Health inspection·March 19, 2025

The following reflects the findings of the California Department of Public Health during the investigation of Facility Reported Incident number 929241. 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: 47444, HFEN A deficiency was written for Facility Reported Incident 929241 at F-tag/S/S F609/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. The facility failed to report an allegation of abuse when a resident made staff aware of the allegation of abuse, in a timely manner, and adhere to the Health & Safety Code 1418.91(a). On 11/7/24, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding an alleged abuse towards one long-term care resident. Resident 1 is a 66 year-old female who was admitted to the facility on 10/2/24 with diagnoses of Unspecified Fracture (broken) of Unspecified Thoracic (upper spine) Vertebra (spine bone), Parkinsonism (a disorder of the central nervous system that affects movement, often including tremors), Epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures), muscle weakness. . ." Based on interview and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH-state agency) for one of three sampled residents (Resident 1). This failure resulted in delayed investigation of the allegation of abuse and potential for continued abuse towards Resident 1. Findings: During a review of Resident 1's "Admission Record (AR), " dated 11/7/24, the AR indicated Resident 1 was admitted to the facility on 10/2/24 with diagnoses including, fracture [broken] of thoracic [upper spine] vertebra [spine bone], muscle weakness and history of falls. During a review of Resident 1's "Minimum Data Set (MDS - assessment tool)," dated 10/8/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS - assessment of cognitive function) score was 15 (a score of 13-15 suggests resident is cognitively intact). During an interview on 11/05/24 at 9:15 a.m. with Resident 1 and Resident 1's Family Member (FM) 1, Resident 1 stated she told her daughter (within the first week of being admitted to the facility) Certified Nursing Assistant (CNA) 1 was rough and rude to her while providing care. FM 1 stated a request was made to Clinical Manager (CM) on 10/30/24 for CNA 1 not be scheduled to care for Resident 1 due to CNA 1's attitude and being rough during care. Resident 1 stated CNA 1 had been assigned to care for Resident 1 after the request was made on 10/30/24. During an interview on 11/07/24 at 10:37 a.m. with CM, CM stated Resident 1's daughter (FM 2) reported to CM on 10/30/24, CNA 1 had an attitude and was rough during care of Resident 1. CM stated Resident 1's daughter requested CNA 1 not be assigned to care for Resident 1. CM stated he did not report Resident 1's concerns or request regarding CNA 1 to the Administrator or other member of the leadership team. During an interview on 11/07/24 at 11:26 a.m. with Resident 1, Resident 1 stated during her first week in the facility, she asked CNA 1 to help her move up in bed. Resident 1 stated CNA 1 grabbed the collar of her gown, got in her face, and yelled "I am not going to hurt myself to move you up." Resident 1 stated she was afraid of CNA 1. During a concurrent interview and record review on 1/17/25 at 12:05 p.m. with Administrator, the facility's "Summary Of Incident (SOI), " dated 11/12/24 was reviewed. The SOI indicated, "10/30/24 - The daughter of [Resident 1], [FM 2], requests CNA, [CNA 1], not be her Mom's CNA due to [CNA 1] being rough when providing care per [CM]. " Administrator stated it was the expectation the staff submitted a grievance report or contacted Administrator, or a member of the leadership team, for resident, family or staff reported care concerns. Administrator stated she was made aware of Resident 1's concerns regarding care provided by CNA 1 on 11/7/24 (eight days later). Administrator stated Resident 1 and FM 2 were interviewed and allegations of abuse by CNA 1 toward Resident 1 were identified and reported to CDPH on 11/7/24 (eight days later). Administrator stated CM needed to report Resident 1's concerns of CNA 1 being rough and rude during care to Administrator or a member of leadership on 10/30/24 to help protect Resident 1 from potential continued abuse. During a review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect & Exploitation Policy, " dated 10/2022 the P&P indicated, "Responsibility: The Administrator has the overall responsibility for the coordination and implementation of the community's abuse, neglect and exploitation policy. . . E. Protection 1. Protection of Resident. Upon learning of alleged abuse, neglect, mistreatment or exploitation, the Administrator or supervisor on duty should attempt to take necessary steps to verify residents are protected from subsequent episodes of abuse, neglect, mistreatment, or exploitation. . . a. If an associate encounters an abusive situation involving a resident, they should attempt to: . . . ii. Follow up with reporting of the incident to the supervisor/manager on duty or Executive Director as soon as possible. . . G. External Reporting 1. Alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property should be reported: a. As soon as practical, 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 b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. c. Such alleged violation shall be reported to: i. The State Survey Agency; and ii. Adult protective services. " This violation has a direct relationship to the health, safety, or security of the resident, and therefore constitutes a Class "B" Citation.