Health inspection·April 23, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00886820. Representing the Department, HFEN # 43452. A Class B Citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations: §483.12(c) Freedom from Abuse, Neglect, and Exploitation 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. §483.12(c) Freedom from Abuse, Neglect, and Exploitation In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §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. 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. On 3/7/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about resident abuse. The facility failed to implement their policy regarding reporting of residents' allegation of sexual abuse and to submit a conclusion report of investigation within five days or in accordance with state or federal law for Resident 2. As a result, there was a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further sexual abuse for Resident 2. A. A review of Resident 2's Admission Record indicated Resident 2, a 60 years old female was admitted to the facility on 5/2/2023 and readmitted on 12/9/2023 with diagnosis including type 2 diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) with hypoxia (low levels of oxygen in the body causing confusion, bluish skin, and changes in breathing and heart rate), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and chronic congestive heart failure (CHF- a progressive condition that affects the pumping power of the heart muscle). A review of Resident 2's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 12/16/2023, indicated Resident 2's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact for daily decision-making and required moderate assistance to dependent from staff for activities of daily living (ADL- toileting hygiene, shower/bathe self, upper and lower body dressing and putting on/taking off footwear). A review of Resident 2's Nursing Notes dated 2/16/2024 at 8:30 p.m. indicated, resident (Resident 2) verbalized concern another resident (Resident 5) last night around 11:30 p.m., as per Resident (2), another resident (Resident 5) went into the room and peeked into room Bed A and Bed B curtain, she (Resident 2) intervened and told resident to leave them alone since they are sleeping... resident (5) walked to her, initiating conversation with her, patient (Resident 2) stated that he (Resident 5) touched her arm and he mentioned how soft her skin was... He (Resident 5) also told her that he wanted to get nude and cuddle, resident (Resident 2) pressed call light for assistance and Certified Nursing Assistant 1 (CNA 1) removed Resident 5 from room. A review of Resident 2's Social Worker Progress Notes dated 2/20/2024 indicated, Social Services (Social Services Director - SSD) informed by Assistant Director of Nursing (ADON), resident (2) with incident over the weekend with a male resident entering room and disturbing her sleep. A review of Resident 2's Care Plan: Psychosocial well-being dated 2/16/2024 indicated, Resident (2) is at risk for psychosocial impairment due to incident of another resident verbalizing sexual remarks towards her. During an interview with Resident 2 on 3/7/2024 at 1:50 p.m., Resident 2 stated, on 2/15/2024 at around 10:00 p.m. - 10:30 p.m., the entry door was closed when all of a sudden, Resident 5, a male resident entered their room and opened Resident 1 (Bed B) and Resident 2's (Bed A) curtain while sleeping. Resident 2 stated, Resident 5 then walked into her bed and told her to get nude because he wants to cuddle with her, she told him to leave because they are not married, and he does not belong there. Resident 2 then pressed the call light and CNA 1 answered the call light and removed Resident 5 from their room. Resident 2 stated, the CNA did not report anything that night, therefore she told the charge nurse the next day of the incident. Resident 2 further stated, the SSD talked to her the following Monday and explained to her of the reporting protocol and asked her if they would like to report the incident. Resident 2 stated, she doesn't remember refusing about reporting but she's afraid that Resident 5 might do it again. b. A review of Resident 5's Admission Record indicated Resident 5 was admitted to the facility on 12/9/2023 with diagnoses including type 2 diabetes (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), diastolic congestive heart failure (CHF- a progressive condition that affects the pumping power of the heart muscle), and cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). A review of the MDS dated 12/16/2023, indicated Resident 5's cognitive skills for daily decisions was severely impaired. The MDS indicated Resident 5 required moderate assistance to supervision from staffs for ADLs - eating, oral hygiene and personal hygiene. A review of Resident 5's Situation Background Assessment Recommendation (SBAR - a written or verbal communication tool used to provide essential and concise information, usually during crucial situations) dated 2/17/2024 indicated, Resident (5) wandering around facility - noted multiple episodes of wandering facility and entering resident's room. A review of Resident 5's Care Plan for Mood state, dated 2/17/2024 indicated, Resident 5 has an alteration in mood/behavior related to wandering facility/entering residents' room with intervention to monitor behavior every shift. During an interview with SSD on 3/7/2024 at 2:36 p.m., SSD stated, she was informed of the report of the sexual allegation by Resident 2, and she spoke to her on 2/20/2024. SSD stated, she asked Resident 2 if she would like them to report the sexual abuse allegation but Resident 2's family member refused. SSD stated, she did not report the incident to the State agency, Police or Ombudsman. SSD further stated, she followed-up with Resident 2 for the next 48 hours. When asked if this incident was reportable to the State, Police and Ombudsman, SSD stated, "yes". SSD was asked why it was not reported to the State Agency, SSD stated, "I'm unable to answer that". During an interview with CNA 1 on 3/7/2024 at 5:26 p.m., CNA 1 stated, Resident 5 tends to wander around the facility and would enter other residents' room. CNA 1 stated, he found Resident 5 inside Resident 2's room because Resident 2 pressed her call light. CNA 1 stated, he did not see what Resident 5 did inside Resident 2's room and how long he was in Resident 2's room. During an interview with Administrator (ADM), on 3/7/2024 at 5:42 p.m., ADM stated, he was called on the day of 2/17/2024 regarding Resident 2's allegation of sexual abuse and he instructed the ADON to open an investigation. ADM stated, Resident 2 refused on reporting the sexual abuse and it is their right to refuse. ADM stated, they did not report the allegation of sexual abuse accordingly to their policy. A review of the facility's policy and procedure (P&P) titled, "Abuse Reporting and Prevention", checked on 1/16/2024 indicated, "To ensure that resident rights are protected by providing a method of investigation and reporting of alleged violations involving mistreatment, neglect, abuse including injuries of unknown sources, unusual occurrences... The Administrator, as the abuse coordinator, will investigate each alleged violation thoroughly and report results to appropriate agencies and personnel. The administrator of his/her designee, will report each alleged abuse to the Ombudsman's office and Department of Public Health immediately or within 2 hours... All alleged allegations and all substantiated incidents will be reported to the Department of Public Health and to all other agencies as required by State law... The results of the investigation must be reported within 5 working days of the incident." The facility failed to implement their policy regarding reporting of residents' allegation of sexual abuse and to submit a conclusion report of investigation within five days or in accordance with state or federal law for Resident 2. As a result, there was a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further sexual abuse for Resident 2. The above violations had direct or immediate relationship to the health, safety, or security of Resident 2.