Health inspection·July 3, 2024

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (b) The facility must develop and implement written policies and procedures. (b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. (c) 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 (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 CFR § 72523 Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. § HSC 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. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 5/13/2024, the California Department of Public Health (CDPH) received a facility reported incident involving verbal abuse from Resident 2 to Resident 1. On 5/22/2024, the CDPH conducted an unannounced visit at the facility for abuse. The facility failed to: 1. Implement its abuse policy and procedure titled "Reporting Abuse" which indicated the Administrator, or his or her designee, shall provide the appropriate agencies or individuals with written report of the findings of the investigation within five (5) working days of the incident. As a result, this placed Resident 1and other residents in the facility at risk for further abuse. A) Resident 1 was a 73-years-old female, admitted to the facility on 1/23/2024 with diagnoses including diabetes (high blood sugar), hypertension (high blood pressure), dysphagia (difficulty swallowing), depression (loss of pleasure or interest), and anxiety (feeling fear, afraid, and worry). A review of Resident 1's History and Physical (H&P) dated 4/18/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) dated 4/11/2024, the MDS indicated Resident 1 was totally dependent (helper does all the effort) from staff for oral, toileting, and personal hygiene. B) Resident 2 was a 69-years-old female, admitted to the facility on 5/8/2024 with diagnoses including schizophrenia (mental illness that effects how person thinks, feels, and behaves) bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels), depression, and anxiety. A review of Resident 2's H&P dated 5/10/2024, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. A review of an SOC 341 (form adopted by the California Department of Social Services CDSS, required under Welfare and Institutions Code WIC, to report suspected dependent adult/elder abuse), indicated that the incident was initially reported to the Los Angeles County Department of Public Health, Health Inspection Division on 5/12/2024 via email. During a telephone interview on 5/22/2024 at 2:28 p.m. with the Administrator (ADM) the ADM stated, "I will be honest with you regarding the five days investigation report, it was not reported to the Health Department." A review of facility's Policy and Procedure (P&P), titled "Reporting Abuse" indicated the Administrator, or his or her designee, shall provide the appropriate agencies or individuals with written report of the findings of the investigation within five (5) working days of the incident. The facility failed to: 1. Implement its abuse policy and procedure titled "Reporting Abuse" which indicated the Administrator, or his or her designee, shall provide the appropriate agencies or individuals with written report of the findings of the investigation within five (5) working days of the incident. As a result, this placed Resident 1and other residents in the facility at risk for further abuse. This violation had a direct or immediate relationship to the health, safety, or security of residents.