Health inspection·December 11, 2024

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident (FRI) number 920313. The inspection was limited to the specific FRIs investigated and does not represent the findings of a full inspection of the facility. Representing the Department: HFEN #37697 A deficiency was written for FRI # 920313 at F-tag 609/D. 42 Code of Federal Regulations part 483.12(b) §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual's obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. §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 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. Based on interview and record review, the facility failed to report allegations of abuse to the Department within 24 hours for two of two sampled residents (Resident 1, Resident 2). This resulted in the Department being unaware of the incident and had the potential for the abuse to continue. Findings: On 9/12/24, an unannounced visit was conducted at the facility to investigate a complaint regarding an allegation of abuse. Resident 1 was a 72-year-old male who was admitted to the facility on 9/21/23 and had a history of muscle weakness, unsteadiness on feet and disorientation (a mental state marked by confusion about person, place or time). Resident 2 was an 86-year-old male admitted to the facility on 1/13/24 with a history of dysphagia (difficulty swallowing), muscle weakness, difficulty in walking and repeated falls. During an interview on 9/12/24 at 2:51 p.m. with Social Services Assistant (SSA), SSA stated on 8/19/24, Resident 1 informed the staff he had a physical altercation with Resident 2. SSA stated her and Social Services Director (SSD) checked the facility security cameras and found no evidence Resident 1 and Resident 2 had a physical altercation. SSA stated the allegation of physical abuse between Resident 1 and Resident 2 was not reported to the California Department of Public Health (CDPH) because SSD stated they could not find evidence the physical altercation occurred. SSA stated the allegation should have been reported, "Any allegation is reportable to CDPH whether true or false." During a review of Resident 2's "Progress Notes (PN)," dated 8/19/24, the PN indicated, "(Social Services) Staff investigated accusations between two residents (Resident 1 and Resident 2) about alleged physical altercation between them, immediate investigation proved that it is unfounded for abuse or suspected abuse. . ." 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 8/12/24, the BIMS indicated, Resident 1 had a score of 13 (cognitively intact). During an interview on 9/16/24 at 12:15 p.m. with Resident 1, Resident 1 stated, "(Resident 2) is crazy. Every time (Resident 2) see me, he wants to hit me." Resident 1 stated the last encounter (could not recall date) he had with Resident 2, Resident 2 tried to hit him, and Resident 1 had placed his hand on Resident 2's chest to keep him away. Resident 1 stated Resident 2 fell to the floor when he (Resident 1) placed his hand on Resident 2's chest to prevent him from striking him. Resident 1 stated he talked to SSD about his issues with Resident 2 and SSD told him if the incidents continued, one of them would have to leave the facility. Resident 1 stated he spoke with both SSA and SSD approximately one month ago about Resident 2's attempt to strike him and the fall incident. During an interview on 9/16/24 at 12:33 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 2 was fixated on Resident 1. CNA 1 stated the facility staff must keep Resident 1 and Resident 2 separated and redirect them away from each other. During an interview on 9/18/24 at 11:13 p.m. with Activities Assistant (AA), AA stated she was aware Resident 1 and Resident 2 had multiple altercations but was not sure of specific times or dates. AA stated approximately one month ago, Resident 2 had to be redirected away from Resident 1 during church due to Resident 2 verbalizing wanting to hit Resident 1. AA stated Resident 1 pushed Resident 2 causing a fall or Resident 2 fell on the floor after an altercation with Resident 1. AA stated approximately two and a half weeks ago Resident 1 was sitting by a window in which she observed Resident 2 heading towards Resident 1 to strike him. AA stated she intervened and redirected Resident 2 before he was able to strike Resident 1. AA stated she reported this incident to SSA. During an interview on 9/18/24 at 11:39 a.m. with Director of Nursing (DON), DON stated she spoke to Resident 2's CNA (not identified) after his fall incident approximately one month ago and had noted Resident 2 later that evening was trying to strike Resident 1 with a spoon. During a review of Resident 1 and Resident 2's Electronic Medical Record (EMR), dated 1/2024 to 9/2024, the EMR indicated, no documentation of physical altercations noted between Resident 1 and Resident 2. During a review of the facility's job description titled, "Director of Social Services," undated, the P&P indicated, "The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of our facility's Social Services Department in accordance with current federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. . . As Director of Social Services, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. . . Accurately document and investigate all reports of abuse according to the Abuse Prevention Policies and Procedures. Ensure the safety of residents at all times. Notify the DON and Administrator immediately of suspected abuse. . ." During a review of the facility's policy and procedure (P&P) titled, "ABUSE PREVENTION PROGRAM," dated 7/22/21, the P&P indicated, "All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to the Ombudsman or law enforcement and CDPH as required by law and in accordance with this policy. . . Should an alleged/suspected violation or substantiated incident of mistreatment, neglect, injuries of unknown source be reported (in which abuse is suspected), the Nursing Supervisor or the Supervisor of the witness shall be responsible for completing an SOC 341 and reporting to the appropriate agency. . ." In violation of the above cited, the facility failed to report alleged abuse to the Department within 24 hours for two residents. 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 the resident and represents a Class B citation.