Health inspection·October 25, 2024

F609 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual’s obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. §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. 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 9/16/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident regarding resident abuse. The facility failed to protect Resident 1’s and Resident 2’s right to be free from verbal abuse (a type of abuse that uses language) when on 8/24/2024, Resident 2 had an exchange of verbal profanity (the use of language that is considered socially offensive, known as swearing or cussing) with Resident 1. Resident 1 and Resident 2, who were roommates, were not separated until 9/6/2024. In addition, the facility failed to implement its policy and procedure (P&P) titled “Reporting of Alleged Violations,” by failing to report the alleged verbal abuse to CDPH no later than two hours after the allegation occurred on 8/24/2024 (specific time not indicated). As a result, Resident 1 and Resident 2 were 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 1, Resident 2 and other residents. a. A review of Resident 1’s Admission Record indicated the facility originally admitted Resident 1 on 6/9/2021 and readmitted on 12/19/2022 with diagnoses that included major depressive disorder (a serious mental health condition that causes a persistent low mood or loss of interest in activities, which interferes with daily life), muscle weakness, and acute (very serious, extreme, or severe) respiratory failure (a serious condition that makes it difficult to breathe on your own). A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care-planning tool), dated 7/9/2024, indicated Resident 1 could understand and be understood. The MDS indicated Resident 1 was dependent (helper does all the effort) with toileting, showering, upper and lower body dressing, putting on and taking off footwear and personal hygiene. The MDS indicated Resident 1 needed moderate assistance with oral hygiene. A review of Resident 1’s Activity Progress Notes, dated 9/2/2024 at 3:20 p.m., written by the Activities Director (AD), indicated that on 8/24/2024, Resident 1 was showing aggressive behavior towards her roommate Resident 2. Resident 2 was calling Resident 1 a demon and stated she (Resident 1) is a horrible person. The Activity Progress Notes indicated Resident 2 stated that Resident 1 had a lot of evil inside her, "so stay away from me you evil (used verbal profanity).” A review of Resident 1’s Situational-Background-Assessment-Recommendation (SBAR, communication form between members of the health care team caring for a resident about his / her condition) form, dated 9/6/2024, timed at 12:35 p.m., indicated Resident 1 was involved in a verbal altercation and was assessed for signs of injury and emotional distress. A review of Resident 1’s Care Plan, developed on 9/6/2024, indicated Resident 1’s involvement in a verbal altercation. The interventions included were to monitor any signs of emotional distress, offer room change to the resident, and to provide emotional support and encourage resident to verbalize feelings. During an interview on 9/16/2024 at 10:49 a.m., with Resident 1, Resident 1 stated that during an activity's session (unable to recall the exact day), she (Resident 1) was moved to Room 2 because of an argument with Resident 2. Resident 1 stated, “I don’t know what happened.” b. A review of Resident 2’s Admission Record indicated the facility admitted Resident 2 on 7/27/2023 with diagnoses that included bipolar disorder (a mental illness that causes extreme mood swings, or shifts in mood, energy, and activity levels), history of transient ischemic attack (TIA- a temporary blockage of blood flow to the brain) and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of Resident 2’s MDS dated 8/3/2024, indicated Resident 2 had the ability to usually understand and is usually understood. The MDS indicated Resident 2 was dependent on personal hygiene, putting on and taking off footwear, showering, and required maximum assistance (helper does more than half the effort) with toileting. A review of Resident 2’s SBAR form dated 9/6/2024, timed at 12:37 p.m., indicated Resident 2 was being verbally aggressive towards another resident (Resident 1) during the activity's session. A review of Resident 2’s Care plan, developed on 9/6/2024, indicated Resident 2’s involvement in a verbal altercation. The interventions included were to monitor for any signs of emotional distress, offer room change, and to encourage resident to verbalize feelings. During an interview on 9/16/2024 at 12:31 p.m. with the AD, the AD stated he had abuse training but feels like he did not get enough training. The AD stated that on 8/24/2024 the verbal altercation between Resident 1 and Resident 2 was not documented by the AD in the Activity Progress Notes until 9/2/2024. The AD stated Resident 1 and Resident 2 were roommates