Health inspection·February 28, 2023

F 609 § 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. Title 22 § 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 1/20/2023, an unannounced visit was conducted to the facility to investigate a complaint regarding resident abuse. The facility failed to ensure all alleged violations involving abuse including injuries of unknown source were reported immediately to the State Survey Agency (SSA), the Ombudsman Program (residents' advocate group), and law enforcement, for Residents 1, 3, 4, and 5, as indicated in the facility’s policy. The facility did not make the necessary reports when: 1. Resident 1 informed Certified Nursing Assistant 1 (CNA 1) that Resident 2 spat on her and pushed a table towards her. 2. CNA 2, Licensed Vocational Nurse 4 (LVN 4) and Registered Nurse 2 (RN 2) documented a grievance on 10/9/2022 about Family Member 1 (FM 1) yelling over the phone at Resident 3 and using profanities. 3. FM 2 emailed SS 1 on 10/26/2022 concerned about Resident 5 having black areas on the side of the head and questioning why staff did not know was hitting the resident. 4. FM 3 called LVN 3 on 5/17/2022 after Resident 4 told FM 3 she was hit by someone in the facility. As a result, there were no investigations conducted to rule out abuse which placed Residents 1, 3, 4, and 5 at risk for further abuse. 1. A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident on 11/28/2022 with diagnoses including Alzheimer's disease (a brain disease that affects memory, language and thinking skills). A review of Resident 1's History and Physical, dated 11/30/2022, indicated resident was able to make needs known and able to make simple medical decisions. A review of Resident 1's MDS dated 12/26/2022, indicated Resident 1's cognitive skills for daily decision-making were moderately impaired (obvious difficulty with problem-solving, remembering names and details, and may withdraw socially as new situations and places are challenging). During an interview on 1/20/2023 at 10:44 a.m., CNA 1 stated Resident 1 informed her that Resident 2 (her roommate) spat on her and pushed a table towards her. CNA 1 stated she could not remember the date she was informed and stated she did not report the allegation to a supervisor. CNA 1 stated she did not report the allegation because it did not happen in her shift. During an interview on 1/20/2023 at 1:41 p.m., the Director of Staff Development (DSD) stated CNA 1 should have reported Resident 1's allegation of abuse to a supervisor. During an interview on 1/20/2023 at 2 p.m., Resident 1 stated Resident 2 spat on her face and yelled at her (unable to recall when) which made her mad. During an interview on 1/20/2023 at 2:39 p.m., the Administrator stated she was not informed of Resident 2’s allegation. 2. A review of Resident 3's Admission Record indicated the facility admitted the resident on 1/11/2023 with diagnoses including Alzheimer's disease. A review of Resident 3's MDS, dated 10/13/2022, indicated the resident’s cognitive skills for daily decisions were severely impaired. On 1/20/2023 at 3:49 p.m., a review of the Grievance Log indicated on 10/9/2022 at 6:15 p.m., CNA 2 heard FM 1 on the phone yelling at Resident 3 and using profanities. CNA 2 reported the incident to LVN 4 who reported to RN 2. RN 2 reported to the Administrator who instructed RN 2 to fill out a Grievance Issues and Concerns form. On 1/20/2023 at 4:41 p.m., during an interview, the Administrator stated the incident sounded like an argument and not abuse. 3. A review of Resident 5's Admission Record indicated the facility admitted the resident on 7/3/2022 with diagnoses including Parkinson's disease (a progressive disorder of the nervous system that affects movement) and dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 5's MDS, dated 11/9/2022, indicated the resident's cognitive skills for daily decisions were severely impaired. On 1/23/2023 at 11:01 a.m., during an interview with Social Services 1 (SS1) and concurrent review of the Grievance Log, indicated on 10/26/2022 FM 2 emailed reporting that for the second or third time he saw Resident 5 with black spots on the side of her head and no one knew who hit her. SS 1 stated the Administrator was informed. SS 1 stated she did not ask nursing staff about FM 2’s reported injuries, did not document FM 2's allegation in Resident 5’s clinical record, and did not investigate the allegations that someone was hitting Resident 5. During an interview on 1/23/2023 at 11:31 a.m., the Administrator stated she did not read FM 2’s entire email. 4. A review of Resident 4's Admission Record indicated the facility re-admitted the resident on 4/19/2019 with diagnoses including dementia. A review of Resident 4's MDS dated 10/30/2022, indicated the resident had moderately impaired cognition. A review of the Grievance Log indicated that on 5/17/2022, FM 3 called LVN 3 to inform her about Resident 4 telling FM 3, "Someone hit her." On 1/23/2023 at 4:52 p.m. during an interview with LVN 3 and concurrent review of the Grievance Log dated 5/17/2022, LVN 3 stated she received a phone call from FM 3 about the resident telling him someone hit her. LVN 3 stated she immediately notified the RN 2. On 1/23/2023 at 4:46 p.m. during an interview, the Administrator confirmed FM 3 allegation was not reported to the SSA. A review of facility's policy and procedure titled, "Abuse and Crime Prevention and Reporting" dated 10/11/2022 indicated "It is the policy of this facility to implement steps to potentially prevent, report and investigate in accordance with local, state and /or federal laws and regulations, to the appropriate agency, any allegations of and /or suspected conditions of abuse. All employees and covered individuals of the facility who observed, reasonably suspect, or have knowledge of an incident of abuse are to report to his/her supervisor and / or Abuse Prevention Coordinator and may also separately report directly to the appropriate agencies without fear of retaliation /reprisal. When an allegation or reasonable suspicions occurs of alleged or known incident involves abuse or serious bodily injury, repot to police, CDPH (SSA) and Ombudsman immediately and not more than two hours". The facility failed to ensure all alleged violations involving abuse including injuries of unknown source were reported immediately to the SSA, the Ombudsman Program, and law enforcement, for Residents 1, 3, 4, and 5, as indicated in the facility’s policy. The facility did not make the necessary reports when: 1. Resident 1 informed CNA 1 that Resident 2 spat on her and pushed a table towards her. 2. CNA 2, LVN 4 and RN 2 documented a grievance on 10/9/2022 about FM 1 yelling over the phone at Resident 3 and using profanities. 3. FM 2 emailed SS 1 on 10/26/2022 concerned about Resident 5 having black areas on the side of the head and questioning why staff did not know was hitting the resident. 4. FM 3 called LVN 3 on 5/17/2022 after Resident 4 told FM 3 she was hit by someone in the facility. As a result, there were no investigations conducted to rule out abuse which placed Residents 1, 3, 4, and 5 at risk for further abuse. The above violations had a direct relationship to the health, safety, or security of Residents 1, 3, 4 and 5.