Health inspection·November 2, 2023

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. Title 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 9/19/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint and a facility reported incident about resident abuse. The facility failed to implement its Abuse Prohibition Policy by not to reporting to CDPH an allegation of verbal abuse (form of emotional abuse where someone uses words to invoke fear in another person and gain control over them) and physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) made by Family Member 1 (FM 1) on 8/27/2023 that involved Resident 1 and Certified Nurse Assistant 2 (CNA 2). As a result, Resident 1 was placed at an increased risk of further verbal and physical abuse from CNA 2 and had the potential to result in unidentified abuse in the facility. A review of Resident 1's Admission Record indicated the resident was originally admitted to the facility on 11/26/2019 with diagnoses including functional quadriplegia (inability to move from the neck down including arms and legs) and type 2 diabetes (a disease that occurs when the body is unable to regulate the amount of sugar [glucose] in the blood resulting in high levels of blood sugar). A review of Resident 1’s Minimum Data Set (MDS- a standardized assessment and care-screening tool) dated 9/1/2023, indicated Resident 1 had the ability to understand and be understood. The MDS also indicated that Resident 1’s cognitive skills (the mental processes involved in gaining knowledge and comprehension) for daily living decision-making was intact (not affected). During an interview on 9/19/2023 at 11:52 p.m., Family Member 1 (FM 1) stated that on 8/27/2023, FM 1 electronically mailed (e-mailed) the Administrator (ADM), the Director of Nurses (DON), and the Social Services Director (SSD) regarding an allegation of verbal and physical abuse reported to FM 1 by Resident 1. During an interview on 9/19/2023 at 1:24 p.m., the SSD stated receiving an email on 8/27//2023 from FM 1 about an abuse allegation involving Resident 1. SSD stated the email was also sent to the ADM and the DON. During an interview on 9/28/2023 at 12:44 p.m., the ADM confirmed receiving the email on 8/27/2023 about the abuse allegation but he read the email on 8/28/2023. The ADM stated that on 8/28/2023, he spoke to Resident 1 who denied the abuse allegation. The ADM stated that on 9/5/2023, Resident 1 stated that she felt abused and that is when he reported the abuse allegation to CDPH. The ADM further stated that he should have reported the allegation of abuse as soon as he read the e-mail on 8/28/2023. ADM stated that because the e-mail was not directly from Resident 1, ADM wanted to speak first speak with Resident 1 to ask if it was really abuse. A review of the facility’s policy and procedure (P&P) titled, “Abuse Investigate/ Prevent/ Report Alleged Violation,” last reviewed on 7/19/2023, indicated that it is the facility’s procedure to 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 no later than two (2) hours after the allegations is made, if the events that cause the allegation involve abuse or result in serious bodily injury… The facility failed to implement its Abuse Prohibition Policy by not to reporting to CDPH an allegation of verbal abuse and physical abuse made by FM 1 on 8/27/2023 that involved Resident 1 and CNA 2. As a result, Resident 1 was placed at an increased risk of further verbal and physical abuse from CNA 2 and had the potential to result in unidentified abuse in the facility. The above violations had a direct relationship to the health, safety, or security of Resident 1.