Health inspection·May 24, 2023

Health & Safety Code §1418.91(a)(b) (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 3/24/23, an unannounced visit was conducted at the facility to investigate a Facility Reported Incident regarding alleged abuse towards one long-term care resident (Resident 1). Resident 1 was a 52-year-old male, admitted to the facility on 2/10/23. Resident 1's diagnoses included cerebral infarction (blood flow to the brain is blocked off causing damage to brain tissue), Parkinson's disease (a brain disorder causing uncontrollable movements of the body), Dysphagia (difficulty swallowing), Aphasia (unable to communicate), need for assistance with personal care, Bipolar disorder (mental illness that causes unusual shift in a person's mood), Anxiety disorder (excessive worry about activities or events), Acute Kidney failure (kidney's suddenly stop working properly), Gastrostomy status (G-tube, a tube inserted into the stomach through the abdomen to deliver nutrition). Based on interview and record review, the facility failed to report an allegation of abuse within two hours to the California Department of Public Health (CDPH) for one of three sampled residents (Resident 1). This failure resulted in delayed investigation of the suspected abuse and potential for continued abuse towards Resident 1. Findings: During a review of the facility's "Final Analysis," dated 3/14/23, the Final Analysis indicated, "CNA 2 [Certified Nurse Assistant] she witnessed the alleged physical abuse performed by CNA 1 towards a Resident [1] on 3/7/23 after resident's [1] shower." During an interview on 3/24/23, at 11:05 AM, with Speech Therapist (ST), ST stated, CNA 2 stated, she witnessed the suspected abuse of CNA 1 towards Resident 1 in Resident 1's room on 3/7/23. ST stated, CNA 2 reported the alleged abuse incident on 3/10/23 (three days later), at approximately 3 PM. During an interview on 3/24/23, at 11:54 AM, with Administrator, Administrator stated, CNA 2 is currently on suspension for the delayed reporting of the suspected abuse. Administrator stated, the alleged abuse incident occurred on 3/7/23 but CNA 2 reported the alleged abuse incident to ST on 3/10/23 (three days later). Administrator stated, the facility reported the alleged abuse incident to the CDPH on 3/10/23 (three days later from the alleged abuse incident). During an interview on 3/29/23, at 10:02 AM, with CNA 2, CNA 2 stated, she witnessed the alleged abuse by CNA 1 towards Resident 1 which took place on 3/7/23 in Resident 1's room. CNA 2 stated, she assisted CNA 1 to transfer Resident 1 to the bed from the shower chair. CNA 2 stated, she observed Resident 1 urinated on the floor and CNA 1 started calling Resident 1 with bad names in Spanish. CNA 2 stated, [CNA 1] grabbed Resident 1's penis and balls, and then squeezed them. CNA 2 stated, she asked CNA 1 to stop, and CNA 1 "roughly threw" Resident 1 to the bed. CNA 2 stated, "As I left the room, I heard the resident [1] moan." CNA 2 stated, she did not report the alleged abuse incident until 3/10/23 (three days later) and stated, she should have reported the suspected abuse immediately. During a review of Resident 1's "Minimum Data Set" (MDS - assessment tool), dated 3/6/23, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS) score was 0 (a score of 0 suggests resident is severely cognitively impaired). Resident 1's MDS Section G (Functional Status), dated 3/6/23 was reviewed. The MDS indicated, Resident 1 required extensive assistance (full staff support) with one to two persons physical assist with Activities of Daily Living (ADL's - including but not limited to Transfer, Dressing, Eating, Toilet use, and Bathing). During a review of the facility's policy and procedure (P&P) titled, "Abuse - Reporting & Investigations", dated 3/2018, the P&P indicated, "Procedure I. Administrator as Abuse Prevention Coordinator A. Allegations of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime to be reported to the Administrator or designated representative immediately. V. Notification of Outside Agencies of Allegation of Abuse with No Serious Bodily Injury. A. The Administrator or designated representative will notify within two (2) hours notify, by telephone, CDPH, the Ombudsman and Law Enforcement. B. The Administrator or designated representative will send a written SOC341 report to the Ombudsman and Law Enforcement and CDPH Licensing and Certification within two (2) hours." In violation of the above cited, the facility failed to report an abuse allegation timely to the CDPH. This failure resulted in a delay of the investigation and potential for continued abuse towards Resident 1. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1 and constitutes a class "B" citation.