Health inspection·September 25, 2024

The following reflects the findings of the California Department of Public Health during an investigation of a complaint. 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. A failure to comply with the requirements of this section shall be a class "B" violation. On 9/9/24, an unannounced visit was conducted at the facility to investigate a complaint regarding an allegation of sexual abuse. Resident 1 is a 94-year-old female who was admitted to the facility on 7/25/2024 and had a history of Other Sequelae of Cerebral Infarction (alteration of sensation following a disruption of blood flow to the brain), Other abnormalities of gait, Major Depressive disorder (mood), anxiety, and urinary tract infection. Based on observation, interview, and record review, the facility failed to report an allegation of sexual abuse for one of three sampled residents (Resident 1) within 24 hours to the California Department of Public Health (CDPH) and complete a follow up investigation within five business days. This failure had the potential for abuse to continue and for other residents to potentially experience abuse. Findings: During a review of Resident 1's "Progress Notes (PN)," dated September 1, 2024, the PN indicated, "In charge nurse informed that resident [1] stated that she was raped here some days ago by two men." During a concurrent observation and interview on 9/5/24 at 1:21 p.m. with Resident 1, Resident 1 was sitting in a wheelchair in the dining room, holding color crayons in a basket with rabbit stuffed animal on her lap. Resident 1 stated, "I was raped four times by two men since I have been here. It's [allegation of asexual abuse] in the records. Its listed here. I'm afraid to be alone." During an interview on 9/5/24 at 2:55 p.m. with the Director of Nursing (DON), DON stated staff reported to her that Resident 1 was making allegations of rape by two men, she stated she instructed staff to call 911 and follow the abuse protocol. DON stated she did not report the allegation of sexual abuse to the CDPH because she (Resident 1) changed her (Resident 1) story to the nurse. During a review of the facility policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating," undated, 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. Findings of all investigation are documented and reported. Reporting Allegation to the Administrator and Authorities 2. The administrator or the 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; 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. Investigating Allegations 1. All allegations are thoroughly investigated. Follow-Up Report 1. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report. 2. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. 3. The follow-up investigation report will provide as much information as possible at the time of submission of the report. 4. The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation." In violation of the above cited, the facility failed to report alleged abuse to the Department within 24 hours for Resident 1. This failure had the potential for alleged abuse to continue. This violation had a direct or immediate relationship to the health, safety, or security of residents and constitutes a Class "B" citation.