and the verbal altercation occurred prior to lunch, on 8/24/2024, during an activity. The AD stated Resident 2 was cussing at the AD and calling the AD verbal profanity. The AD stated he (AD) then placed Resident 1 next to Resident 2 and that was when Resident 2 stated, “move this (verbal profanity) away from me, she is full of demons.” The AD stated Resident 1 looked at Resident 2 but did not respond to Resident 2. The AD stated he was in shock; it was then time for lunch and the AD removed Resident 2 and sent Resident 2 into her (Resident 2’s) room. The AD stated Resident 2 was directing her comments to Resident 1. The AD stated did not report the verbal altercation between Resident 1 and Resident 2 to anyone at that point. The AD stated it was not until there was an abuse in-service (time and date not specified) that he (AD) then told the Director of Nursing (DON) that there had been an abuse incident. The AD stated he (AD) was educated that they must report abuse to keep residents safe. The AD stated if abuse is not reported, it can be a big issue. The AD stated keeping Resident 1 and Resident 2 in the same room after a verbal altercation increases the residents’ risk for further abuse. During an interview on 9/16/2024 at 2:35 p.m. with the Social Service Director (SSD), the SSD stated that AD mentioned the incident between Resident 1 and Resident 2 on 9/6/2024 (during a meeting). The SSD stated that AD mentioned during the meeting that Resident 1 and Resident 2 had an incident and was not too sure what abuse was and that AD was not sure if he (AD) should have reported it. The SSD stated the AD mentioned Resident 2 was making comments about Resident 1 being evil. The SSD stated Resident 1 and Resident 2 verbal altercation should have been reported and documented immediately. The SSD stated not reporting in a timely manner placed Resident 1 and Resident 2 at risk for further abuse because Resident 1 and Resident 2 were roommates. During an interview on 9/16/2024 at 3:00 p.m. with the DON, the DON stated the AD should have immediately separated residents and informed the nurse so that she (DON) can start the abuse protocol right away. The DON stated that failing to report a resident to resident altercation could lead to the residents not being monitored, placing the residents at risk for distress and further abuse. During an interview on 9/16/2024 at 3:33 p.m. with the Administrator (ADM), the ADM stated the AD should have reported the alleged abuse within two hours if the AD thought the incident, was an abuse. The ADM stated Resident 1 and Resident 2 were separated on 9/6/2024, but if the nursing department was aware of the incident, the room change could have been done earlier. The ADM stated by not separating the involved residents and not providing a room change immediately after the alleged verbal abuse can escalate to further abuse. A review of the facility’s policy and procedures titled, Abuse Prohibition and Prevention Program,” last revised on 04/2024, indicated the facility strives to provide an environment which prohibits and prevents abuse, neglect, and exploitation of residents and misappropriation of resident property. The facility will provide protection of residents from harm during an investigation including but not limited to separation of residents involved in a resident-to-resident altercation. A review of the facility’s policy and procedures titled, “Reporting of Alleged Violations,” last revised on 2/2024, indicated the facility prohibits the use of verbal, mental, sexual, physical abuse, neglect, misappropriation of resident property, exploitation, and or involuntary seclusion, and physical or chemical restraint not required to treat the resident’s symptoms. Verbal abuse: the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Employees, facility consultants and or Attending Physicians must immediately report any suspected abuse or incidents of abuse to the Administrator or Director of Nursing Services. The facility shall ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknow source and misappropriation of resident property are reported immediately, but no later than 2 hours after the allegation is made. The facility failed to protect Resident 1’s and Resident 2’s right to be free from verbal abuse when on 8/24/2024, Resident 2 had an exchange of verbal profanity with Resident 1. Resident 1 and Resident 2, who were roommates, were not separated until 9/6/2024. In addition, the facility failed to implement its policy and procedure (P&P) titled “Reporting of Alleged Violations,” by failing to report the alleged verbal abuse to CDPH no later than two hours after the allegation occurred on 8/24/2024 (specific time not indicated). As a result, Resident 1 and Resident 2 were 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 1, Resident 2 and other residents. The above violations had direct or immediate relationship to the health, safety, or security of Resident 1 and Resident 2.