Health inspection·December 27, 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.

F610 (Investigate/Prevent/Correct Alleged Violation) §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §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. § 72315 - Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. § 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. 22 CCR § 72523 (a) 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. HSC § 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. WIC § 15630 (a) (b) (a) A person who has assumed full or intermittent responsibility for the care or custody of an elder or dependent adult, whether or not they receive compensation, including administrators, supervisors, and any licensed staff of a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care custodian, health practitioner, clergy member, or employee of a county adult protective services agency or a local law enforcement agency, is a mandated reporter. (b)(1) A mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that they have experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an internet report shall be made through the confidential internet reporting tool established in Section 15658, within two working days. (C) If the suspected or alleged abuse is abuse other than physical abuse, and the abuse occurred in a long-term care facility, except a state mental health hospital or a state developmental center, a telephone report and a written report shall be made to the local ombudsman or the local law enforcement agency. During an annual recertification survey conducted on 12/3/2024 to 12/7/2024 the California Department of Public Health determined: The facility failed to: 1a. Report alleged abuse of Resident 69 by Resident 1. b. Ensure Resident 69 was safe from Resident 1 after alleged abuse. c. Monitor Resident 1 and 69 for alleged abuse. 2a. Ensure Resident 146, who was aggressive and combative toward staff and on 8/15/2024 was sent out to a General Acute Care Hospital (GACH) on a 5150 (temporary, involuntary commitment of residents who present a danger to themselves or others due to signs of mental illness) hold, was not placed at the front of the nursing station with access to other residents. b. Ensure Resident 62 was not subjected to Resident 146's aggressive outburst when Resident 146 suddenly grabbed Resident 62's quad (adjustable walking cane with 4-pronged base for extra stability) cane and hit Resident 62 with it. As a result, Resident 146 punched Resident 62 in the chest and arms subjecting Resident 62 to physical abuse. These deficient practices placed Resident 1 and Resident 62 at risk for further abuse and had the potential to cause feelings of intimidation, neglect and not feeling safe in the facility. Findings: 1. A review of Resident 69's Admission Record, indicated the facility initially admitted Resident 69 to the facility on 1/16/2023 and re-admitted on 3/19/2024 with diagnoses of end stage renal disease (kidney failure- a condition in which the kidney's lose ability to remove waste and balance fluids in the body), generalized muscle weakness, and hypertension (high blood pressure). A review of Resident 1's history and physical (H&P), dated 3/20/2024, indicated Resident 69 did not have the capacity to understand and make decisions. A review of Resident 69's Minimum Data Set ([MDS] resident assessment tool), dated 8/30/2024, indicated Resident 69 required substantial/maximal assistance (helper lifts or hold trunk of limbs and provides more than half the effort) with shower and bathing self, lying to sitting on side of bed, and sit to lying. Resident 1 was dependent (resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity). A review of Resident 69's census (room locations within the facility) indicated Resident 69's room was next to Resident 1's room with a shared bathroom from 1/16/2023 until 3/26/2024 when Resident 1 was moved to another room. During a phone interview on 12/26/2024 at 8:44 a.m., Resident 69's family member (FM1) stated Resident 69 was sexually assaulted by resident 1 in the middle of the night in March 2023. FM1 stated he spotted Resident 1 next door to Resident 69's room in July 2024 and wondered why someone would place Resident 1 next to Resident 69 again. FM1 stated Resident 69 said he sometimes sees a shadow of someone going to the restroom and thinks it is Resident 1. During an interview on 11/27/2024 at 2:33 p.m., Resident 69 became agitated when asked about the incident. Resident 1 stated sometime last year in 2023, he could not recall the exact date he was sexually assaulted by Resident 1. Resident 69 stated he was taking a nap in his bed and Resident 1 came into his room and got on top of him, groped his private area, kissed him, and put his hand over his mouth. Resident 1 stated he tried to scream but no one could hear him. Resident 69 stated his roommate finally heard him say call the police. Resident 69 stated that same day he told the charge nurse (unknown), and they did nothing. Resident 69 stated he had to fill out a complaint and was halfway through it, and he was told he was done. Resident 69 stated the next day the Social Service Director (SSD) told him the facility could not address everything on the report and this made him feel terrible. Resident 69 stated after that the SSD never came back to check on him. During a review of Resident 1's Admission Record , the Admission Record indicated Resident 1 was admitted to facility on 12/12/2022 and readmitted on 1/16/2023 with diagnoses of schizophrenia, unspecified (a mental health condition that affects everything from how you feel and behave), unspecified dementia (a group of symptoms that impact memory, thinking, and social abilities), psychotic disturbance (a severe mental disorder that causes a person to lose touch with reality and have abnormal thoughts, perceptions and behaviors, Mood disturbance (a mental health condition that primarily affects your emotional state), and anxiety (an intense, excessive and persistent worry and fear about everyday situations). During a record review of Resident 1's H&P dated 