Other·February 19, 2025

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident 935579. 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: 38993, HFEN A deficiency was written for Complaint #935579 at F-tag/S/S F607/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 12/16/24, 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 4 is a 53-year-old male who was admitted to the facility on 12/30/22 with diagnoses of hemiplegia (a condition that causes weakness or paralysis on one side of the body). . .following cerebral infarction (a type of stroke that occurs when brain tissue dies due to reduced blood flow), need for assistance with personal care. Resident 5 is a 74-year-old male who was admitted to the facility on 11/30/23 with diagnoses of traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain). . .dysphagia (difficulty swallowing), unspecified dementia (group of thinking and social symptoms that interferes with daily functioning). Based on interview and record review, the facility failed to follow their policy and procedure when a resident-to-resident allegation of abuse was not reported to California Department of Public Health (CDPH-state agency) per facility policy and procedure for two of two sampled residents (Resident 4 and Resident 5). This failure resulted in the allegation of abuse not being reported to CDPH timely. Findings: During a review of the "Initial Facility Reported Event" (IFRE), (undated), the IFRE indicated, "Date/Time Reported: 12/16/24 approx. (approximately) 5 p.m. CDPH. . .Obtained knowledge 12/16/24 of incident on 12/14/24 at approx. 5:44 p.m. (approximately 48 hours prior to the abuse being reported) . . .Type of Incident. . . resident-to-resident physical contact. . .An incident of resident-to-resident mistreatment occurred between (Resident 5) and (Resident 4). Per staff witness, both residents were initially arguing when (Resident 4) kicked (Resident 5)." During a review of Resident 4's "Minimum Data Set" (MDS-resident assessment tool) dated 12/8/24, the MDS indicated, "Brief Interview for Mental Status (BIMS). . .12 (moderately impaired cognitively). During a review of Resident 5's "Minimum Data Set" (MDS-resident assessment tool) dated 12/7/24, the MDS indicated, "Brief Interview for Mental Status (BIMS). . . 03 (severe cognitive impairment). During an interview on 12/16/24 at 4:22 p.m. with Administrator (prior to the facility reporting the incident), Administrator stated he was not aware of the resident-to-resident (Resident 4 and Resident 5) altercation on 12/14/24, but it should have been reported to CDPH. During an interview on 12/30/24 at 2:28 p.m. with Social Services Director (SSD), SSD stated when the resident-to-resident (Resident 4 and Resident 5) altercation occurred, the staff should have notified the abuse coordinator right away and it should have been reported to CDPH per facility policy. During a review of the facility's policy and procedure (P&P) titled "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" 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. . . within two hours of an allegation involving abuse or result in serious bodily injury. . ." In violation of Health & Safety Code 1418.91 (a), the department determined that the facility failed to report an allegation of abuse to the CDPH. The above violations caused or occurred under circumstances likely to cause significant anxiety, or other emotional trauma to Resident 5 and constitutes to a B citation.