Health inspection·October 1, 2024

The following reflects the findings of the California Department of Public Health (Department) during the investigation of complaint number CA00917178. State Citation B was written. Regulatory Violations: 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. 22 CCR §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. On 8/30/2024, the Department of Public Health (State Survey Agency [SSA]) made an unannounced visit to the facility to investigate a complaint regarding Resident 1 accused of hitting this staff member and the staff scratched Resident 1 and he marks on him. The facility failed to implement its' policy regarding reporting of residents' allegation of physical abuse and to submit a conclusion report of investigation within five days in accordance with state or federal law for Resident 1. As a result, there was a delay of an onsite inspection by the SSA to ensure the residents' allegation of physical abuse was investigated and the potential to place Resident 1 at risk for further physical abuse at the facility. A review of Resident 1's Face Sheet indicated the resident was originally admitted on 11/11/2021 and readmitted on 8/25/2024 with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), hemiplegia (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 8/2/2024, indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact for daily decision-making and required set-up assistance from staff for activities of daily living (ADL- rolling left and right, sit to lying, sit to stand). The MDS also indicated, Resident 1 uses manual wheelchair. A review of Resident 1's Situation Background Assessment Recommendation (SBAR - a written or verbal communication tool used to provide essential and concise information, usually during crucial situations) Communication Form dated 8/19/2024 indicated, a change of condition due to Physical and Verbal Aggressiveness towards the staff / skin abrasion. The SBAR also indicated, Resident 1 had a skin abrasion on his right upper back. During an interview with Activity Staff 1 on 8/30/2024 at 10:12 a.m., AS 1 stated, there was an incident with Resident 1 on 8/19/2024 at around 8 p.m. in the smoking patio where Resident 1 was being noncompliant with smoking policy. AS 1 stated, Resident 1 was keeping a smoking paraphernalia with him, and he was not allowed to keep it with them. AS 1 then grabbed the smoking paraphernalia from Resident 1 and then Resident 1 punched her on her face. During an interview with Certified Nursing Assistant (CNA) 1, on 8/30/2024 at 12:24 p.m., CNA 1 stated, Resident 1 had a scratched on his back after the incident on 8/19/2024 with AS 1 in the smoking patio. CNA 1 states, she saw AS 1 reached over Resident 1 which is why Resident 1 ended up with a scratch on his back. During an interview with Registered Nurse (RN) 1 on 9/6/2024 at 10:53 p.m., RN 1 stated, AS 1 initially reported that Resident 1 kicked her on her shin, but he did not witness it. RN 1 stated, he told AS 1 to report it to the management. RN 1 stated, AS 1 again reported that she was punched on the face by Resident 1 because Resident 1 was not supposed to keep a smoking paraphernalia with them. RN 1 stated, Resident 1 was being aggressive to the staff, and they ended up calling the Police. RN 1 stated, while interviewing Resident 1 with the help of CNA 1 for translation after the incident, Resident 1 stated, he ended up with a scratch on his back because of AS 1 scratched him. RN 1 stated, he reported the incident to the Administrator (ADM) and the physician. RN 1 further stated the incident was a physical abuse allegation, but he did not report the incident to the State Agency and Ombudsman. RN 1 further stated he thinks any abuse allegation was to be reported within 48 hours. During an interview with ADM on 9/6/2024 at 11:40 a.m., ADM stated, they investigated the allegation but did not report the incident to the State Agency. ADM stated, any incident of abuse allegation should be reported to the State Agency. During a review of the facility's policy and procedure (P&P) titled, "Abuse Prevention/Investigation/Reporting and Resolution", reviewed on 7/12/2024 the P&P indicated, Facility will conduct an immediate investigation of any allegation of any form of abuse. If reportable, facility will document a written abuse report on SOC 341... All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property 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; The local/State Ombudsman; The Resident's Representative of Record; Adult Protective Services; Law enforcement officials; the Resident's Attending Physician; and the facility Medical Director... An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury... 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 five (5) working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility failed to implement its' policy regarding reporting of residents' allegation of physical abuse and to submit a conclusion report of investigation within five days in accordance with state or federal law for Resident 1. As a result, there was a delay of an onsite inspection by the SSA to ensure the residents' allegation of physical abuse was investigated and the potential to place Resident 1 at risk for further physical abuse at the facility. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.