Other·September 4, 2024

The following reflects the findings of the California Department of Public Health during the investigation of Complaint number 903447. 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 #903447 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) (b). On 6/6/24, an unannounced visit was conducted at the facility to investigate a complaint regarding an alleged abuse towards one long-term care resident. Resident 4 is a 81-year-old male who was admitted to the facility on 1/26/24 with diagnoses of Parkinsonism (a disorder of the central nervous system that affects movement, often including tremors), Unspecified Dementia (group of conditions characterized by impairment of at least two brain functions), unspecified severity, without behavioral disturbance. . ." Resident 5 is a 58-year-old female who was admitted to the facility on 9/8/22 with diagnoses of End Stage Renal Disease (condition in which the kidneys lose the ability to remove waste and balance fluids) . . .epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures. . ." Based on interview and record review, the facility failed to ensure the abuse policy was implemented for two of five sampled residents (Resident 4 and Resident 5) when an abuse allegation was not reported to the management by a staff member (Licensed Vocational Nurse - LVN 1). This failure had the potential for delayed investigation and place other residents at risk for abuse. Findings: During an interview on 6/5/24 at 12:14 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated on 5/30/24, Resident 1 reported (to LVN 1) Resident 4 and Resident 5 were afraid of Certified Nursing Assistant (CNA) 2 because she (CNA 2) had hit or yelled at Resident 4, and she was loud or mean to Resident 5. LVN 1 stated when Resident 1 reported the allegations she did not report it to the management because Resident 1 stated she already reported the allegations to the Director of Nursing (DON). LVN 1 stated she would talk to the DON about the allegations when she returned to work on 6/5/24 (6 days later). LVN 1 stated she should have reported the allegations to the management. During an interview on 6/5/24 at 12:48 p.m. with the Assistant Director of Nursing (ADON), the ADON stated when there was an allegation of abuse reported to a staff member the staff member was expected to report the allegation right away. During an interview on 6/12/24 at 12:23 p.m. with Administrator, Administrator stated when there was an allegation of abuse the staff was expected to ensure the safety of the resident and report the allegation (to management). During a review of the facility's policy and procedure (P&P) titled "Abuse, Neglect and Exploitation" dated 2023, the P&P indicated, "Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes. . .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." This violation has a direct relationship to the health, safety, or security of the resident, and therefore constitutes a Class "B" Citation.