Health inspection·November 28, 2023

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. §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. §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 10/19/2023, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) reported that a Certified Nursing Assistant (CNA 1) put lotion on her vagina, and it made her (Resident 1) feel violated in 8/2023. On 10/23/2023 at 2:39 p.m., the CDPH conducted an unannounced visit to the facility to investigate the allegation. The CDPH determined Resident 1 reported to a staff member that she was inappropriately touched in 7/2023 and the facility failed to report the allegation of abuse to the CDPH. The facility failed to: 1. Report an allegation of abuse when Resident 1 filed a grievance (a complaint that may or may not be justified) on 7/12/2023 with the facility’s Social Services Director (SSD) alleging CNA 1 inappropriately touched her (Resident 1). 2. Ensure the abuse coordinator or designee followed the facility’s policy and procedure (P/P), titled, “Abuse- Reporting and Investigations," that indicated outside agencies should be notified of allegation of abuse with no serious bodily injury within two hours and a written Report of Suspected Dependent Adult/Elder Abuse (SOC 341) report will be sent to the Ombudsman, Law Enforcement, and CDPH, licensing and certification within two hours. This deficient practice resulted in the delayed investigation by the CDPH and had the potential for other allegations of abuse to go unreported and for abuse to occur without oversight by the CDPH. A review of Resident 1’s Admission Record (Face Sheet) indicated Resident 1, a 53-year-old female, was admitted to the facility on 10/19/2022 with a diagnosis of diabetes ([DM] a chronic condition associated with abnormally high levels of sugar in the blood). A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 7/24/2023 indicated Resident 1 was able to make independent decisions that were reasonable and consistent and required extensive assistance from two staff members to complete her activities of daily living ([ADLs] tasks related to personal care such as eating, bathing, dressing, grooming and toileting). A review of the facility’s Grievance/Complaint Investigation Report, dated 7/12/2023, indicated Resident 1 expressed she did not like how CNA 1 applied lotion on her body and her groin. The Grievance/Complaint report indicated Resident 1’s complaint was assigned to the Nursing Department and the DSD. During an interview on 10/23/2023 at 10:54 a.m., Family Member (FM) 1 stated Resident 1 informed her that a CNA (CNA 1) applied lotion to her (Resident 1) vagina. FM 1 stated Resident 1 believed the incident was reported to the CDPH by the Director of Staff Development (DSD). During an interview on 10/23/2023 at 2:55 p.m., Resident 1 stated in 7/2023 or 8/2023, CNA 1 touched her inappropriately by applying lotion on her (Resident 1) body and groin area. Resident 1 stated she reported the incident to the DSD and CNA 2. During an interview on 10/25/2023 at 9:45 a.m., the SSD stated Resident 1 reported she did not like how CNA 1 applied lotion to her (Resident 1) body specifically her groin area. The SSD stated she informed the Administrator (ADM), the Director of Nursing (DON) and the DSD of Resident 1’s grievance. The SSD stated inappropriate touching can be considered sexual abuse and should be reported immediately. The SSD stated if abuse was unreported, it can cause psychosocial concerns, resistant to staff performing care and behavioral issues. During an interview on 10/26/2023 at 3:21 p.m., the DON stated inappropriate touching that makes a resident feel uncomfortable is a form of sexual abuse. The DON stated sexual abuse should be reported to the appropriate agencies within a specific time frame. The DON stated if abuse was unreported the resident may fear their safety, experience depression, anxiety and feel violated. During an interview on 10/26/2023 at 3:22 p.m., the ADM stated she was notified of the grievance at the end of 8/2023. The ADM stated all resident concerns and grievances should be investigated and reported to the appropriate agencies. The ADM stated Resident 1’s allegation, which was made in 7/2023, was not reported to the CDPH. The ADM stated she was on leave from the facility at the time the allegation was made, and the interim ADM should have reported the allegation but did not. A review of the facility’s policy and procedure (P/P) titled "Abuse-Reporting and Investigations," dated 8/18/2023, indicated outside agencies should be notified of allegation of abuse with no serious bodily injury within two hours and a written Report of Suspected Dependent Adult/Elder Abuse (SOC 341) report will be sent to the Ombudsman, Law Enforcement, and CDPH licensing and certification within two hours. The facility failed to: 1. Report an allegation of abuse when Resident 1 filed a on 7/12/2023 with the facility’s SSD alleging CNA 1 inappropriately touched her (Resident 1). 2. Ensure the abuse coordinator or designee followed the facility’s P/P, titled, “Abuse- Reporting and Investigations," that indicated outside agencies should be notified of allegation of abuse with no serious bodily injury within two hours and a written Report of Suspected Dependent Adult/Elder Abuse (SOC 341) report will be sent to the Ombudsman, Law Enforcement, and CDPH, licensing and certification within two hours. This deficient practice resulted in the delayed investigation by the CDPH and had the potential for other allegations of abuse to go unreported and for abuse to occur without oversight by the CDPH. These violations jointly, separately, or in any combination, presented had a direct relationship to the health, safety, or security of patients.