Health inspection·August 9, 2024

The following reflects the findings of the California Department of Public Health during an Abbreviated Standard Survey complaint #902125. The inspection was limited to the specific complaint investigated during an Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the Department: 51042, HFEN One deficiency was written for complaint #902125 at F-Tag 609/D F609 (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) §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 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 June 11, 2024, an unannounced visit was conducted at the facility to investigate a complaint regarding an allegation of abuse. Resident 1 was an 86-year-old female who was admitted to the facility on May 3, 2024, and had a history of Muscle weakness, and Anxiety (fear of the unknown). Based on observation, interview, and record review, the facility failed to follow their policy and procedure titled, "Abuse, Neglect, Exploitation, or Misappropriation-Reporting Investigating" for one of the three sampled residents (Resident 1), when Resident 1 made an allegation of neglect and facility did not investigate and report to the California Department of Public Health (CDPH). This failure had the potential to result in Resident 1 experiencing continued neglect. Findings: During a concurrent observation and interview on 6/11/24 at 1:35 p.m. with Resident 1, in Resident 1's room, Resident 1 was lying in bed. Resident 1 stated the facility was taking a long time to attend to her needs. Resident 1 stated, "I was concerned for my life. I wasn't getting my medication, just let's say this, I asked for help so many times and no one knew where anyone was. I waited for 30 minutes for someone to come and then everyone was mad at me for calling the police." During a review of Residents 1's "Minimum Data Set (MDS-Assessment Tool)," dated May 9, 2024. The MDS indicated, Brief Interview for Mental Status BIMS score of 13 (score of 13-15 means cognitive intact). During a review of Residents 1's "Progress Notes (PN)," dated 5/20/24, the PN indicated, "Resident [1] called the police accusing the facility of not taking care of her, when nurse talked to resident, she stated nobody has taken care of her or given her medicine since 9 a.m. When nurse gave resident her medication at 1945 [10 1/2 hours later] she stated all of a sudden [resident 1's medication was provided after 10 1/2 hours, once the police department was called]." During concurrent interview and record review on 6/11/2024 at 2:20 p.m. with the Director of Nursing (DON), DON stated, "There's no care plan for calling the police or complaints because there was no need since the police found nothing. We did not investigate nor report to you because it wasn't needed." DON reviewed Resident 1's care plan and was unable to find documentation of investigation of allegation of neglect. During a review of the facility's policy and procedure titled "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating" (P&P), dated September 2022, indicated, "Policy Statement: All reports of resident abuse (including injuries of unknown origin), 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. Findings of all investigations are documented and reported. Policy Interpretation and Implementation: 1. 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 to 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: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative: d. Adult protective services (where state law provides jurisdiction in long-term care). 3. "Immediately" is defined as: h. within two hours of an allegation involving abuse or result in serious bodily injury; or i. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents." In violation of the above cited, the facility failed to report alleged abuse and neglect to the Department within 24 hours for one Resident 1. This failure had the potential for alleged abuse to continue with no facility intervention and with the Department being unaware of the alleged abuse. This violation had a direct or immediate relationship to the health, safety, or security of residents and represents a "Class B" Citation.