Health inspection·October 2, 2024

The following reflects the findings of the California department of Public Health during the investigation of a complaint numbers 912878, 913395 and facility reported incident # 919622. Health & Safety Code §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 8/30/24, an announced visit was conducted at the facility to investigate a complaint regarding alleged abuse towards one long-term care resident (Resident 1). Resident 3 was a 56 year-old female admitted to the facility on 8/19/21, with diagnoses including hemiplegia (muscle weakness or partial paralysis [unable to move body] on one side of the body that can affect the arms, legs, and facial muscles]) and hemiparesis (one-sided muscle weakness) following cerebral infraction (occurs as a result of disrupted blood flow to the brain and you may become paralyzed on one side of the body, or lose control of certain muscles) affecting left non-dominant (ruling or governing) side, seizure disorder, and dependence on supplemental oxygen. Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, "Abuse Reporting," for one of three sampled residents (Resident 3). This failure resulted in a delay in reporting and had the potential to place all residents at risk for abuse. Findings: During a review of Resident 3's "Resident Grievance/Complaint Investigation Report," (RGCIP) dated 8/29/24, the RGCIP indicated, "On August 29, 2024 (Resident 3) informed State during an interview that CNA (Certified Nursing Assistant 1) pulled a handful of her pubic hairs . . . Began investigation and (CNA 1) suspended pending investigation." During an interview on 9/5/24 at 12:29 p.m. with Regional Quality Assurances Consultant (RQAC), RQAC confirmed Resident 3's allegations were not reported timely to California Department of Public Health. RQAC stated the facility should report according to the State and Federal regulations. During a review of the facility's P&P titled, "Abuse Reporting," revised 1/8/14, the P&P indicated, "To ensure compliance with federal and state laws, and regulations regarding reporting of incidents and suspected incidents of abuse, neglect and mistreatment of resident. . . Reporting Requirements A. The facility will report known or suspected instances of physical abuse to the proper authorities by telephone or through a confidential internet reporting tools required by state and federal regulations. . . ii. If the reportable event does not result in serious bodily injury, the Administrator, or his/her designee, will make a telephone report to the local law enforcement agency within twenty-four (24) hours of the observation, knowledge, or suspicion of physical abuse. In addition, a written report shall be made to the local Ombudsman, the California Department of Public Health, and local law enforcement agency within twenty-four (24) hours of the observation, knowledge, or suspicion of physical abuse." The facility failed to ensure suspicion/allegation of physical abuse was reported timely. This failure resulted in violation of health and safety code and had a direct or immediate relationship to the health, safety, or security of Resident 3 and constitutes a class "B" citation.