.m. with the Social Services Director (SSD), she reviewed the nurses notes dated 1/28/2024 and confirmed that there was an allegation of sexual abuse from Resident 52. The SSD stated she was not aware of Resident 52's allegations of abuse on 1/28/2024. The SSD stated the allegation of sexual abuse should have been reported to the facility abuse coordinator on 1/28/2024 and investigated. The SSD also stated the facility should report and investigate an allegation of abuse regardless of the resident's cognitive level. The SSD further stated the allegation should have been reported to the Police Department, California Department of Public Health (CDPH), and Ombudsman (an official who investigates and helps settle complaints) timely. During a review of the facility's policy and procedure (P&P) titled "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," revised 9/2022, the P&P indicated, "All reports of resident abuse, 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 facility management. 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 other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency; the local/state ombudsman; law enforcement officials. 'Immediately' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury." The facility failed to follow their abuse policy for one of 24 sampled residents (Resident 52) when staff did not report and investigate Resident 52's allegation of abuse timely. This failure had the potential to compromise Resident 52's safety and delay abuse investigations. This violation had a direct or immediate relationship to the health, safety or security of patients or residents