Health inspection·September 20, 2024

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms. 42 CFR §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)(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. On 8/9/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct its annual Recertification Survey. The facility failed to protect Resident 36’s right to be free from verbal abuse (a type of abuse that uses language) when on 8/7/2024, Resident 32 called Resident 36 an "asshole" while pointing at Resident 36 in the main dining room and failed to implement its Abuse Prohibition and Prevention Policy and Procedure (P&P) by not reporting to CDPH on 8/7/2024 the allegation of verbal abuse reported by Resident 36. As a result, Resident 36 was subjected to verbal abuse while under the care of the facility and there was a delay for an onsite inspection by CDPH to ensure the safety of Resident 36 and other residents. Residents who are subjected to verbal abuse are at increased risk for low self-esteem (when someone lacks confidence in themselves and their abilities), anxiety (a feeling of fear, dread, and uneasiness), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities for long periods of time) and social isolation (.when someone has few or no social connections or support, and lacks relationships with others). A review of Resident 36's Face Sheet (Admission Record), the Face Sheet indicated the facility admitted Resident 36 on 3/14/2024, with diagnoses including hypertension (a condition in which the blood vessels have persistently raised pressure) and benign prostatic hyperplasia (BPH- a non-cancerous condition that causes the prostate gland to enlarge, which can impact urine flow). A review of Resident 36's Minimum Data Set (MDS- an assessment and care screening tool) dated 3/26/2024, the MDS indicated Resident 36's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact. The MDS further indicated that Resident 36 was independent in performing activities of daily living (ADLs- basic self-care tasks that residents perform every day). A review of Resident 32's Face Sheet, the Face Sheet indicated the facility admitted Resident 32 on 11/29/2023 with diagnoses including heart failure, dementia (loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and Alzheimer`s disease (a progressive disease that destroys memory and other important mental functions). A review of Resident 32's MDS dated 6/11/2024, the MDS indicated Resident 32's cognitive skills for daily decision making was impaired and that Resident 32 the required partial to moderate assistance from staff with showers, dressing and personal hygiene. During an interview on 8/10/2024 at 6:30 p.m. with Resident 36, the resident stated that about one and half months ago (Resident unable to recall exact date, the date is later determined to be 8/7/2024), Resident 36 informed the Social Service Director (SSD) that Resident 32 was using curse words (a word or phrase that's generally considered blasphemous, obscene, vulgar, or otherwise offensive) when he (Resident 32) called Resident 36 an "asshole" while pointing at Resident 36 in the main dining room. Resident 36 stated that "after a few days", Resident 36 reported the incident to the SSD. During an interview on 8/11/2024 at 1:30 p.m., the SSD stated that he (SSD) was informed by Resident 36 that Resident 32 had called Resident 36 an "asshole". The SSD stated that calling somebody an "asshole" is verbal abuse. The SSD stated that when Resident 36 informed SSD about the allegation of abuse, SSD informed the Administrator (ADM). During an interview on 8/11/2024 at 2:42 p.m. with the Administrator (ADM) the ADM stated that he is the designated abuse coordinator. The ADM stated that on 8/7/2024 Resident 36 told ADM regarding the incident involving Resident 32. ADM stated that he did not report the allegation to the SSA. During an interview on 8/11/2024 at 2:50 p.m. with the Activity Director (AD), the AD stated that on 8/7/2024 at around 12:30 p.m., while in the main dining room, Resident 32 was cursing and stated, "piece of shit, asshole" and he (Resident 32) was also looking at the direction of Resident 36. The AD said she (AD) did not see if Resident 32 was pointing his (Resident 32) fingers, but Resident 32 was looking at the direction of Resident 36. The AD stated that she (AD) tried to redirect Resident 32 and told Resident 32 that he (Resident 32) was being inappropriate. A review of the facility`s policy and procedures titled "Abuse Prohibition and Prevention Program," last revised in March 2023, indicated that the facility has policies and procedures for ... protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation of property. Further review of the facility`s policy and procedures titled "Abuse Prohibition and Prevention Program," last revised in March 2023, indicated that "Mandated Reporter: any person who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonable appears to be physical abuse, abandonment, isolation, financial abuse, or neglect, or is told by and elder or dependent adult that he or she experienced behavior constituting physical abuse, abandonment, isolation, financial abuse, or neglect, or reasonable suspects abuse shall report the known or suspected instance of abuse ...the facility shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse ... The facility failed to protect Resident 36’s right to be free from verbal abuse when on 8/7/2024, Resident 32 called Resident 36 an "asshole" while pointing at Resident 36 in the main dining room and failed to implement its Abuse Prohibition and Prevention Policy and Procedure (P&P) by not reporting to CDPH on 8/7/2024 the allegation of verbal abuse reported by Resident 36. As a result, Resident 36 was subjected to verbal abuse while under the care of the facility and there was a delay for an onsite inspection by CDPH to ensure the safety of Resident 36 and other residents. Residents who are subjected to verbal abuse are at increased risk for low self-esteem, anxiety, depression, and social isolation. The above violation had a direct relationship to the health, safety, or security of Resident 36.