Health inspection·December 11, 2024

§483.12(c) Reporting of Alleged Violations 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. 22CCR §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. H&S 1418.91 Abuse Reporting (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. On 10/30/2024 the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) regarding a sexual abuse allegation involving Resident 1. On 10/31/2024, the CDPH conducted an unannounced visit to the facility to investigate the FRI’s allegation. The facility failed to: 1. Implement its abuse Policy and Procedure (P&P) titled, "Abuse Investigation and Reporting" which indicated all allegations of abuse would be reported to the State Licensing/Certification Agency (CDPH) immediately, but no later than two hours. As a result, there was a potential for a delay in the investigation by the CDPH and pertinent information lost and/or destroyed. A review of Resident 1’s Admissions Record, Resident 1 a 90- year- old- female, Admission Record indicated Resident 1 was admitted to the facility on 3/1/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and cerebral infarction (when the blood supply to part of the brain is blocked or reduced). A review of Resident 1’s Minimum Data Set ([MDS]) resident assessment tool), dated 10/1/24/, indicated Resident 1 had moderately impaired cognitive (a physical or mental condition that significantly limits a person's ability to function in their daily life) skills for daily decision making and required -partial assistance with toileting hygiene, showering, and upper/lower body dressing. A review of Resident 1’s Social Services Notes, dated 10/25/2024, indicated Resident 1 was on the phone with her daughter and stated someone tried to crawl in her bed and rape her. The Social Services Notes indicated Resident 1 stated the person was a family member. The Social Services Note indicated Resident 1’s daughter, who was on the phone with the resident at the time, stated Resident 1 was hallucinating and confused, and ended the call. During an interview on 10/31/2024 at 12:04 p.m., the Social Services Director (SSD), stated the Activities Assistant (AA) informed her of Resident 1’s alleged abuse allegations on 10/25/2024. The SSD stated she reported the allegations to the Director of Nursing (DON) immediately. The SSD stated the DON informed her to initiate a Social Services Note. The SSD stated the risk of failing to report abuse in a timely manner could result in placing a resident at risk for further abuse. During an interview, on 10/31/2024, at 12:37 p.m., the DON stated the SSD had informed her of Resident 1’s abuse allegation. The DON stated the reason the allegation was not reported was due to Resident 1’s daughter claiming Resident 1 was hallucinating and confused. The DON stated the time frame for reporting abuse was within two hours. The DON stated the allegation should had been reported on 10/25/24 and was not. The DON stated the risk of failing to report abuse in a timely manner could result in further abuse. During an interview, on 10/31/2024, at 1:04 p.m., with the Administrator (ADM), stated he was informed of Resident 1’s abuse allegations on 10/30/24. The ADM stated the allegation was not reported to CDPH within two hours on 10/25/2024. The ADM stated abuse should be reported timely in order to prevent unnecessary harm. A review of the facility's P&P titled, "Abuse Investigation and Reporting" dated 7/2017 indicated all alleged violations involving abuse would be reported by the facility Administrator, or his/her designee to the State Licensing/Certification Agency immediately, but no later than two hours. The facility failed to: 1. Implement its abuse P&P titled, "Abuse Investigation and Reporting" which indicated all allegations of abuse would be reported to the State Licensing/Certification Agency (CDPH) immediately, but no later than two hours. As a result, there was a potential for a delay in the investigation by the CDPH and pertinent information lost and/or destroyed. This violation had a direct or immediate relationship to the health, safety, or security of residents.