Health inspection·April 16, 2024

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 following reflects the findings of the California department of Public Health during the investigation of a complaint 866219 and facility reported incident 866384. On 10/19/23, an announced visit was conducted at the facility to investigate a complaint regarding alleged abuse towards one long-term care resident (Resident 3). Resident 3 was a 61-year-old female, admitted to the facility on 3/7/23. Resident 3's diagnoses included muscle wasting and atrophy, unspecified psychosis not due to substance or known physiological condition, major depressive disorder, overactive bladder, other abnormalities of gait and mobility (any deviations from normal walking), and chronic pain. Based on observation, interview, and record review, the facility failed to report a suspicion and allegation of abuse for one of 10 residents (Resident 3). These failures resulted in delayed investigation of abuse for Resident 3 and had the potential for Resident 3 to be at risk for further abuse. Findings: During a review of Resident 3's "BIMS (Brief Interview for Mental Status- an assessment tool for cognition)," dated 9/8/23, the BIMS indicated, Resident 3 had a score of 12 (moderate impairment). During a concurrent observation and interview on 10/19/23 at 11:46 a.m. with Resident 3 in Resident 3's room, Resident 3 stated, Certified Nursing Assistant (CNA) 9 had been shouting at her. Resident 3 stated she should have reported (CNA 9's) behavior towards her a long time ago but did not want to get anyone in trouble. Resident 3 stated when she would request assistance with care and (CNA 9) would shout at her, "I don't have time for this." Resident 3 stated approximately a month and a half ago she had requested assistance to use the restroom and CNA 9 had refused to assist her. Resident 3 stated two CNAs (CNA 10, CNA 11) where passing by and witnessed CNA 9 refusing to assist her. Resident 3 stated CNA 10 and CNA 11 assisted her to the restroom. Resident 3 stated CNA 9 came back to Resident 3's room and stated, "You (Resident 3) better figure out a way to call them (CNA 10 and CNA 11) back to get you back up [off the toilet] because I (CNA 9) am not." Resident 3 stated she had reported these issues with the Director of Staff Development (DSD) and with the Activities Assistant (AA). Resident 3 stated she was saddened when she reported it and broke down crying. Resident 3 stated (CNA 9) had been threatening to move her to another area of the facility as well. During the interview Resident 3 was observed to be crying when talking about her interactions with CNA 9. Resident 3 stated Family Member (FM) 1 was involved with her care and had information regarding CNA 9 threatening to move her. During a review of Resident 3's "Functional Status (FS - an assessment tool), dated 9/8/23, the FS indicated, Resident 3 required extensive one person assistance for toileting, eating, dressing, personal hygiene, and bed mobility. The FS indicated Resident 3 required total assistance with bathing. During a review of Resident 5's BIMS, dated 9/12/23, the BIMS indicated, Resident 5 had a score of 12. During an interview on 10/19/23 at 12:15 p.m. with Resident 5, Resident 5 stated he has had issues with the way (CNA 9) had been treating him. Resident 5 stated, "(CNA 9) does not know how to talk to residents." Resident 5 stated (CNA 9) would tell him things such as, "You will stand when I tell you to stand" and "I have other people to care for not just you." Resident 5 stated he reported the treatment he received from (CNA 9) but did not recall who he told. Resident 5 stated, "If I am an isolated case (regarding CNA 9 behavior) then I have no say, but if there are others [Residents] complaining about her (CNA 9) then my concerns should hold water. So, as I said people (person in general) are consistent with their attitude and behaviors and with others complaining [about CNA 9] that should paint a picture on who they are and how comfortable (CNA 9) is on how she acts around us residents." During an interview on 10/19/23 at 1:07 p.m. with AA, AA stated Resident 3 and CNA 9 in the beginning of Resident 3's facility stay were good friends. FM 1 stated that changed over time. AA stated (CNA 9) can get overwhelmed and can come off rough. FM 1 stated Resident 3 had told her she was getting tired of (CNA 9's) attitude toward her. AA stated Resident 3 had told her that (CNA 9) was threatening to move her to another location. AA stated she took Resident 3 to the DSD in regard to her complaints. AA stated she did not report what Resident 3 had told her as an allegation of abuse. During an interview on 10/19/23 at 1:30 p.m. with FM 1, FM 1 stated she had witnessed (CNA 9) told Resident 3 that she did not have time to take her to the restroom. FM 1 stated Resident 3 would then have to hold her urine or lose control and go in her pants. FM 1 stated she had also witnessed (CNA 9) told Resident 3 that if she wanted to get up out of bed she needed to stay up or stay in bed. FM 1 stated she would receive text messages from (CNA 9) stating how Resident 3 was too needy and that if Resident 3 would not calm down than she would have her moved to another location. FM 1 stated she had a fear that Resident 3 would be retaliated against if they reported the issues at first. FM 1 stated she eventually spoke to DSD a week ago about her concerns. FM 1 stated she did tell DSD about (CNA 9) telling Resident 3 about either staying up or staying in bed. FM 1 stated Resident 3 felt intimidated by (CNA 9.) During a review of Resident 3's assessment for "Bowel and Bladder (B&B - an assessment tool)," dated 9/8/23, the B&B indicated, Resident 3 was occasionally incontinent of bladder and always continent of bowel. During an interview on 10/19/23 at 1:48 p.m. with CNA 10, CNA 10 stated approximately one month ago at approximately 6:00 p.m. to 6:30 p.m. she went to visit Resident 3. CNA 10 stated Resident 3 had her call light on to use the restroom. CNA 10 stated she witnessed "(CNA 9) tell (Resident 3) in a rude and unprofessional manner that she would have to wait to use the restroom since she was busy." CNA 10 stated her and (CNA 11) assisted Resident 3 to the toilet since (CNA 9) stated she was too busy. CNA 10 stated (CNA 9) told Resident 3, "Don't even bother calling me, you better call those girls [CNA 