Health inspection·January 3, 2025

F609 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual's obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. § 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 12/2/2024, the California Department of Public Health (CDPH) received a complaint and on 12/17/2024 received a Facility Reported Incident (FRI) alleging that a Social Worker (Social Services Director [(SSD]) and a resident (Resident 1) were tugging back and forth, pulling Resident 1's jacket because the SSD tried to take Resident 1's jacket after Resident 1 was found to have a bottle medication ([Norco] a medication used to treat moderate to severe pain) that she (Resident 1) was not allowed to have. The allegation indicated the SSD forcefully took the jacket from Resident 1, causing Resident 1 pain to her right arm, which was ongoing. On 12/16/2024 the CDPH conducted an unannounced visit to the facility to investigate the complaint and FRI. During the investigation, the CDPH determined on 10/18/2024, Resident 1 was found to have a medication bottle that contained Norco, which was in a pocket of her sweater. The SSD asked Resident 1 to give her the bottle of medication and Resident 1 refused to give it to her. The SSD struggled with Resident 1, tugging on her sweater in an attempt to take it from her. The SSD eventually took Resident 1's sweater from her causing pain in Resident 1's right and left shoulders. On 10/18/2024 Resident 1's Responsible Party (RP) 1, reported that Resident 1's sweater was taken from her by staff who tugged on it, causing Resident 1 pain to both of her shoulders and Resident 1 being afraid of the SSD. On 10/25/2024, Resident 1 complained of left and right shoulder alleging the pain resulted from the SSD pulling/tugging and taking the sweater from her (Resident 1). The facility failed to: 1. Report an alleged physical altercation between the SSD and Resident 1 to the CDPH within two hours of the facility being made aware of the allegation. 2. Ensure Resident 1 was treated with respect and in a dignified manner, when the SSD tugged at and eventually took Resident 1's sweater and a medication bottle containing Norco from her without her permission and after Resident 1 refused to give the SSD the bottle of medication. 3. Follow their Policy and Procedure (P/P), titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention" dated 12/2007, that indicated the facility will report any allegations within timeframes required by Federal requirements. 3. Follow their P/P, titled, "Resident Rights," dated 12/2021, that indicated the facility employees will treat all residents with kindness, respect, and dignity. These failures resulted in the facility not reporting an allegation of abuse and the CDPH being unaware of the allegation causing a delay in the CDPH's investigation and placing Resident 1 at high risk for injuries and physical abuse. These failures resulted in Resident 1's complaint of pain to her left and right shoulders, Resident 1 being afraid of the SSD and not wanting to interact with her anymore. These deficient practices had the potential for other abuse allegations to go unreported, for long term injury/pain and for care and services to be unprovided to Resident 1 due to fear of interacting with the SSD. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on 10/17/2024 with diagnoses including bipolar disorder (a serious mental illness that affects how a person thinks, feels, and behaves), atrioventricular block ([AV block] a heart rhythm disorder that causes the heart to beat slower than it should) and diabetes type 2 ([DM] a disease that occurs when blood glucose, also called blood sugar [b/s], is too high). A review of Resident 1's History and Physical (H/P), dated 10/18/2024, indicated, Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set [(MDS), a resident assessment tool, dated 10/24/2024, indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1's cognition (ability to register and recall information) was intact. The MDS indicated Resident 1 had functional limitations in range of motion ([ROM] the direction a joint can move to its full potential) on one side of her lower extremities ([LE] legs). A review of Resident 1's Situation, Background, Assessment and Recommendation ([SBAR] a form of communication between members of a health care team) dated 10/18/2024, indicated Resident 1 was hiding narcotics (strong medication used to treat moderate to severe pain) in her sweater, the narcotics were taken away from Resident 1 by the SSD. A review of Resident 1's Nurse Progress Notes dated 10/18/2024 and timed at 2:08 p.m., indicated Resident 1 retrieved a bottle out of her sweater and self-administered one pill from the bottle then returned the bottle to the pocket of her sweater. The Nurse Progress Notes indicated Resident 1 refused to give the medication bottle to LVN 1, LVN 1 called SSD for assistance and the SSD took the medication bottle away from Resident 1. A review of Resident 1's Nurse Progress Note dated 10/25/2024 and timed at 6:35 p.m., indicated the Interdisciplinary Team ([IDT] a group of medical professionals from different disciplines who work together to help a resident achieve their goals) met at Resident 1's bedside to address the resident's concern regarding her right and left shoulder pain, which she (Resident 1) reported occurred following an incident on Friday (10/18/2024) when her jacket was tugged by another staff member (SSD). During a telephone interview on 12/16/2024 