Other·January 12, 2023

The following reflects the findings of the California Department of Public Health during the investigation of a complaint 810998 and a facility reported incident # 811880. The inspection was limited to the specific complaint/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: 38993, HFEN A deficiency was written for Complaint #810998 / Facility reported incident #811880 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. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 11/9/22, an unannounced visit was made to the facility to investigate a complaint regarding the potential abuse of Resident 1. Resident 1 is a 62-year-old female who was admitted to the facility on 11/1/2022 with diagnoses that included anxiety disorder, unspecified, major depressive disorder, recurrent, unspecified, post-traumatic stress disorder, chronic. Based on interview and record review, the facility failed to ensure an allegation of abuse for one of three sampled residents (Resident 1) was reported within 24 hours to the Department. This had the potential for all residents to be at risk of abuse due to alleged abuse going unreported. During a concurrent interview and record review, on 11/14/22 at 12:30 PM, with Administrator, Resident 1's "Progress Notes" (PN), dated 11/12/22 at 7:45 AM, was reviewed. The PN indicated, ". . .as resident [Resident 1] was smoking outside resident proceeded to call 911 emergency services, resident [Resident 1] claimed that she was being abused by staff and needed law enforcement." The abuse allegation was not reported to the administrator or other officials according to state law. Administrator confirmed the finding and stated, the abuse allegation should have been reported immediately. During an interview on 11/30/22, at 9:03 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, "When the police arrived she [Resident 1] said we were abusing her." LVN 1 stated, the abuse allegation was not reported. LVN 1 stated, when an abuse allegation is made it should be reported to the Director of Nursing or the Administrator as soon as possible and therefore no report to the Department. During a review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" dated 9/22, the P&P indicated, "If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. . . "Immediately" is defined as: a. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury." During a review of the Department's intake system, there was no documentation the facility reported the alleged abuse of Resident 1 within 24 hours of the allegation. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1 and constitutes a class "B" citation.