Health inspection·November 13, 2024

(Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) §483.12(b) The facility must develop and implement written policies and procedures that: §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. (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §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(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. On 9/18/2024, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 6) threw oatmeal at another resident (Resident 2) and the Administrator did not investigate it. On 9/26/2024 CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation, CDPH determined Resident 2 and Resident 6 were involved in a physical altercation on 9/13/2024 and a verbal altercation on 9/14/2024 that was not investigated by the facility's Administrator (ADM) or reported to the CDPH. The facility failed to: 1. Ensure the physical and verbal altercations between Resident 2 and Resident 6 were reported to Administrator (ADM), and the CDPH, when a Certified Nursing Assistant (CNA 6) witnessed Resident 2 and Resident 6 throwing oatmeal at each other on 9/13/2024, and when Restorative Nursing Assistant (RNA) 1 witnessed a verbal altercation between Resident 2 and Resident 6 on 9/14/2024 and reported it to the ADM. 2. Ensure a verbal altercation between Resident 2 and Resident 6 was investigated by the ADM when she was made aware of the incident on 9/14/2024. 3. Ensure nursing and administrative staff followed their policy and procedure (P/P) titled, "Abuse Reporting and Prevention" that indicated the facility must ensure that the residents are protected by providing a method of investigation and reporting of any alleged violations involving mistreatment and resident to resident altercation by the administrator or his/her designee to the Ombudsman's office and the Department of public Health and must investigate all allegations and all substantiated incidents and the results of the investigation must be reported to CDPH, within 5 working days of the incident(s). As a result of these failures, CDPH was unable to investigate the Resident-to-Resident altercations between Resident 2 and Resident 6 in a timely manner and had the potential for facts related to the allegations to be forgotten by staff and other witnesses. A review of Resident 2's Admission Record (Face Sheet) indicated Resident 2 was admitted to the facility on 2/26/2024 and readmitted on 9/2/2024, with a diagnosis of anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). A review of Resident 2's Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 9/9/2024, indicated Resident 2 was able to make independent decisions that were reasonable and consistent. A review of Resident 6's Admission Record (Face Sheet), indicated Resident 6 was admitted to the facility on 11/7/2021 with a diagnosis of cerebral infarction ([stroke] a condition that occurs when blood flow to the brain is blocked or there is sudden bleeding in the brain). A review of Resident 6's MDS dated 7/18/2024, indicated Resident 6 was able to make decisions and express his needs, despite being forgetful. A review of Resident 6's History and Physical (H&P) dated 8/27/2024, indicated Resident 6 had the capacity to understand and make decisions. During an interview on 9/26/2024 at 4:23 p.m., Resident 2 stated there was a past situation between him and a previous roommate (Resident 6) that he did not want to elaborate on because he already told the Administrator about it. During a telephone interview on 9/27/2024 at 1:28 p.m., RNA 1 stated Resident 2 and Resident 6 had a verbal altercation in the dining Room on 9/14/2024 (unsure of the time). RNA 1 stated Resident 2 approached Resident 6 and asked Resident 6 to be his friend, but Resident 6 did not want to talk to Resident 2 and Resident 6 started to move his hands and yell at Resident 2. RNA 1 stated Resident 2 responded to Resident 6 by using racial slurs (demeaning language that is offensive toward members of a racial or ethnic group) at Resident 6. RNA 1 stated she called the ADM on 9/14/32024 and informed her of Resident 2 and Resident 6's verbal altercation. RNA 1 stated during the same telephone call she also informed the ADM of another incident that occurred between Resident 2 and Resident 6 on 9/13/2024 during the 7 a.m. to 3 p.m. shift, that she heard from CNA 6. RNA 1 stated, the CNA told her that Resident 2 and Resident 6 were throwing oatmeal at each other in their room. RNA 1 stated it was the duty of all staff at the facility to report any alleged mistreatment and/or resident altercation immediately to the ADM because the residents' safety was a priority. During an interview on 9/27/2024 at 4:06 p.m., the ADM stated she did not report the verbal altercation that occurred on 9/14/2024 between Resident 2 and Resident 6 to CDPH or investigated it because she did not see the incident as mistreatment but rather a roommate incompatibility and stated the incident on 9/13/2024 was not reported to her so she did not know about it. The ADM stated it was the duty of the facility to report any allegations of mistreatment and/or resident to resident altercation to CDPH in a timely manner. The ADM stated there was no conclusion to submit to CDPH because no investigation was conducted. The ADM stated it was necessary to conduct a thorough investigation and send the conclusion report to CDPH, to verify the findings and find solution and/or perform a corrective action to the problem. A review of the facility's P/P titled, "Abuse Reporting and Prevention" revised 4/2024, the P/P indicated the facility must ensure that the residents are protected by providing a method of investigation and reporting of any alleged violations involving mistreatment and resident to resident altercation by the administrator or his/her designee to the Ombudsman's office and the Department of public Health. The P/P indicated the facility must investigate all allegations and all substantiated incidents and the results of the investigation must be reported to CDPH, within 5 working days of the incident(s). The facility failed to: 1. Ensure physical and verbal altercation between Resident 2 and Resident 6 was reported to the ADM, and the CDPH, when CNA 6 witnessed Resident 2 and Resident 6 throwing oatmeal at each other on 9/13/2024, and when RNA 1 witnessed a verbal altercation between Resident 2 and Resident 6 on 9/14/2024 and reported it to the ADM. 2. Ensure a verbal altercation between Resident 2 and Resident 6 was investigated by the ADM when she was made aware of the incident on 9/14/2024. 3. Ensure nursing and administrative staff followed their P/P titled, "Abuse Reporting and Prevention" that indicated the facility must ensure that the residents are protected by providing a method of investigation and reporting of any alleged violations involving mistreatment and resident to resident altercation by the administrator or his/her designee to the Ombudsman's office and the Department of public Health and must investigate all allegations and all substantiated incidents and the results of the investigation must be reported to CDPH, within 5 working days of the incident(s). As a result of these failures CDPH was unable to investigate the Resident-to-Resident altercations between Resident 2 and Resident 6 in a timely manner and had the potential for facts related to the allegations to be forgotten by staff and other witnesses. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 2 and Resident 6. pg. 2