Other·January 23, 2023

The following reflects the findings of the California Department of Public Health during the investigation of the complaints of CA00813847 and CA00816052 Event ID: JB9811 Representing the Department: HFEN # 38174 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 11/30/22, an unannounced visit was conducted at the facility to investigate a complaint regarding Resident/Patient/Client Abuse. The facility failed to implement its abuse prohibition policy for Resident 1 when an allegation of sexual abuse was not reported to the California Department of Public Health (CDPH). This failure resulted in potential abuse reoccur and impact the resident's safety and emotion wellbeing. Review of Resident 1's face sheet indicated she was admitted to the facility on 6/7/22 with a diagnosis that includes periprosth fracture (fractures around joint replacement prostheses) around internal prosth (a device that is placed inside a person's body during a procedure to permanently replace a body part) right knee and discharged on 8/10/22. Review of Resident 1 ' s minimum data set (MDS, an assessment tool) dated 6/11/22 indicated she has a Brief Interview for Mental Status (BIMS) score of 14 (a score of 13 - 15 indicates intact cognition). Review of Resident 1 ' s Interdisciplinary Team (IDT, team members from different departments involved in a resident's care) notes dated 6/28/22, indicated Resident 1 stated she had been violated by her assigned aide during morning shift change on 6/27/22. The IDT note indicated that the facility notified the CDPH, Law Enforcement, Ombudsman (Long Term Care Ombudsman, an organization that the representatives assist the long-term care facilities residents for the health and safety issues). Review of the facility ' s investigative report dated 6/28/22, indicated on 6/27/22, assigned CNA A put ointment on Resident 1's private area during the care, Resident 1 felt that CNA A put his hand in her private area two times. Resident 1 felt a "true violation" had occurred. Resident 1 has no diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) or cognition impairments. The facility investigation report indicated "...substantiated sexual abuse upon interview with Resident 1." During a telephone interview with the Ombudsman on 12/5/22 at 8:35 a.m., she stated she received the SOC 341 from the facility and remembered Resident 1 called her to report about the sexual allegation. The Ombudsman stated Resident 1 indicated she (the resident) was "distraught" about what happened to her regarding the sexual abuse allegation. During an interview and concurrent record review with the administrator (ADM) on 11/30/22 at 10:05 a.m., he provided the SOC 341 (State of California Report of Suspected Dependent Adult/Elder Abuse) document dated 6/28/22 which indicated telephone report made to Law enforcement. The ADM stated he knew the SOC 341 was sent to CDPH on same day of 6/28/22 and would provide evidence. The ADM provided the SOC 341 document sent to the Ombudsman but not to CDPH. The ADM stated the reporting was handled by the previous executive director and he was not sure if the investigative report was also sent to CDPH on same time. Review of the Centers for Medicare & Medicare Services (CMS) complaint/Incidents tracking system (the complaints and incidents report to CDPH, CDPH is the agency for CMS to investigate these complaints/incidents) on 12/1/22, indicated there was no report that the facility reported to CDPH about Resident 1 ' s sexual abuse allegation. Review of the facility ' s policy, "Elder Abuse Prevention, Identification, Response, Reporting," dated 11/28/16, indicated "The appropriate community leader makes any required verbal and written report to the local enforcement and to the Department of Public Health, generally the time frame for reporting is to report immediately, but not later than 24 hours after the allegation of alleged violations involving abuse." In violation of the above cited standards, the facility failed to implement its abuse prohibition policy for Resident 1 when an allegation of sexual abuse was not reported to the CDPH. This failure resulted in potential abuse reoccur and impact the resident's safety and emotion wellbeing. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.