Health inspection·March 21, 2025

Health and Safety Code - §1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a Patient 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 facility staff failed to report an incident of alleged abuse within the required time frame as indicated by state law. This violated state law and had the potential to put Patient 1's health, safety, and security at risk. On 2/21/25 at 10:35 A.M., an unannounced visit was conducted at the facility to investigate an abuse allegation involving Patient 1, and certified nursing assistant (CNA 1). According to the facility's Admission Record, Patient 1 was admitted to the facility on 10/2/24, with diagnoses which included dementia (progressive memory loss), with agitation. On 2/21/25, Patient 1's clinical record was reviewed. According to the Minimum Data Set, (MDS-a clinical assessment tool), Patient 1 had a cognitive score of 9, indicating cognition was moderately impaired. According to the Functional Abilities section, Patient 1 could ambulate without any assistive devices. According to the facilities SBAR (Situation-Background-Assessment-Recommendation- a communication tool between staff to alert them of a change in condition), Communication Form, dated 1/31/25 at 10 A.M., "Patient (Patient 1) sustained a skin tear to right lateral heel when being assisted in room by (CNA 1) ...Excused (CNA 1) from providing care for patient at this time until further investigation. Supervisor (LN 3), notified." An interview and document review were conducted with the Director of Staff Development (DSD) on 2/21/25 at 11:45 A.M. The DSD stated CNA 4 informed him about the incident between Resident 1 and CNA 1 the morning of on 1/31/25. The DSD stated he received a text message from license nurse (LN) 1 on 1/31/25 regarding the incident. A review of LN 1's printed text message, dated 1/31/25, provided by the DSD, indicated, "At approximate 0430 am...CNA 1 hooked his right arm under pt (patient) left arm and escorted him to his room...Pt was yelling and cussing stating you are hurting me...loud commotion and pt yelling that his foot was hurt. This nurse intervened...a deep horseshoe shaped laceration (cut) to right lateral heel...Sorry. Hooked right arm under pt right arm...I instructed (CNA 1) to be nicer to the patient... as his approach was aggressive before he made it in the bedroom..." The DSD stated that he interpreted the incident as an accident and not an allegation of abuse. An interview was conducted with the Social Services Director (SSD) on 2/21/25 at 11:56 A.M. The SSD stated she was not informed of the incident that involved Resident 1 and CNA 1. An interview was conducted with the Assistant Director of Nursing 1 (ADON 1) on 2/21/25 at 11:57 A.M. The ADON stated she was not informed of an abuse allegation involving Patient 1 and CNA 1. An Interview was conducted with the DON on 2/21/25 at 12:35 P.M. The DON stated he checked with Administrator (ADM), the facility's Abuse Coordinator to see if he was aware of the incident that involved Patient 1 and CNA 1. The DON stated the incident was never reported as an allegation of abuse. The DON stated any abuse allegation needed to be reported to the Abuse Coordinator and needed to be thoroughly investigated. The DON stated the allegation was never elevated up to the department heads, and it should have been reported and investigated. The DON stated the ball was dropped and all residents were at risk for potential harm and abuse. A follow-up interview was conducted with the DSD on 2/21/25 at 1:13 P.M. The DSD stated he could not recall the entire conversation with CNA 4 and LN 1, and he could not recall if the word, "abuse" was mentioned or not. The DSD stated he did not hear any more about the incident that day (1/31/25) and he assumed someone else was handling it. The DSD stated the ball was dropped by several staff members and the event should have been investigated to clarified as to what really happened. An interview was conducted with LN 3 on 2/21/25 at 1:34 P.M. LN 3 stated she was the charge nurse on the night shift 1/31/25. LN 3 stated LN 1 notified her that CNA 1 was sent home that night. LN 3 stated she did not know why LN 1 sent CNA 1 home. LN 3 stated she was only told about the injury on Patient 1's heel. LN 3 stated she instructed LN 1 to document what occurred and to let other staff know what happened, and to also inform the DSD. LN 3 stated she did not follow-up to ensure the DSD was notified and that the incident had been documented. An interview was conducted with CNA 3 on 2/25/25 at 8:02 A.M. CNA 3 stated she was working in the secured unit on the 1/31/25. CNA 3 stated she heard CNA 1 trying to redirect Patient 1 back to his room. CNA 3 stated she could hear CNA 1 telling Patient 1 to sit down on his bed, and Patient 1 was yelling stop. CNA 3 stated she did not hear a crash or any other commotion inside Patient 1's room. The next thing CNA 3 heard was CNA 1 asking LN 1 to check on Patient 1's foot, because it was bleeding. An interview was conducted with LN 4 on 2/25/25 at 8:13 A.M. LN 4 stated on 1/31/25 early morning, she was sitting with LN 1 in the nursing station. LN 4 stated she saw Patient 1 walked around the hallway. LN 4 stated CNA 1 then approached Patient 1 redirected the patient back to his room. LN 4 stated CNA 1 grabbed Patient 1 and walked him back to his room, while Patient 1 was resisting the redirection. LN 4 stated she next heard a loud noise, so she turned around and saw Patient 1 sitting on his bed. LN 4 stated CNA 1 came out of the room minutes later and asked LN 1 to look at the patient because he noticed blood on the floor of the patient's room. LN 4 stated a few minutes later, she heard LN 1 say to CNA 1, "Step away, you just abused this patient'." LN 4 heard CNA 1 replied, "No I didn't." LN 4 stated CNA 1 looked confused and LN 1 ordered CNA 1 to leave the unit immediately. An interview was conducted with CNA 1 on 2/25/25 at 9:08 A.M. CNA 1 stated Patient 1 came out of his room and was next to the medication cart. CNA 1 stated Patient 1 started to fondle himself and then he was touching the medication cart. CNA 1 stated both LN 4 and LN 1 were sitting at the nurse's desk, opposite of the medication cart. CNA 1 stated he put his left hand on Patient 1's mid-section and started to walk the patient back towards his room. CNA 1 stated once in the room, it was a tight area trying to maneuver the patient past the main door and the bathroom door. CNA 1 stated he slipped but caught himself before falling and the bathroom door slammed shut. CNA 1 stated once the bathroom door slammed, he believed Patient 1 got startled, because the patient started to yell, "Help, help." CNA 1 stated he directed Patient 1 on his bed and then noticed blood on the floor. A following up interview was conducted with LN 1 on 2/25/25 at 2:05 P.M. LN 1 stated she documented in the nursing note and also nursing text message that there was a possible abuse by CNA 1 against Patient 1. LN 1 stated prior to the text message she telephoned the DSD and informed him of a possible staff to patient abuse. LN 1 stated she kept waiting for someone from the facility to contact her as part of the facility's investigation. LN 1 stated no one ever did so she notified the Department of Public Health. LN 1 stated she felt CNA 1 was rough and impatient with the Patient, which resulted in Patient 1's injury. LN 1 stated as a mandated reported and she felt by documenting the event and informing the DSD, the incident would be investigated and reported. According to the facility's policy, titled Abuse, Neglect, Exploration or Misappropriation-Reporting and Investigating, dated 2001, "1. If resident abuse...is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or individual making the allegation immediately reports to his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying licensing the facility; ...3. Immediately is defined as: within two hours of an allegation involving abuse..." The facility failed to report the allegation of staff to patient abuse to the California Department of Public Heath, as required by State law. The DSD, LN 3, and other staff members present on 1/31/25, never elevated the allegation of abuse to the facility's Abuse Coordinator. This violated state law and had the potential to put Patient 1's health, safety, and security at risk. The above violations either jointly, separately, or in any combination had a direct or immediate relationship to health, safety, or security of patients.