Health inspection·February 2, 2024

F609 §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. § 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 12/11/2023, the California Department of Public Health (CDPH) received an anonymous complaint alleging a resident (Resident 3), who was mute (unable to speak), was slammed onto his bed by an African American man (Care Giver) who then pressed is knee into Resident 3's body. The Care Giver closed Resident 3's door and a thump was heard against the wall. Resident 3's face was noted with bruises. On 12/13/2023 at 12:15 p.m., CDPH conducted an unannounced visit to the facility to investigate the allegation of abuse. The CDPH determined the allegation of abuse could not be substantiated, however, determined the facility did not report to the CDPH an allegation of abuse or injuries to Resident 3's face when were noted. The facility failed to: 1. Report an allegation of abuse when Resident 3 was found with red marks and abrasions to his face, forehead, nose, and eyebrows and dried blood in his right ear on 12/10/2023. 2. Follow their policy and procedure (P/P), titled, "Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating," that indicated if resident abuse or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to State law. This deficient practice resulted in a delay in the CDPH's investigation and posed a risk for pertinent information to be lost and/or forgotten and had the potential for other suspicions of abuse to go unreported. A review of Resident 3's Admission Record (Face Sheet) indicated Resident 3, a 65 year-old male, was admitted to the facility on 9/15/2023 with the diagnoses including hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a slight paralysis or weakness on one side of the body) following a cerebral infarction ([a stroke] when blood flow to the brain is disrupted due to problems with the blood vessels that supply it). A review of Resident 3's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 9/21/2023 indicated Resident 3's cognitive skills for daily decision-making were severely impaired. A review of a screen shot photo of Resident 3's face, taken with the facility's cell phone, dated 12/10/2023 and time stamped at 3:34 p.m., indicated Resident 3 had multiple red marks and abrasions on the bridge of his nose, his left eyebrow, his left ear, his lip, his forehead, and face. A review of a screen shot photo of Resident 3's face, taken with the facility's cell phone, dated 12/10/2023 and time stamped at 3:35 p.m. indicated Resident 3 had two red abrasions on the right side of his forehead, dried blood in his right ear, a red scratch from his right ear to his right cheek measuring approximately four to five inches in length and red marks/abrasions on his nose and face. During an interview on 12/14/2023 at 1:38 p.m., a Certified Nursing Assistant (CNA 1) stated he noticed the scratch on Resident 3's right cheek and a bruise on his chest on 12/11/2023 and reported it to the treatment nurse. During an interview on 12/15/2023 at 3:01 p.m., CNA 2 stated Resident 3 was assigned to her on 12/10/2023 during the 3 p.m. - 11 p.m. shift and she noticed red marks on Resident 3's face and dried blood in his right ear. CNA 2 stated she reported what she saw to the Registered Nurse Supervisor (RNS 2) and told RNS 2 that Resident 3's condition needed to be addressed. During an interview on 12/15/2023 at 3:35 p.m., the Licensed Vocational Nurse (LVN 1) stated she took a picture of Resident 3's face to document how Resident 3 looked the afternoon CNA 4 took care of Resident 3 (12/10/2023). LVN 1 stated she was concerned for Resident 3's well-being after witnessing CNA 4's aggressive behavior towards her (LVN 1) and RNS 2. LVN 1 stated she did not know where the scratches on Resident 3's right cheek came from, and she did not inform the Director of Nursing (DON) or the Administrator (ADM) of the injuries to Resident 3's face. During an interview on 12/18/2023 at 10:41 a.m., the DON stated any allegation or suspicion of abuse should be reported to the CDPH within two hours if there is serious injury. The DON stated the suspicion of abuse should be reported to her, the Ombudsman, and the police. The DON stated if abuse is unreported, there is a potential for further abuse to occur. A review of the facility's P/P titled "Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating," dated 9/2022 indicated if resident abuse or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The facility failed to: 1. Report an allegation of abuse when Resident 3 was found with red marks and abrasions to his face, forehead, nose, and eyebrows and dried blood in his right ear on 12/10/2023. 2. Follow their policy and procedure (P/P), titled, "Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating," that indicated if resident abuse or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. This deficient practice resulted in a delay in the CDPH's investigation and posed a risk for pertinent information to be lost and/or forgotten and had the potential for other suspicions of abuse to go unreported. These violations jointly, separately, or in any combination, had a direct relationship to the health, safety, or security of patients.