Other·May 1, 2024

The following reflects the findings of the California Department of Public Health during The Terraces at Los Altos Recertification Survey, Event ID: 1B5X11. Representing the California Department of Public Health: 32398, Health Facilities Evaluator Nurse A Class "B" Citation was written for the following violation: F609 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, 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 not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. From 4/2/24 to 4/9/24, an unannounced visit was conducted at the facility for a recertification survey. The facility failed to ensure an allegation of abuse was reported to the proper agencies per the facility's abuse policy when Resident 23's abuse allegation was not reported after surveyor notified the administrator (ADM) and executive director (ED). This failure left information relevant to an allegation of abuse unreported to agencies required to be reported to for such allegations. Resident 23 was lying in bed when surveyor entered room. Surveyor asked about Resident 23's care in the facility when she stated a nurse on the night shift from last night was rough while she was cleaning Resident 23. Resident 23 further stated she screamed, and the nurse told her to stop screaming. Review of Resident 23's clinical information yielded a face sheet that indicated she was admitted with diagnoses which included atrial flutter (a type of abnormal heart rhythm, or arrhythmia), muscle weakness, and osteoarthritis (joint pain and stiffness). Resident 23's Minimum Data Set (MDS, an assessment tool) indicated she had full mental capacity per her brief interview of mental status, dated 2/29/2024, with a score of 15 (on a scale of 0-15, 15 being full capacity). During an interview with Resident 23 on 4/02/24 at 8:41 AM, in her room, she stated a nurse on night shift was rough when she was cleaning her. Resident 23 stated she screamed, and the nurse told her to stop screaming. She stated it happened last night and did not know the name of the staff. Resident 23 added that it happens maybe once a week. This surveyor notified the ADM and ED, who were both in the ADM's office, of the allegation made by Resident 23. The ADM and ED both acknowledged the information. During an interview with ADM on 4/09/24 at 8:57 AM, she stated the facility did not have any suspicions of abuse with Resident 23, so they did not report the allegation to the Department. A review of the facility's policy and procedure titled "California LPC-Elder Abuse Prevention, Identification, Response, Reporting," revised 10/2023, indicated, "... E. Reporting Abuse, Exploitation, Neglect or Misappropriation. In Life Plan Communities Generally, the timeframe for reporting is to report immediately, but not later than 24 hours after the allegation of alleged violations involving abuse... d. The appropriate community leader makes any required verbal and written report to the local law enforcement and to the Department of Public Health... e. The community leader shall report allegations as dictated by state or local agencies (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures." The facility failed to ensure an allegation of abuse was reported to the proper agencies. This failure left information relevant to an allegation of abuse unreported to agencies required to be reported to for such allegations. The above violation had a direct or immediate relationship to the health, safety, or security of the residents.