Health inspection·March 2, 2023

42 CFR §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. 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 12/20/2022, the State Survey Agency (SSA) made an unannounced visit to the facility to conduct a complaint and a facility-reported incident (FRI) regarding staff to resident abuse. The facility failed to report the allegation of staff to resident abuse to the SSA for Resident 1. On 12/15/2022, Licensed Vocational Nurse 1 (LVN 1) was informed about the allegation of staff to resident abuse, but it was not reported to the Abuse Coordinator (or Administrator Designee) and to the SSA within 2 hours. The facility reported the allegation on 1/12/2023 (32 days from the date the allegation was made). As a result, Resident 1 was at risk for abuse. A review of Resident 1's Face Sheet (admission record) indicated the facility admitted an 80-year-old female resident on 4/21/2021, with diagnoses including spinal stenosis (happens when the space in the spine narrows and creates pressure on the spinal nerves), cardiomegaly (enlarged heart), and morbid obesity (an abnormal or excessive fat accumulation that presents a risk to health). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/21/2022, indicated the resident's cognitive (involving conscious intellectual activity such as thinking, reasoning, or remembering) skills for daily decision making were intact. The MDS also indicated the resident required supervision on transfer and locomotion on unit (how resident moves between locations in her room and adjacent corridor on same floor) and required extensive assistance with toilet use. The MDS indicated Resident 1 was not steady and was only able to stabilize with staff assistance on walking with assistive device and turning around and facing the opposite direction while walking. During a telephone interview on 12/20/2022 at 1:38 p.m., LVN 1 stated that Certified Nursing Assistant 2 (CNA 2) informed LVN 1 on 12/15/2022 about the allegation of verbal abuse by CNA 1 to Resident 1 on 12/11/2022. LVN 1 stated that the verbal abuse allegation was not reported to the Director of Nursing (DON) and SSA. LVN 1 stated that if abuse allegations are not reported timely, the resident could potentially experience further abuse. During an interview on 1/12/2023 at 2:10 p.m., the Administrator stated that an allegation of abuse should be reported within 2 hours of knowledge of the abuse or allegation of abuse to protect the residents. The Administrator stated they could not find any documented evidence that the DON has reported the allegation of abuse. A review of the facility's policy and procedure titled, "Abuse, Neglect and Exploitation Prevention," dated 9/26/2022, indicated that if there is an abuse allegation, the allegation must be reported no later than two hours after the allegation is reported. The facility failed to report the allegation of staff to resident abuse to the SSA for Resident 1. On 12/15/2022, LVN 1 was informed about the allegation of staff to resident abuse, but it was not reported to the Abuse Coordinator (or Administrator Designee) and to the SSA within 2 hours. The facility reported the allegation on 1/12/2023 (32 days from the date the allegation was made). As a result, Resident 1 was at risk for abuse. The above violations had direct or immediate relationship to the health, safety, or security of Resident 1.