Health inspection·June 29, 2022

The following reflects the findings of the California Department of Public Health during the investigation of: Complaint #: CA00784074 F609 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. § 72541 - Unusual Occurrences Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. On 5/6/22 the Department received a report alleging that one of the caregivers at the facility called Resident 1 “a female dog,” used profanity and hit her in the stomach and hit her on the foot. On 5/9/2022 the Department conducted an unannounced visit at the facility to investigate a staff to resident abuse incident. The facility failed to follow its policy to ensure an allegation of physical abuse was reported to the State Licensing Agency (SA) and to the Abuse Coordinator (person responsible to investigate abuse allegations in the facility) within two hours for Resident 1, when Resident 1, informed the facility’s staff that an unknown person punched her in the shoulder, leg, and stomach. As a result, Resident 1 was at risk for further abuse and resulted in a delay in investigation of the abuse allegation. During a review of Resident 1’s Admission Record (face sheet), the face sheet indicated Resident 1 was a 76-year-old female, admitted to the facility on 3/16/2022, with diagnoses that included muscle weakness and legal blindness. During a review of Resident 1’s History and Physical (H/P), dated 4/5/2022, the H/P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1’s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 12/17/21, the MDS indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 required one-person assist for bed transfer, dressing, eating, toilet use, and personal hygiene. During an interview with the Director of Nursing (DON), on 5/9/2022, at 1:15 p.m., the DON stated Family Member (FM1) reported to her on 5/8/2022, after lunch, that Resident 1 was hit by someone on Friday 5/6/2022. The DON stated the facility’s staff should have reported the incident within two hours, but the facility’s staff did not. During an interview with Resident 1 on 5/9/2022, at 1:20 p.m., Resident 1 stated on 5/6/2022, someone entered her room and punched her in the stomach. Resident 1 stated she told FM 1 and FM1 informed the facility. During an interview with the DON, on 5/9/2022, at 2:46 p.m., the DON stated she had reported the incident to her administrator the day before, on 5/8/2022. During a phone interview with the Administrator (ADM) on 5/9/2022, at 3:01 p.m., the ADM stated the incident was reported to her on 5/8/2022 around 2:00 or 3:00 p.m. ADM stated she was going to report on 5/9/2022 but she did not report it to the Department because she was still conducting the investigation. During a review of Resident 1’s Change of Condition/Situation, Background, Assessment Recommendation ([COC/SBAR] an internal communication tool) form, dated 5/9/2022 at 2:22 p.m., indicated Resident 1 claimed she was hit by somebody on her shoulder, leg and stomach on 5/6/2022 and the FM1 reported it to the administrator and the physician. During a concurrent review of the facility’s “Abuse-Reporting & investigations” Policy (P/P), revised March 2018, with DON, on 5/9/2022, at 3:17 p.m., the P/P indicated the facility would report all allegations of abuse as required by law. The P/P indicated notification of outside agencies of abuse allegations with no serious bodily injury should be made by the administrator or designated representative within 2 hours by telephone to the California Department of Public Health (CDPH) and the ombudsman and Law enforcement. The P/P also indicated the Administrator or designated representative would send within 2 hours a written SOC341 report to the Ombudsman, Law Enforcement and CDPH Licensing and Certification. The facility failed to follow its policy to ensure an allegation of physical abuse was reported to the State Licensing Agency (SA) and to the Abuse Coordinator (person responsible to investigate abuse allegations in the facility) within two hours for Resident 1, when Resident 1, informed the facility’s staff that an unknown person punched her in the shoulder, leg, and stomach. As a result, Resident 1 was at risk for further abuse and resulted in a delay in investigation of the abuse allegation. This violation presented a direct or immediate relationship to the health, safety, security, or welfare of Resident 1.