Health inspection·January 5, 2022

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. On 11/16/2021 the State Survey Agency (SSA) made an unannounced visit to the facility for its annual recertification survey. The facility failed to report to the SSA and the Ombudsman Resident 132’s allegation of verbal abuse from her roommate (Resident 131) as per facility's abuse policy. As a result, Resident 131 continued to verbally abuse Resident 132. A review of Resident 132’s Admission Record (Face Sheet) indicated the facility re-admitted the resident on 1/5/2019, with diagnoses including atherosclerotic heart disease (condition caused by plaque buildup in the wall of the arteries that supply blood to the heart), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (an intense, excessive, and persistent worry or fear about everyday situations). A review of Resident 132’s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 10/19/2021, indicated the resident had the ability to make self-understood and to understand others. During an interview, on 11/16/2021 at 2:42 p.m., Resident 132 stated her roommate (Resident 131) called her filthy names including the "B word." Resident 132 stated Resident 131 had been calling her names and directing foul language towards her about four months ago and ongoing. Resident 132 stated she would turn down the lights and television volume to the lowest setting but Resident 131 would still scream and call her dirty names. Resident 132 stated she had told staff and Certified Nurse Assistant 8 (CNA 8). During an interview, on 11/18/2021 at 3:12 p.m., CNA 8 stated Resident 132 had told her that Resident 131 would yell at her and call her names that include foul language. CNA 8 stated she had heard Resident 131 scream while in the room but have not witnessed Resident 131 using foul language toward Resident 132. CNA 8 stated Resident 132 had told her, "You would not believe the names she called me," but would not repeat what was said to her. CNA 8 stated verbal abuse was anything threatening and intimidating as well as any sort of foul language from one resident to another. CNA 8 stated verbal abuse should be reported. CNA 8 confirmed that she did not report this to charge nurse or supervisor. CNA 8 stated verbal abuse allegation should be reported immediately to charge nurse and supervisor. During an interview, on 11/19/2021 at 8:45 a.m., CNA 8 stated she did report the verbal abuse to a charge nurse. CNA 8 stated Resident 132 complained that Resident 131 was going at it again and yelled at her. CNA 8 stated she did not remember the charge nurse whom she reported to as well as the date of when it happened. During an interview, on 11/19/2021 at 10:43 a.m., the Administrator (ADM) stated she was not aware of the verbal abuse allegation made by Resident 132 until she was notified by Social Services Director (SSD) who had informed her on 11/16/2021. The ADM read the definition of verbal abuse included in the facility's policy which defined verbal abuse as "any 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" and confirmed demeaning words and foul language directed to a resident is considered verbal abuse. The ADM stated the verbal abuse allegation should have been reported to her immediately once staff was notified by Resident 132 alleging verbal abuse by another resident. During an interview, on 11/19/2021 at 3:41 p.m., in the presence of the ADM, CNA 8 denied Resident 132 reported to her that she was called names by Resident 131. CNA 8 stated what she meant was that she did not think they were compatible, and they were fussing back and forth. CNA 8 stated Resident 132 had told her that Resident 131 said not nice things about her but was not informed of any name calling. When CNA 8 was asked if she had stated what the Resident 132 had told her which was "You would not believe the names she called me." CNA 8 stated she may have felt a little stressed. A review of the facility's policy titled, "Policy: Abuse and Mistreatment of Residents," reviewed and approved on 4/9/2021, indicated it is the facility's policy for any mandated reporter working in a facility to report abuse to their supervisor as well as the California Department of Public Health (CDPH)." The policy defined a mandated reporter as any person who has assumed full or intermittent responsibility for care or custody of an elder or dependent adult, whether or not that caretaker receives compensation. This includes administrators, supervisors, and any staff of a public or private facility that provides care or services for elder of dependent adults, or any elder or dependent adult care custodian, health practitioner, or employee of a county adult protective services agency or a local law enforcement agency. The policy further stated, "any mandated reporter in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, abandonment, isolation, financial abuse, or neglect, or reasonably suspects of abuse, shall report the known or suspected instance of abuse by telephone immediately or as soon as practically possible, and by written report sent within two hours, to the local Ombudsman and the local law enforcement agency shall report any case of known or suspected abuse to the State Department of Health Services. The facility failed to report to the SSA and the Ombudsman Resident 132’s allegation of verbal abuse from her roommate (Resident 131) as per facility's abuse policy. As a result, Resident 131 continued to verbally abuse Resident 132. The above violation had a direct relationship to the health, safety, or security of Resident 1.