10, CNA 11]." CNA 10 stated she provided Resident 3 with her cell number to call her if there was no one to pick her up off the toilet when she was done. CNA 10 stated she and CNA 11 did return to assist Resident 3 off the toilet when she was done. CNA 10 stated her thoughts were, "Why is she (CNA 9) treating [Resident 3] like this." CNA 10 stated Resident 3 had expressed to her she did not like using the call light when CNA 9 was working because of the way she is treated and out of fear of retaliation. CNA 10 stated she did not report the incident as an abuse or as an allegation of abuse. During an interview on 10/19/23 at 2:10 p.m. with Activities Director (AD), AD stated approximately two weeks ago she had met with Resident 3 along with the DSD. AD stated Resident 3 was upset and sad. AD stated Resident 3 requested CNA 9 not provide care to her because they were not getting along. AD stated Resident 3 had told her and DSD that CNA 9 would tell her, "I don't have time for this [in regard to providing care]." AD stated her and DSD consoled Resident 3, hugged her and told her everything would be fine. AD stated the DSD told Resident 3 she would take care of it [situation]. AD stated she did not report what Resident 3 had told her as an allegation of abuse. During an interview on 10/19/23 at 2:17 p.m. with CNA 11, CNA 11 stated approximately one month ago her, and CNA 10 noticed Resident 3's call light was on. CNA 11 stated her, and CNA 10 entered Resident 3's room and observed CNA 9 attending to Resident 3's roommate. CNA 10 stated Resident 3 had loudly stated that she had to use the restroom. CNA 11 stated CNA 9 had stated in a loud annoyed tone, "hey I already told you [Resident 3], you have to wait an hour." CNA 11 stated her and CNA 11 placed Resident 3 on the toilet. CNA 11 stated CNA 9 told Resident 3, "Make sure you get your little friends [CNA 10, CNA 11] number because I'm not getting you off [the toilet]." CNA 11 stated her, and CNA 11 took Resident 3 off the toilet. CNA 11 stated Resident 3 had begun to cry, stated she was scared of CNA 9, and had reported some of the issues to the DSD but nothing had been done. CNA 11 stated she had not reported the incident as an abuse or as an allegation of abuse. During an interview on 10/19/23 at 2:34 p.m. with DSD, DSD stated a few weeks ago she had met with Resident 3 who reported to her CNA 9 was, "treating me different." DSD stated Resident 3 also reported to her that she would hear CNA 9 state that she did not have time. DSD stated she had spoken with FM 1 who stated there were issues between Resident 3 and CNA 9. DSD stated she had heard about CNA 9 texting FM 1 about Resident 3, and it was not appropriate. DSD stated it is not within the authority of a CNA to move residents to other locations or to indicate that they could in response to resident behaviors. DSD stated, "Absolutely not that's exploitation or grounds for termination [in regard to CNAs telling family and residents about moving them]." DSD stated it is not within the authority of a CNA to call resident family members in regard to behaviors or any other resident issues. DSD stated, "I could see that being a threat. CNAs should not be talking about stuff that are not in control [of]. I would see that as a threat that if they don't do this than I [CNAs] won't do that." DSD stated she had not reported what Resident 3 explained to her as an allegation of abuse. During an interview on 10/19/23 at 3:23 p.m. with CNA 9, CNA 9 stated Resident 3 can be very needy. CNA 9 stated she had never had other staff provide care for Resident 3 when she was assigned to her. CNA 9 stated she had never texted FM 1 in regard to Resident 3. CNA 9 stated all the information she had provided was honest and true. During a review of FM 1's Text Messages (TM) dated 6/21/23 at 6:49 p.m., the TM indicated, CNA 9 had texted FM 1 about Resident 3. FM 1 texted CNA 9 that she would speak to Resident 3. CNA 9 responded to FM 1, "I won't move her [Resident 3]." During an interview on 10/19/23 at 3:57 p.m. Director of Nursing (DON), DON stated an allegation of abuse is, "Any allegation of mistreatment neglect, physical, emotional or sexual misconduct." DON stated mistreatment is, "If care is being withheld, meds, talked down for example." During a review of the facility's policy and procedure (P&P) titled, "Abuse and Reporting Orientation," dated 12/2020, the P&P indicated, "'Abuse of an elder or dependent adult ' is defined as the following . . . neglect . . . Isolation, abduction, or other treatment with resulting physical harm or pain or mental suffering . . . deprivation by a custodian of goods or services that are necessary to avoid physical harm or mental suffering. . . Neglect includes, but is not limited to, all of the following . . . Failure to assist in personal hygiene . . . Failure to provide medical care for physical and mental health needs. . . 'Mental Suffering' means fear, agitation, confusion, severe depression or other forms of serious emotional distress that is brought about by threats, harassment or other forms of intimidating behavior." During a review of the facility's job description (JD) titled, "Certified Nursing Assistant," dated 2/2019, the JD indicated, "The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan . . . Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and shift. . . Answer resident calls promptly . . . Check residents routinely to ensure that their personal care needs are being met. . ." During a review of the facility policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," revised September 2022, the P&P indicated, "All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. . . .Reporting Allegations to the Administrator and Authorities 1. If residents, 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 the law. 2. The administrator or individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; . . . 3. "Immediately" is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. In violation of the above cited, the facility failed to ensure staff reported a suspicions of abuse and allegations of abuse timely. This failure resulted in a delay of the investigations and had the potential for Resident 3 to be at risk for further abuse. This violation had a direct or immediate relationship to the health, safety, or security of Resident 3 and constitutes a class "B" citation.