Health inspection·February 4, 2022

The following reflects the findings of the California Department of Public Health during the investigation of a facility reported incident 762519. Representing the Department: 38993, HFEN State Citation B was written. 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 12/7/21, an unannounced visit was made to the facility to investigate a facility reported incident regarding the potential abuse of Resident 1. Resident 1 is an 86-year-old female who was admitted to the facility on 5/29/19 with diagnoses that included major depressive disorder and anxiety disorders. Based on interview and record review, the facility failed to ensure staff reported an allegation of sexual abuse timely for one of three sampled residents (Resident 1). This failure resulted in a delay of the investigation. Findings: During a review of the facility's "Report of Suspected Dependent Adult/Elder Abuse" (SOC 341), dated 11/24/21 indicated, "At approximately 1135, [Resident 1] told Certified Nursing Assistant (CNA 1) during patient care that (CNA 2) "cupped" her vagina while changing resident's bed linens in her room. [Resident 1] stated to CNA 1 "to me, that was considered rape. . . [Resident 1] stated that the incident occurred between two weeks or a month ago. [Resident 1] was unsure of the exact date." During an interview on 12/7/21, at 10:20 AM, with Resident 1, Resident 1 stated, approximately two to three months ago, CNA 2 entered her room close to midnight and said the room was filthy and a mess. CNA 2 started yanking off her covers and clothes and then cupped her hand and covered Resident 1's vagina. Resident 1 stated, she told CNA 2 to get out of her room and don't make her yell rape. During an interview on 12/7/21, at 10:55 AM, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, when a resident reported abuse, it was the responsibility of staff to report the allegation to the abuse coordinator, fill out the SOC 341 and remove the staff the allegation was against, to ensure the resident's safety. During an interview on 12/7/21, at 11:15 AM, with LVN 3, LVN 3 stated, when a resident made an allegation of abuse, it was the responsibility of staff to report the allegation to the abuse coordinator within two hours and fill out the SOC 341 within 24 hours. During an interview on 12/8/21, at 5:54 AM, with LVN 1, LVN 1 stated, approximately a month ago CNA 2 reported while providing care to Resident 1, Resident 1 accused her [CNA 2] of getting fresh with her. LVN 1 stated, when CNA 2 told her about the allegation, she documented it in the behavior log but did not report the allegation to anyone. LVN 1 stated, there was no body assessment completed on the resident at the time of the allegation. LVN 1 stated, when there was an allegation of sexual abuse, staff were to fill out an SOC 341 and the Director of Nursing (DON) informed of the allegation. During an interview on 12/8/21, at 6:02 AM, with CNA 2, CNA 2 stated, over a month ago while providing care to Resident 1, Resident 1 accused her of inappropriately touching her private parts. CNA 2 stated, she reported the allegation to LVN 1 right away. During a concurrent interview and record review, on 12/17/21, at 4:13 PM, with DON, Resident 1's behavior logs were reviewed. DON stated the facility was not monitoring Resident 1 for sexual abuse allegations. DON stated, the allegation should have been reported at the time it was made. During a review of the facility's policy and procedure (P&P) titled, "Abuse Prevention Program - Reporting" dated 12/7/16, the P&P indicated, "Any alleged violation involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of property are promptly reported to the Director of Nursing Services or designee and the licensed nurse of resident immediately. B. All employees of [facility name] are mandated reporters. C. The Director of Nursing or designee shall thoroughly investigate all allegations. D. The facility Director of Nursing or designee will take steps to ensure and prevent further potential abuse while investigation is in progress. E. If the accused is an employee of the facility, he/she will be suspended pending investigation at discretion of the facility Director of Nursing or designee until the investigation has been completed or per facility policy. F. The licensed nurse will complete an assessment of the resident or residents involved (victim and perpetrator) and document findings in the medical record and interdisciplinary care plan as indicated. G. A facility incident report regarding the incident will be completed. H. The licensed nurse shall notify the physician of the allegation and resident's legal representative, status of the investigation, and the resident's condition." In violation of the above cited, the facility failed to ensure staff reported an abuse allegation timely. This failure resulted in a delay of the investigation. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents and constitutes a class "B" citation.