7/27/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's MDS, dated 9/17/2024, the MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/ or touching/ steadying and/or contact guard assistance as resident completes activity) in shower bathing self, putting on and taking off footwear, independent in sit to stand, and sit to lying and wheels 50 feet with two turns. A review of the Situation Background Assessment Recommendation Communication Form (SBAR) dated 3/26/2023 at 3:57 p.m., indicated CNA 5 reported that Resident 1 attempted to kiss Resident 69 in Resident 69's room. The SBAR indicated Resident 69 stated that he woke up and Resident 1 was hovering in front of his face, and no one saw what happened. The SBAR indicated a Charge nurse (unidentified) and a Registered Nurse (unidentified) assessed both parties and Resident 1 denied doing anything. The SBAR indicated Resident 1 was transferred to another room immediately. The SBAR indicated Resident 69 stated that he felt uncomfortable. During an interview on 11/27/2024 at 11:25 a.m., the SSD stated that she was aware of the alleged incident in 2023 between Resident 1 and Resident 69. The SSD stated she checked on Resident 69 once to see if he was ok. The SSD stated when there is an alleged incident of abuse the two residents need to be separated. The SSD verified on 11/27/2024 Resident 1 was placed 10 rooms from Resident 69. The SSD stated she had no documentation of the alleged incident. The SSD stated it was important to monitor the victim of the alleged abuse for 72 hours to make sure the resident feels safe, and the perpetrator was not a continuous threat to the resident. The SSD stated if the 72-hour monitoring was not documented it wasn't done. During an interview on 11/27/2024 at 1:52 p.m., with Registered Nurse (RN 1), RN 1 stated when there is a suspected resident to resident abuse the two residents are separated and the abuse is reported to the abuse coordinator who is the Administrator (ADM). RN 1 stated if there was an allegation of physical abuse, facility staff called the police, the primary doctor, the ombudsman (resident advocate) and the family. RN 1 stated the two residents are monitored for 72 hours. RN 1 stated when separating the two residents it was not wise to put Resident 1 down the hallway from Resident 69 because Resident 1 was independently ambulatory and could easily walk to Resident 69's room. During an interview on 12/4/2024 at 10:10 a.m., the Facility Nursing Consultant stated he was the DON at the time the incident occurred in 2023. The Facility Nursing Consultant stated when there is an alleged resident to resident altercation the victim and the aggressor need to be separated immediately to ensure the safety of both residents. The Facility Nursing Consultant stated the victim must be monitored for emotional distress and the SSD may need to recommend behavioral support. The Facility Nursing Consultant stated the SSD also monitors and documents on both residents. The Facility Nursing Consultant stated there needs to be a room change to separate the residents because if they are in the same vicinity the victim can be triggered of the incident again. The Facility Nursing Consultant stated the room placement of Resident 1 and Resident 69 was close (the same Hallway). The Facility Nursing Consultant stated if there are no other rooms available to maintain their separation Resident 1 should have been sent out to another facility. During an interview on 12/6/2024 at 10:11 a.m., the Administrator (ADM) stated when there is an allegation of abuse the staff must report to the Administrator, the police, the ombudsman, the California department of public health (CDPH), and call the family. The ADM stated it was important that everything was done according to policy and procedure so that the facility does not have another incident like this one. 2. A review of Resident 62s Admission Record indicated Resident 40 was admitted to the facility on 1/16/2024 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Post-Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), difficulty of walking, and abnormalities of gait and mobility. A review of Resident 62's MDS, dated 10/24/2024, the indicated Resident 62's cognitive skills (ability to think and reason) for daily decision-making were intact. The MDS indicated Resident 62 required set up assistance with eating, oral hygiene, dressing, personal hygiene, and supervision with showering. A review of Resident 146's Admission Record, indicated Resident 146 was admitted to the facility on 8/2/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder, PTSD, acquired absence of left foot, and acquired absence of right leg below the knee. A review of Resident 146's MDS, dated 8/4/2024, indicated Resident 146's cognitive skills for daily decision-making were moderately impaired. The MDS indicated Resident 146 required set up assistance with eating, partial assistance (helper does less than half the effort) with oral hygiene, substantial assistance (helper does more than half the effort) with showering and dressing, and resident was dependent on staff with toileting hygiene. A record review of Resident 146's Interdisciplinary (IDT resident's healthcare team consisting of various specialties) Team Progress Note, 8/16/2024 12:52 p.m., the note indicated on 8/15/2024 the following events transpired: a. At 3:20 p.m., Resident 146 made sexual advancement to an unnamed Certified nurse assistant (CNA) while he was being changed in his room. The Charge nurse assessed the resident and Resident 146 started to get confused, agitated, cursing, trying to get out of bed. Resident 146 was transferred to his wheelchair. b. At 4:30 p.m., the physician was notified. c. At 4:40 p.m., Resident 146 started to get more confused, agitated, and was cursing at people around him, yelling, "This is my house, get out of my house! I do not want no one in my house!". d. At 5 p.m., a CNA (unidentified) tried to encouraged Resident 146 to eat but Resident 146 refused, grabbed the food tray the CNA was trying to serve, and the food fell on the floor and anything else Resident 146 could r