Health inspection·March 1, 2024

F609 (Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) §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(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 1/16/2024 during an annual recertification survey, the California Department of Public Health (CDPH) received a complaint from Resident 299 alleging verbal abuse from Resident 51 including calling Resident 299 an offensive profanity (language that is considered socially offensive due to being vulgar, and obscene) in a different language other than English that resulted in Resident 299 having to move to a different room. Upon investigation, CDPH has determined the facility failed to report Resident 51 verbal abuse to Resident 299. The facility failed to: 1. Ensure an allegation of verbal abuse of Resident 299 reported to CDPH, the State Long Term Care Ombudsman (an agency that provides support for residents of nursing homes, board and care homes and assisted living facilities) and the local police department within the regulated time frame of two hours. 2. Ensure staff followed the facility's policy and procedure (P&P) titled, "Abuse-Reporting and Investigations," to report the allegation of abuse to the appropriate agencies including CDPH, the State Long Term Care Ombudsman, and the local police department. As a result of these deficient practices Resident 299 was placed at risk for possible continuous abuse, for allegations of abuse to go unreported, delay in the CDPH's investigation and the potential for important information to be lost. A review of Resident 299's Admission Record, indicated Resident 299, a 61-year-old female, was admitted to the facility on 12/22/2023, with diagnoses including functional paraplegia (paralysis that affects your legs, but not your arms), chronic obstructive pulmonary disease ([COPD] a common lung disease causing restricted airflow and breathing problems) and idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic body functions). A review of Resident 299's Minimum Data Sheet ([MDS] a standardized assessment and care screening tool) dated 10/19/23, indicated Resident 299 had an intact cognitive skill (ability to learn, understand, and make decisions) for daily decision making and required partial assistance from staff for all activities of daily living (ADL). A review of Resident 51's Admission Record indicated Resident 51, an 85-year-old female, was admitted to the facility on 10/1/2021 and re-admitted on 12/7/2022, with diagnoses including hyperlipidemia (unhealthy level of fat in the blood), hypertensive heart disease without heart failure (the heart is unable to pump blood around the body properly), diabetes mellitus without complications (elevated blood glucose level). A review of Resident 51's MDS dated 10/11/23, indicated Resident 51 was had an intact cognitive skill for daily decision making and was independent or required partial assistance from staff for all ADL. During an interview on 1/16/2024 at 11:05 a.m., Resident 299 stated her previous roommate (Resident 51) verbally abuse her by calling Resident 299 an offensive profanity (language that is considered socially offensive due to being vulgar, and obscene) in a different language other than English that resulted in Resident 299 having to move to a different room. During an interview on 1/19/2024 at 10:43 a.m., with Resident 299 and family member (FM 1), FM 1 stated Resident 299 had a verbal altercation with Resident 51 on 1/10/2024. FM 1 stated Resident 51 called Resident 299 with offensive profanity in a different language other than English. FM 1 stated they informed the Social Services Director (SSD) about the incident on 1/10/2024 and the facility decided to transfer Resident 299 to a different room. During a concurrent interview and record review on 1/19/2024 at 10:58 a.m., the SSD stated she was informed by Resident 299 and FM 1 of the verbal abuse allegations but failed to document regarding the verbal abuse incident between Resident 299 and Resident 51. A review of Resident 299's Social Services Progress Notes, indicated no documentation the verbal abuse allegation between Resident 299 and 51 was reported to the Ombudsman's office or to the DPH and local police department. During an interview on 1/19/2024 at 11:06 a.m., the Administrator (Adm), stated on 1/10/2024 Resident 299's FM 1 informed about the verbal abuse incident between Resident 299 and Resident 51. The Adm stated it was not reported to CDPH, Ombudsman and local Police Department and no investigation held regarding the verbal abuse allegations between Resident 299 and Resident 51. The Adm confirmed there was no documentation the allegation of verbal abuse was reported and investigated. During an interview on 1/19/2024 at 11:18 a.m., Licensed Vocational Nurse (LVN 1) stated that any form of abuse reported to the facility staff must be reported to the administrator, documented, and investigated. During a review of facility's policy and procedure titled "Abuse Prevention and Prohibition Program" implemented 10/1/2023 indicated the facility promptly and thoroughly investigates reports of resident abuse, neglect, mistreatment, misappropriation of property, injuries of an unknown source, and criminal acts. In order to facilitate reporting, ensure confidentiality, and promote order at the facility, the Administrator, or his/her designee, shall be the individual who reports known or suspected instances of abuse of residents at the facility to the proper authorities." The facility failed to: 1. Ensure an allegation of verbal abuse involving Resident 299 and Resident 51 was reported to CDPH, the State Long Term Care Ombudsman and the local police department within the regulated time frame of two hours. 2. Ensure staff followed the facility's P&P titled, "Abuse-Reporting and Investigations," to report the allegation of abuse to the appropriate agencies including CDPH, the State Long Term Care Ombudsman, and the local police department. As a result of these deficient practices Resident 299 was placed at risk for possible continuous abuse, for allegations of abuse to go unreported, delay in the CDPH's investigation and the potential for important information to be lost. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.