Health inspection·August 8, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00905911. Representing the Department, HFEN # 43261. A Class B Citation was written. REGULATORY VIOLATIONS: §483.12(c)-Freedom from Abuse, Neglect, and Exploitation. 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. §483.12(c)- Freedom from Abuse, Neglect, and Exploitation. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §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. Title 22 California Code of Regulations: § 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. California Code, Health, and Safety Code - HSC § 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. On 6/21/2024, the Department of Public Health (State Survey Agency-SSA) made an unannounced visit to the facility to investigate a complaint related to abuse and neglect. The facility failed to report to the State Survey Agency an unusual occurrence that occurred on 6/15/2024, when Resident 2 threw a filled cup of coffee at Resident 1. As a result, there was a delay of an onsite inspection by the SSA to ensure the safety of the residents and to ensure all possible abuse was investigated. During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on 7/17/2021 and was re-admitted on 11/20/2022 with diagnoses including lack of coordination, diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and dementia (a chronic or persistent disorder of the mental processes caused by brain disease). During a review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 4/13/2024, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was severely impaired and requiring moderate to maximal assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use). During a review of Resident 2's AR, the AR indicated that Resident 2 was originally admitted to the facility on 6/2/2023 and was re-admitted on 3/24/2024 with diagnosis including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), anxiety, depression (a mood disorder that causes persistent feeling of sadness and loss of interest) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). During a review of Resident 2's MDS dated 6/1/2024, the MDS indicated Resident 2 has a severe impairment in cognition for daily decision-making and requiring maximal assistance from staff for ADLs. During a review of Resident 2's SBAR (situation, background, appearance and review/notify- structured tool for healthcare provider that provides communication between members. Also, being used as documentation for any changes of condition) form dated 6/15/2024, the SBAR form indicated that Resident 2 was screaming, cursing and threw filled cups to the roommate and staff member. During an interview with Resident 1 Family Member (R1FM) on 6/21/2024 at 9 a.m., R1FM stated that she (R1FM) notified the Director of Social Services (DSS) regarding her concerns against Resident 2. R1FM stated that Resident 2 was constantly yelling, screaming, and cursing. R1FM also stated that she (R1FM) found out that Resident 2 threw a cup of coffee at Resident 1. R1FM stated that she fears for her mother's (Resident 1) safety. During an observation and interview with Licensed Vocational Nurse 1 (LVN 1) by the hallway, on 6/21/2024 at 11:26 a.m., Resident 2 was heard screaming/yelling and cursing. LVN 1 stated that Resident 2 was constantly screaming and cursing whenever she (Resident 2) needs something. LVN 1 stated that Resident 2 also had an episode that Resident 2 threw cups to both staff and a resident. During an interview with the DSS, on 6/24/2024 at 10:55 a.m., DSS stated that she (DSS) was made aware regarding R1FM's issues and unable to do anything else since R1FM was the one that complained against Resident 2. DSS stated that there was no witness or documentation that she (DSS) found that R1FM's statement really happened and calling the police for assistance was necessary due to R1FM's agitation toward the facility staff. DSS stated that for any allegations of possible abuse, they must report it and do an investigation. During a concurrent interview and record review with the Facility Administrator (FA) on 6/24/2024 at 11:25 a.m., Resident 2's SBAR form was reviewed. FA stated that the issue with Resident 2's screaming, cursing, and throwing cups to a resident and staff was not reported to him (FA); and unable to do the reporting. FA stated and added that for any possible abuse/neglect, they have to do an investigation and provide reports to the ombudsman (an affiliated organization who serves as an advocate for patients), police and state agency. During a review of facility's policy and procedure (P&P), titled, "Abuse Reporting and Investigation" reviewed on 4/25/2024, P&P indicated to thoroughly investigate reports of ALL allegations of abuse, mistreatment, neglect, exploitation, misappropriation of resident property, or injuries of an unknown source. P&P also indicated to promptly report ALL allegations of abuse as required by law and regulations to the appropriate agencies. The facility failed to report to the State Survey Agency an unusual occurrence that occurred on 6/15/2024, when Resident 2 threw a filled cup to Resident 1. As a result, there was a delay of an onsite inspection by the SSA to ensure the safety of the residents and to ensure all possible abuse was investigated. The above violation had a direct relationship to the health, safety, and security of Resident 1.