Health inspection·December 12, 2023

The following reflects the findings of the California Department of Public Health during an Abbreviated Standard Survey facility reported incident #765566 The inspection was limited to the specific facility reported incident investigated during an Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the Department: 37697, HFEN A deficiency was written for Facility Reported Incident #862904,862905 / Complaint# 861826 at F-Tag 609/D. 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. A failure to comply with the requirements of this section shall be a class "B" violation. Based on interview and record review, the facility failed to implement their policy on abuse for one of three sampled residents (Resident 1) when an allegation of abuse was not reported to the California Department of Public Health (CDPH). This failure had the potential for abuse to continue and for other residents to potentially be abused. Findings: On 9/26/23, an unannounced visit was conducted at the facility to investigate a complaint regarding an allegation of abuse. Resident 1 was a 55-year-old male who was admitted to the facility on 2/11/16 and had a history of paraplegia (inability to move lower half of the body), anxiety, major depression disorder and low back pain. During an interview on 9/26/23 at 1:41 p.m. with Resident 1, Resident 1 stated he had issues with the way the facility Administrator in Training (AIT) had been treating him. Resident 1 stated a recent issue was when the AIT entered his room, removed a bag of items from atop of his closet and threw it on the floor. Resident 1 stated he made an official grievance to the facility regarding the AIT and had met with facility leadership. During a concurrent interview and record review on 9/27/23 at 11:35 a.m. with Social Services Director (SSD), Resident 1's "INTERDISCIPLINARY TEAM CONFERENCE RECORD (IDTCR)," dated 8/30/23 was reviewed. The IDTCR indicated, "Meeting held to discuss concerns of the resident . . . Arrogance for violating the rights and privacy of the residents: Entering without knocking first and doing whatever he [AIT] wants without asking or explaining anything. He [AIT] is affecting the condition of the of the patient [Resident 1] . . . Harassment and bad behavior towards any person - Always watching us. . . Abusing of his position and superiority, violating norms of the state and the facility . . ." SSD stated she and the Director of Nursing were part of the IDTCR on 8/30/23. SSD verbalized Resident 1 did state he felt harassed by the AIT. SSD stated per facility policy and procedure (P&P) when Resident 1 stated he felt harassed it should have been reported to the California Department of Public Health (CDPH) as an allegation. SSD stated a report was not made to CDPH regarding Resident 1's allegation of harassment. During an interview on 9/27/23 at 1:23 p.m. with AIT, AIT stated it is the P&P of the facility to report any allegation of harassment to CDPH. During an interview on 9/27/23 at 1:49 p.m. with Administrator, Administrator stated if a resident accuses a staff member of harassment than the facility abuse P&P is to be followed. Administrator stated he may have reviewed the IDTCR for Resident 1 that was done on 8/30/23 but did not recall what the document stated. During a review of the facility's P&P titled, "EMPLOYEE GUIDE TO ELDER ABUSE REPORTING," undated, the P&P indicated, "The official name of the law is the California Elder Abuse and Dependent Adult Civil Protection Act . . . The Act requires employees of various facilities, including skilled nursing facilities ('SNFs'), to report elder abuse to State agencies if they witness abuse, if they hear about the abuse from a resident or other individual, or if they reasonably suspect for any other reasons that a resident was abused. . . As an employee of a SNF, you must report elder abuse if . . . If a resident tells you that he or she has been abused. . . Elder abuse includes all of the following . . . Any other treatment that causes physical harm, pain or mental suffering to a resident." In violation of the above cited, the facility failed to report alleged abuse and neglect to the Department within 24 hours for 1 Resident 1. This failure had the potential for alleged abuse to continue with no facility intervention and with the Department being unaware of alleged abuse. This violation had a direct or immediate relationship to the health, safety, or security of residents and represents a Class B citation.