Health inspection·October 18, 2024

The following reflects the findings of the California Department of Public Health during the investigation of: Complaint #: 913243 Event ID: 8H3Y11 Representing the Department, HFEN #49330 State Citation B §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph § 483.95. (4) Establish coordination with the QAPI program required under § 483.75 (5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual's obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. (ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. (iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act. §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. HSC 1418.91. (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident 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. On 8/15/24 at 9:50 A.M., an unannounced visit was conducted at the facility to investigate a complaint regarding Resident 1's facial bruise. The facility failed to initiate their abuse policy and procedure related to an injury of unknown origin and placed Resident 1 at risk for further abuse. This failure also placed other residents at risk for abuse and delayed the abuse investigation process. A review of the Facility's undated reference document titled Injuries of Unknown Origin indicated, "Bruises were more likely to indicate abuse when found in the following areas: Head/neck...Abusive bruising was often found on more than one plane of the body...both the inner and outer sides of the arm..." Policy & Procedure titled Abuse & Criminal Activity Identification, Screening, Prevention, Response, Reporting and Investigating, dated 3/15/24, indicated, "all (facility) employees and other "workers" will comply with mandated reporting requirements..." and "...it is the policy of (the facility) to assure that every staff member and contractor fully understands their responsibility, as mandated reporters under California law, 42 CFR 483.12...." Resident 1's record was reviewed. The Record of Admission indicated Resident 1 was admitted to the facility on 2/21/24 with diagnoses which included Alzheimer's disease (a disease which destroys memory and other important mental functions), vascular dementia with behavioral disturbance (a disorder that causes problems with personality and behavior), and hearing loss. According to Resident 1's MDS (an assessment tool), her BIMS (used to assess cognition) indicated Resident 1 was rarely or never understood. On 8/15/24 at 10:32 A.M., a joint observation and interview was conducted in Resident 1's bedroom. Resident 1 was observed laying on her back in bed. Resident 1 had dark purple discoloration surrounding her right eye. Certified Nursing Assistant (CNA) 1 stated staff thought Resident 1 had a fall, which created the facial bruise, but nobody witnessed it. CNA 1 stated Resident 1 always wore her hair down and a large hat which covered her face. Resident 1 was wearing a black baseball cap, and her hair was down and there was bruising on her face visible from the doorway. CNA 1 was sitting in a chair at Resident 1's bedside. CNA 1 stated she was assigned to stay with Resident 1 and was doing "supervision with assistance..." which meant always being with Resident 1. CNA 1 stated she is unsure how Resident 1 sustained the injury. CNA 1 stated "...it's hard to take care of her..." and Resident 1 is hard of hearing. CNA 1 stated Resident 1 had aggressive behaviors. "She doesn't understand that we are only trying to help...[Resident 1] she walks facing down and won't let you touch her (Resident 1) and will push you or punch you..." On 8/15/24 at 10:56 A.M., Resident 1 was observed waking up. Resident 1 was awake and stated, "done here we are eating." Resident 1 said other words that were unintelligible. On 8/15/24 at 11 A.M., an interview was conducted with Licensed Nurse (LN). LN 1 stated on 8/3/24 around 8:30 A.M., Resident 1 was eating breakfast in the dining room. LN 1 stated CNA 2 noticed the bruise on Resident 1's face, then informed LN 1. LN 1 stated staff were not certain when Resident 1 was injured because it was often difficult to see her face. LN 1 stated Resident 1 always wore her hair down and a large hat which covered her face. LN 1 stated Resident 1 had dementia and was unable to tell staff how she got the bruise. LN 1 stated when staff attempted to remove her hat to provide care, Resident 1 "...gets aggressive and tries to hit staff..." and "...she screams and yells..." LN 1 stated staff also found two dime sized bruises on Resident 1's left forearm. LN 1 stated the cause of the bruises was unknown and stated "...we have possible conclusions, but we really don't know how it happened...it was probably a fall, but we don't know for sure..." LN 1 stated if a resident has an injury with an undetermined cause "we would tell the administrator because it could be abuse." On 8/15/24 at 12:36 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated she considered the bruise to be possible abuse because they could not determine how Resident 1 acquired the bruise. The DSD further stated if you see an injury of unknown origin, it needs to be reported. The DSD stated if an injury of unknown origin is not reported " their safety gets compromised...it's a serious offense... We are supposed to keep them (residents) safe. " The DSD stated the facility did not report the injury and "we did not keep them safe." The DSD stated the Administrator (Admin) was the facility's abuse coordinator. On 8/15/24 at 2:08 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the Interdisciplinary Team (IDT- team consisting of members from different disciplines) concluded, based on Resident 1's history, that the resident had a "...possible fall..." The DON stated Resident 1 is a vulnerable resident with dementia. The DON stated, "...people with dementia are more prone to be victimized...they cannot talk..." The DON stated the "possible fall" was unwitnessed and the resident was not seen on the ground or assisted up from the ground by staff. On 8/15/24 at 2:32 P.M., an interview was conducted with the Administrator (ADM) via telephone. The ADM stated on 8/3/24, Resident 1 was sent to the Emergency Department for evaluation of the bruise. The ADM stated the ombudsman informed the facility that the hospital reported the bruise to the state agency. The ADM stated Resident 1's bruise was not reported to the state agency by the facility. The ADM stated, police were not notified because it was reported by the hospital and "...We did not deem it suspicious in nature for abuse reporting..." In violation of the above cited standards, the facility failed to initiate their abuse policy and procedure related to an injury of unknown origin and placed Resident 1 at risk for further abuse. This failure also placed other residents at risk for abuse and delayed the abuse investigation process.