Health inspection·March 21, 2024

42 CFR §483.12 (c) Freedom from Abuse, Neglect, and Exploitation. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. 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. H&S § 1418.91 (a) A long-term health care facility shall report all incidents of alleged 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 2/8/2024 the California Department of Public Health (CDPH) received a Facility Reported Incident indicating that on 2/7/2024, Resident 1 was pushed from the chair and was on the floor outside the facility on. On 2/9/2024, the CDPH conducted an unannounced visit at the facility and discovered there was another alleged incident on 2/7/2024 in which Resident 1 abused Resident 2. The facility failed to: 1. Implement its abuse policy and procedure (P&P) which indicated the facility would report allegations of abuse, immediately, but no later than 2 hours to the state survey agency. As a result, there was a delay in the investigation by the CDPH. Resident 1 was an 81-year-old male, admitted to the facility on 9/14/2021 and readmitted on 5/25/2023. Resident 1’s with diagnoses including unspecified osteoarthritis (when flexible tissue at the ends of bones wear down), muscle weakness and intervertebral disc degeneration (breakdown of one or more of the discs of the spine). A review of Resident 1’s Minimum Data Set ([MDS], a standardized care assessment and care screening tool), dated 12/14/2023, indicated Resident 1 could understand and be understood by others. The MDS indicated Resident 1 required supervision or touching assistance (staff provides verbal cues and/or touching/steadying assistance as resident completes activity) with activities of daily living (ADLs) such as lower body dressing, personal hygiene and walking 10-150 feet. A review of Resident 1’s Change in Condition (COC) dated 2/2/2024 at 11:16 a.m. indicated Resident 1 went to another resident’s room (Resident 2) and poured/sprinkled his urine on Resident 2, who was in bed. The COC indicated Resident 1 was upset that Resident 2 had always locked the bathroom door and made it difficult for him to use the bathroom. Resident 2 was an 80-year-old male, admitted to the facility on 2/16/2022 with diagnoses including unspecified osteoarthritis right hip, muscle weakness, and difficult in walking. A review of Resident 2’s MDS dated 11/23/2023, indicated Resident 2 could understand and be understood by others. The MDS indicated Resident 2 required setup or clean-up assistance with ADLs such as personal hygiene, sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair or on the side of the bed) and transfer (ability to get to and from a bed to chair or on and off a commode). A review of Resident 2’s COC dated 2/2/2024, at 11:16 a.m. indicated Resident 1 went to Resident 2’s room with aggressive behavior to confront Resident 2 because Resident 2 always locked the bathroom door, making it impossible for Resident 1 to use the bathroom. The COC indicated Resident 1 sprinkled/poured his urine on Resident 2 while Resident 2 was in bed. During an interview on 2/9/2024, at 11:11 a.m., Resident 1 stated, he was angry that Resident 2 always locked the bathroom door. Resident 1 stated one day (on 2/2/2024), he wanted to use the restroom and the door was locked. Resident 1 stated, he asked Resident 2 why he locked the door and threw urine on Resident 2. During an interview on 2/9/2024 at 11:45 a.m., Resident 2 stated, on 2/2/2024 Resident 1 came to his room and threw a bottle of urine on his shoulder and the left side of his face. During an interview on 2/9/2024 at 3:22 p.m., the Director of Nursing (DON) stated the incident between Resident 1 and Resident 2 on 2/2/2024 should have been reported to the CDPH but it was not done. The DON stated the facility should have reported the abuse to the CDPH to provide protection and safety for the residents. During an interview on 2/9/2024 at 3:54 p.m., the Administrator (ADM) stated, the Social Services Director (SSD), had informed him of Resident 2’s allegation of abuse by Resident 1 on 2/2/2024. The ADM stated, the abuse allegation should have been reported to DPH to conduct investigations. The ADM stated if abuse was not reported, it placed residents at risk for future injuries or retaliations. A review of the facility’s P&P titled, “Abuse Prevention and Prohibition Program” dated 8/1/20/23 indicated the facility will report allegations of abuse, neglect, mistreatment, injuries of unknows source, misappropriation of resident property of other incident that qualify as crime immediately, but no later than 2 hours after forming the suspicion- if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protector services, law enforcement and the Ombudsman. The facility failed to: 1. Implement its abuse P&P ensure an allegation of abuse was reported to the CDPH within two hours. As a result, there was a delay in the investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of residents.