Health inspection·August 9, 2024

The following reflects the findings of the California Department of Public Health during the investigation of Complaint number 899012. The inspection was limited to the specific Complaint 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 #899012 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 family member made staff aware of the allegation of abuse, in a timely manner, and adhere to the Health & Safety Code 1418.91 (a) (b). On 5/16/24, an unannounced visit was conducted at the facility to investigate a complaint regarding an alleged abuse towards one long-term care resident. Resident 1 is a 89-year-old female who was admitted to the facility on 12/4/21 with diagnoses of Alzheimer's (a progressive disease that destroys memory and other important mental functions) disease, unspecified, depression, unspecified, and anxiety disorder, unspecified. Based on interview and record review, the facility failed to report an allegation of abuse for one of three sampled residents (Resident 1) when a Family Member (FM) 1 made Licensed Vocational Nurse (LVN) 1 aware of the allegation of abuse. This failure had the potential for delayed investigation and place other residents at risk for abuse. Findings: During an interview on 5/16/24 at 8:40 a.m. with FM 1, FM 1 stated over the weekend (approximately 4-5 days earlier), she reported to Licensed Vocational Nurse (LVN) 1 every time a male staff (unidentified) walked by Resident 1 would say he hits me. During an interview on 5/16/24 at 11:56 a.m. with LVN 1, LVN 1 stated "When there is an allegation of abuse the allegation was to be reported (to the management) right away." During an interview on 5/16/24 at 1 p.m. with LVN 1, LVN 1 stated approximately two weeks ago, Resident 1's FM had reported to her Resident 1 seemed upset when a male staff would work with her. Resident 1 would say the male staff would hit her. LVN 1 stated she did not report the allegation. During an interview on 5/16/24 at 1:08 p.m. with LVN 2, LVN 2 stated when an allegation of abuse was reported, an SOC 341 (form used to report suspected dependent adult/elder abuse) was to be completed, social services, the police department, California Department of Public Health (CDPH) and the Ombudsman were to be notified immediately or as soon as possible. During an interview on 5/16/24 at 1:16 p.m. with Director of Nursing (DON), DON stated there was no allegations of abuse reported recently. DON stated when an allegation of abuse was made, the staff were expected to complete an SOC 341 right away and an abuse investigation was to be initiated. During an interview on 5/16/24 at 1:35 p.m. with Social Service Director (SSD), SSD stated she was not made aware of any allegation of abuse. During a concurrent interview and record review on 6/5/24 at 4:33 p.m. with DON, the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" dated 9/22, the P&P indicated, "All reports of resident abuse. . .are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. . .If resident abuse. . .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. . ." DON stated the staff member should have followed the facility policy and procedure and reported the allegation of abuse. 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 1 and constitutes to a B citation.