Health inspection·February 20, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00940314. A Class B Citation was written. Regulatory Violations: 42 CFR §483.12 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)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §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. 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. 22 CCR §72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. On 1/29/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding an employee to resident abuse. The facility failed to implement policies and procedures (P&P) to ensure reporting of a reasonable suspicion of an abuse in accordance with state and federal law for Resident 1. This resulted in a delay of an onsite inspection by the State Agency (SA) to ensure the safety of the residents and had the potential to result in unidentified abuse in the facility as well as failure to protect residents from any possible abuse. A review of Resident 1's Admission Record indicated Resident 1, a 79 year-old female was originally admitted to the facility on 2/4/2022 and was re-admitted on 7/3/2024 with diagnoses including hypokalemia (low potassium [important mineral that the body needs, to work properly] level in the blood, hypertension (HTN - elevated blood pressure), and chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/7/2024, MDS indicated Resident 1's cognitive skill for daily decision-making were moderately impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand). During a concurrent interview and record review on 1/29/2025 at 1:24 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Progress Notes (PN), dated 10/2/2024 was reviewed. Resident 1's PN indicated LVN1 documented that, "Resident 1 confabulated stories that the CNA (Certified Nursing Assistant) raped her and touched her (Resident 1)." LVN1 validated the documentation and stated that he (LVN1) did not remember reporting the issue to the Director of Nursing (DON), neither to the Facility Administrator (FA). LVN1 stated that he (LVN1) was supposed to report any possible abuse to the DON and FA. During an interview on 1/29/2025 at 1:26 p.m., with the Registered Nursing Supervisor (RNS) 1, RNS1 stated that she (RNS1) was not aware of Resident 1's issue of possible abuse. RNS1 stated that if LVN1 reported it to her (RNS1), RNS1 could have done an investigation and notify the DON and/or FA; and report it to the local police, ombudsman and the Department of Public of Health (DPH). During an interview on 1/29/2025 at 1:28 p.m., with the DON, DON stated that she (DON) was not informed of Resident 1's issue of possible abuse. DON stated that they need to do an investigation and notify the DON and/or FA; and report it to the local police, ombudsman and DPH. DON also stated that even if a resident has episodes of making up stories, they (facility staff) still are mandated reporter, and a possible abuse investigation was necessary. During an interview on 1/29/2025 at 1:31 p.m., with the Social Service Director (SSD), SSD stated that she (SSD) was not informed of Resident 1's issue of possible abuse. SSD stated that the facility needs to do a proper investigation regardless of resident's condition and facility staff are mandated to report for resident's safety. During a review of the facility's P&P titled, "Reporting Abuse," reviewed on 6/19/2024, the P&P indicated that "facility to ensure compliance with federal, and state laws and regulations regarding reporting of incidents and suspected incidents of abuse, neglect and mistreatment of residents." P&P also stated that "facility staff are mandatory reporters." During a review of the facility's P&P, titled, "Abuse and Neglect," reviewed on 6/19/2024, the P&P indicated that "the facility will report all allegations of abuse and criminal activity, as required by law and regulations, to the appropriate agencies." P&P also indicated that, "allegations of abuse...are to be reported to the administrator or designated representative immediately." The facility failed to implement P&P to ensure reporting of a reasonable suspicion of an abuse in accordance with state and federal law for Resident 1. This resulted in a delay of an onsite inspection by the SA to ensure the safety of the residents and had the potential to result in unidentified abuse in the facility as well as failure to protect residents from any possible abuse. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.