Health inspection·March 5, 2025

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident number 938496. The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. A deficiency was written for Facility Reported Incident #938496 at F-tag 607/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. (b) A failure to comply with the requirements of this section shall be a class "B" violation On 1/8/25, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Resident 1's allegation of abuse against staff. Based on interview and record review, the facility failed to implement their policy and procedure for abuse for one of three sampled residents (Resident 1) when an allegation of abuse was not reported within twenty-four hours to the California Department of Public Health (CDPH). Findings: Patient 1 is a 61 year old male, who was admitted at the facility on 7/13/23. Resident 1's admitting diagnoses included acute/chronic respiratory failure (a serious condition when the lungs cannot get enough oxygen into the blood), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS- an assessment tool) under the section "BIMS (Brief Interview for Mental Status - an assessment of cognition [mental processes including perception, memory, and thought])," dated 10/10/24, the BIMS indicated, Resident 1 had a score of 15 (cognition intact). During an interview on 1/8/25 at 12:09 p.m. with Department Manager (DM), DM stated on 12/30/24 a care conference (a meeting to discuss a resident's plan of care) with Resident 1's family Member (FM 1) was conducted. DM stated during the care conference FM 1 stated Resident 1 had made an allegation of abuse regarding a staff taking away his call light (no name or specific date given). DM stated Resident 1 is unable to speak (uses a communication board [a visual tool with pictures, symbols and words that a person can indicate what they are saying by using their head in a yes or no manner] to indicate needs) or move and is dependent on staff for all aspects of care. DM 1 stated Resident 1 uses the call light by applying pressure with his head to call staff for assistance. During a concurrent interview and record review on 1/8/25 at 12:12 p.m. with DM, Resident 1's "ABUSE REPORTING PACKAGE (ARP)," dated 1/3/25 was reviewed. The ARP indicated, "All suspected cases must be reported within . . . 24HOURS." The ARP indicated Resident 1 made an allegation of abuse regarding neglect (the act of not giving enough care or attention to someone or something). The ARP indicated a report to CDPH about the allegation of abuse was not made until 1/3/25 at 2:06 p.m. DM stated the facility had not followed their policy and procedure regarding reporting abuse. DM stated, "We (facility) needed to report (allegation of abuse) within twenty four hours." In violation of the above cited standards, the facility failed to implement their policy and procedure for abuse for one of three sampled residents (Resident 1) when an allegation of abuse was not reported within twenty-four hours to the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents and constitutes a class "B" citation. `