Health inspection·June 21, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00900185. Representing the Department, HFEN # 43452. A Class B Citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations Freedom from Abuse, Neglect, and Exploitation §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. Title 22 California Code of Regulations § 72527. Patients' Rights. (10) To be free from mental and physical abuse. § 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. On 5/16/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate an allegation regarding elder abuse. The facility failed to implement its' policy and procedures titled "Abuse Reporting and Investigation", by failing to report to CDPH, the alleged elder abuse made by Resident 1's Representative. As a result, there was a delay in the investigation of the alleged abuse and a potential risk for Resident 1 to suffer further abuse. A review of Resident 1's Admission Record, dated 5/17/24, indicated, Resident 1 was admitted to the facility on 7/6/23 with diagnoses including hypertension (HTN, high blood pressure), heart failure (HF, a medical condition where the heart muscle doesn't pump blood as well as it should), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breath), reliance on supplemental oxygen, abnormalities of gait and mobility, and dementia (a group of conditions affecting brain functions such as memory loss and impaired judgement). A review of Resident 1's Minimum Data Set (MDS - a care planning and assessment tool), dated 4/10/24, indicated, Resident 1 had mild cognitive issues (ability to think, understand and make daily decisions). The same MDS indicated Resident 1 required supervision from staff while eating, and maximal assistance from staff for toileting, bathing, dressing and personal hygiene. During a concurrent interview and record review on 5/17/24 at 12:29 pm, with Licensed Vocational Nurse (LVN) 1, Resident 1's nursing progress note, dated 4/20/24, was reviewed. The progress note indicated the Resident Representative (RR) accused facility of elderly abuse. LVN 1 verified the progress noted and stated she reported the incident to the Administrator (ADM) (date unknown) who is the Abuse Prevention Coordinator (APC). During a concurrent interview and record review on 5/17/24 at 4:37 pm, with ADM, Resident 1's nursing progress note, dated 4/20/24, was reviewed. The progress note indicated RR accused facility of elderly abuse... some CNAs slapped... Resident 1's hand... police were called. The ADM verified the progress note indicated alleged abuse, and stated it was unfortunate and the allegation was made out of spite by the RR, because she did not get a room change. The ADM confirmed and stated the incident was not reported to the Department. During a review of the facility's policy and procedures titled "Abuse Reporting and Investigation", dated 1/10/24, indicated, "Policy: To promptly report ALL allegations of abuse as required by law and regulation to the appropriate agencies within the required time frames... To thoroughly investigate reports of ALL allegations of abuse... Role of Administrator: Administrator as Abuse Prevention Coordinator (APC)... 1. All allegations of abuse... shall be reported to the APC immediately... When the APC receives a report of an incident or suspected incident of abuse... the APC shall initiate and investigation immediately... Reporting Procedure: 1. All allegations of abuse, including but not limited to, neglect, exploitation, or mistreatment, ... will be reported by the facility Administrator or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility b. The local/State Ombudsman c. Local law enforcement... All alleged violations involving abuse... shall be reported by APC / designees to local CDPH (California Department of Public Health), LTC (Long Term Care) Ombudsman and Local Law Enforcement either by telephone mail or in writing (SOC 341) immediately: a. within 2 hours after the allegation is made or reported." The facility failed to implement its' policy and procedures titled "Abuse Reporting and Investigation", by failing to report to CDPH, the alleged elder abuse made by Resident 1's Representative. As a result, there was a delay in the investigation of the alleged abuse and a potential risk for Resident 1 to suffer further abuse. The above violation had a direct relationship to the health, safety, and security of Resident 1.