at 11:10 a.m., Resident 1's Responsible Party (RP) 1 stated Resident 1 informed her that on 10/18/2024, she (Resident 1) was holding onto her sweater when the SSD pulled the sweater away from her (Resident 1's) with the intent to take Resident 1's Norco medication bottle from her (Resident 1). RP 1 stated Resident 1 did not give permission for the SSD to take away her medication and trying to take the medication by tugging on Resident 1's sweater caused Resident 1 pain in both of her shoulders. RP 1 stated she reported the incident to the Director of Nurses (DON) on approximately 10/21/2024 but stated she did not receive a follow up to her report. RP 1 stated Resident 1 does feel safe with the SSD and does not want to interact with her anymore. During an interview on 12/16/2024 at 12:18 p.m., LVN 1 stated on 10/18/2024 she saw Resident 1 take a bottle labeled Norco from her sweater pocket, take a pill, and put the bottle back in her sweater pocket. LVN 1 stated she asked Resident 1 to give her the medication bottle but Resident 1 refused to give it to her. LVN 1 stated she asked the SSD for assistance, and we (LVN 1 and the SSD) informed Resident 1 that she could not self- administer the Norco. LVN 1 stated Resident 1 was holding onto her sweater and refused to relinquish the bottle of medication, that was when the SSD took the sweater from Resident 1. LVN 1 stated she did not report the incident because she did not think it was abuse but stated taking Resident 1's sweater from her without her permission was a violation of Resident 1's rights. During an interview on 12/16/2024 at 1:15 p.m., the SSD stated she was called into Resident 1's room on 10/18/2024 by LVN 1 because LVN 1 found Resident 1 had medication (Norco) in a medication bottle that she (resident 1) in her sweater pocket. The SSD stated she asked Resident 1 to give her the medication bottle, but Resident 1 refused. The SSD stated we (the SSD and LVN 1) educated Resident 1 on the risks of self-administrating Norco and informed Resident 1 it was against the facility's policy to keep narcotics in her possession, but Resident 1 still refused to give them the medication so she (SSD) took the sweater from Resident 1 in order to get the medication bottle from inside her sweater pocket. During an interview on 12/16/2024 at 3 p.m., the DON stated she was notified of the incident that occurred between the SSD and Resident 1 on approximately 10/25/2024. The DON stated the facility did not report the incident because neither she nor the Administrator (ADM) thought the incident was abuse. The DON stated the facility should have reported the incident because Resident 1 complained of shoulder pain following the incident and because Resident 1 did not feel safe around the SSD. A review of the facility's Job Description titled, "Director of Nursing" dated 9/2020, indicated the DON reports the following in accordance with established facility procedures and regulatory standards, accidents and incidents, resident grievances, complaints, and allegations of resident abuse or misappropriation of resident property. A review of the facility's policy and procedure (P/P), titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention" dated 12/2007, indicated the facility will implement measures to address factors that may lead to abusive situations such as investigate and report any allegations within timeframes required by federal requirements. During a review of the facility's P&P titled "Resident Rights," dated 12/2021, the P&P indicated the facility employees will treat all residents with kindness, respect, and dignity. During a review of the facility's Policy and Procedure (P/P), titled, "Self-Administration of Medications" revised 12/2016, the P/P indicated residents have the right to self-administer medications if the IDT team has determined that it is clinically appropriate and safe for the resident to do so. As part of their overall evaluation, the staff and practitioner will assess each resident' mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. The facility failed to: 1. Report an alleged physical altercation between the SSD and Resident 1 to the CDPH within two hours of the facility being made aware of the allegation. 2. Ensure Resident 1 was treated with respect and in a dignified manner, when the SSD tugged at and eventually took Resident 1's sweater and a medication bottle containing Norco from her without her permission and after Resident 1 refused to give the SSD the bottle of medication. 3. Follow their P/P, titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention" dated 12/2007, that indicated the facility will report any allegations within timeframes required by Federal requirements. 3. Follow their P/P, titled, "Resident Rights," dated 12/2021, that indicated the facility employees will treat all residents with kindness, respect, and dignity. These failures resulted in the CDPH being unaware of the allegation causing a delay in the CDPH's investigation and placing Resident 1 at high risk for injuries and physical abuse. These failures resulted in Resident 1's complaint of pain to her left and right shoulders, Resident 1 being afraid of the SSD and not wanting to interact with her anymore. These deficient practices had the potential for other abuse allegations to go unreported, for long term injury/pain to occur and for care and services to be unprovided to Resident 1 due to fear of interacting with the SSD. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1.