Health inspection·August 2, 2024

42 CFR §483.12 (c)(1)(4) 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. 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. 22 CCR § 72527. Patient’s 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. HSC § 1418.91 (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. The California Department of Public Health (CDPH) received a complaint on 6/20/2024 regarding a resident who was hit in the eye by his roommate. On 6/21/2024, at 11:30 a.m., the CDPH conducted an unannounced investigation at the facility. The facility failed to: 1). Implement its abuse policy and procedure (P&P) titled "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating" which indicated the facility will report allegations of abuse within two hours, to the CDPH. As a result, there was a delay in the investigation by the CDPH. a. Resident 1 was a 64-year-old- male, admitted to the facility on 6/4/2024, with diagnoses that included cerebral infarction (a disrupted blood flow to the brain due to problems with the blood vessels that supply it), atrial fibrillation (abnormal heartbeat), and celiac disease (a chronic digestive and immune disorder that damages the small intestine). A review of Resident 1's History and Physical (H&P), dated 6/6/2024, indicated Resident 1 had fluctuated capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a comprehensive assessment and care- screening tool), dated 6/17/2024, indicated Resident 1, required partial to moderate assistance with personal hygiene, showering, and dressing. During an interview on 7/3/24 at 1:15 pm, with Resident 1, Resident 1 stated, a week ago (date unknown), he got into a fight over the TV being too loud with Resident 2. Resident 1 stated, Resident 2 blocked the door with his wheelchair and grabbed his private parts. b. Resident 2 was a 65-year-old male, admitted to the facility on 10/30/2023 and readmitted on 4/22/2024. Resident 2’s diagnoses included cardiomegaly (when the heart has a hard time pumping the blood), dementia (difficulties with reasoning, judgment, and memory), and schizoaffective disorder (loss of contact with reality and mood problem). A review of Resident 2's H&P, dated 4/24/2024, indicated Resident 2 did not have the capacity to understand and make decisions. A review of Resident 2's MDS dated 5/6/2024, indicated Resident 2's cognition was impaired (ability to learn, reason, remember, understand, and make decisions). During an interview on 6/25/2024 at 5:19 p.m. with Director of Nursing (DON), the DON stated, “I am not aware of an altercation on 6/16/2024 between the residents.” The DON stated the incident was not reported to administrator and the facility policy was not followed by staff. A review of the facility's P&P titled, "Abuse-Reporting & Investigations," dated 3/2018, indicated, the facility will report all allegations of abuse and to the appropriate agencies promptly. The P&P indicated abuse incidents will be reported to the Administrator (the Abuse Prevention Coordinator) and the Administrator or designated representative will notify law enforcement immediately or within two hours of the initial report. The facility failed to: 1). Implement its abuse P&P titled "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating" which indicated to report to the CDPH allegation of abuse within two hours. As a result, there was a delay in the investigation by the CDPH. This presented a direct or immediate relationship to the health, safety, or security of Residents 1 and 2.