Health inspection·January 15, 2025

W&I 15630(b)(1) (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. Freedom from Abuse, Neglect, and Exploitation 42 CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 42 CFR §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. 42 CFR §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. 42 CFR §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. 42 CFR §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. 22 CFR § 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. § HSC 1418.91 Abuse Reporting (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. On 12/16/2024, the California Department of Public Health (CDPH) conducted an unannounced annual recertification survey at the facility. The facility failed to: 1. Report abuse allegations to the State Agency (CDPH), ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and the police department when Resident 88's Responsible Party (RP 1) informed Registered Nurse (RN) 1 that Certified Nursing Assistant (CNA) 2 said hurtful things to Resident 88. 2. Report abuse allegations to the State Agency, ombudsman, and the police department when Resident 259 informed Licensed Vocational Nurse (LVN) 3 that CNA 2 made him feel uncomfortable during a bed bath. These failures resulted in a delay of an investigation by the State Agency and had the potential for ongoing abuse. a. Resident 88 was a 71-year-old female, initially admitted to the facility on 4/8/2022 and readmitted on 10/6/2024 with diagnoses including urinary tract infection (UTI, an infection in the bladder/urinary tract), type two diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest). A review of Resident 88's Minimum Data Set ([MDS], a resident assessment tool), dated 10/13/2024, indicated Resident 88's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 88 was dependent on staff's assistance with eating, oral hygiene, toileting, bathing, and dressing. A review of Resident 88's History and Physical Examination (H&P), dated 10/8/2024, indicated Resident 88 could make needs known but could not make medical decisions. A review of Resident 88's Progress Notes, dated 9/3/2024 and timed at 5:31 p.m., indicated, on 9/3/2025 at 5:30 p.m., Resident 88's Responsible Party (RP 1) called the facility to report that Resident 88 was confused and claimed that CNA 2 had been saying hurtful things to the resident, which made Resident 88 upset and affected her eating. The Progress Note indicated a supervisor and nurse went to Resident 88's room to speak with the resident, and Resident 88 repeated the same concerns. During an interview on 12/16/2024 at 11:10 a.m., RP 1 stated Resident 88 had a CNA that did not treat the resident well. RP 1 stated she called the facility to inquire if that CNA was still taking care of Resident 88 and was informed that the CNA described had not taken care of Resident 88 for some time. During an interview on 12/18/2024 at 9:41 a.m., RN 1 stated on 9/3/2024, RP 1 was at the facility during dinner time, and reported Resident 88 stated CNA 2 was saying hurtful things to her a few days prior. RN 1 stated Resident 88 told her and another nurse the same story. RN 1 stated her role as a mandated reporter was to report to the Administrator (ADM) and the Director of Nursing (DON), outside agencies including the police department, ombudsman, and the State Agency. RN 1 stated she did not report to the three outside agencies because reported to the DON and thought it would be handled from there. RN 1 stated reporting to the three agencies ensured that the allegation, whether real or not, was investigated to ensure the residents involved were safe and no other potential abuse occurred. During an interview on 12/18/2024 at 11:34 a.m., the Director of Staff Development (DSD) stated an abuse allegation needed to be reported to the ADM and to the three outside agencies, whether those with knowledge of the allegation believed it to be true or not. The DSD stated any staff member had the ability to report to the police department, ombudsman, and the State Agency if they had any knowledge of an abuse allegation. The DSD stated any abuse allegation needed to be reported within two hours. The DSD stated she was unaware whether the allegation was reported to the ADM or the three outside agencies. The DSD stated the lack of reporting had the potential to subject other residents to abuse by CNA 2. b. Resident 259 was an 82-year-old male, initially admitted to the facility on 9/25/2023 and readmitted on 12/11/2024 with diagnoses including UTI, sepsis (a life-threatening blood infection), and type two diabetes mellitus. A review of Resident 259's MDS, dated 9/26/2024, indicated Resident 259's cognition was moderately impaired. The MDS indicated Resident 259 required supervision with eating and oral hygiene and required substantial assistance (helper does more than half the effort) with dressing and personal hygiene. A review of Resident 259's H&P, dated 12/13/2024, indicated Resident 259 had the capacity to understand and make decisions. During an interview on 12/18/2024 at 9:05 a.m., with CNA 3, CNA 3 stated Resident 259 refused to have CNA 2 assigned to him, and he did not want to see CNA 2 and to get CNA 2 out of his room. CNA 3 stated she informed LVN 3 and the DSD. During an interview on 12/18/2024 at 10 a.m., with Resident 259, Resident 259 stated he felt uncomfortable with CNA 2 when CNA 2 gave him a bath. Resident 259 stated "[CNA 2] touched me inappropriately, it felt like [CNA 2] was masturbating (stimulating genitals for sexual pleasure) me." Resident 259 stated he notified another nurse of the incident. During an interview on 12/18/2024 at 10:26 a.m., with LVN 3, LVN 3 stated Resident 259 had an issue with CNA 2 and that Resident 259 stated, "Get [CNA 2] out of my room." LVN 3 stated the alleged incident occurred on Resident 259's shower day and Resident 259 preferred a bed bath than going to the shower room. LVN 3 stated when she went to Resident 259's room, Resident 259 had told her that he did not want CNA 2 "touching him down there" and that "[CNA 2] is jacking me off (stimulating genitals for sexual pleasure)". LVN 3 stated due to Resident 259 being uncomfortable with the care CNA 2 provided to him, LVN 3 informed the DSD and switched the CAN's assignment. LVN 3 stated she assumed the DSD would report to the DON and ADM. LVN 3 stated abuse allegations were reported to the ADM, then to the police department, ombudsman, and the State Agency. LVN 3 stated she did not report to the three outside agencies because she felt that she reported to her superiors and they would handle the rest of the reporting. During an interview on 12/18/2024 at 11:48 a.m., the DSD stated Resident 259's allegations were not reported. The DSD stated Resident 259's allegation against CNA 2 should have been reported to the police department, ombudsman, and the State Agency due to Resident 259's statements of possible sexual abuse. During an interview on 12/18/2024 at 3:41 p.m., the ADM stated once a staff member had knowledge of an abuse allegation, they were expected to report it to him. The ADM stated everyone had the ability to report any abuse allegations to the police department, ombudsman, and the State Agency. The ADM stated none of the staff members that had knowledge of Resident 88 and 259's abuse allegations reported to the police department, ombudsman, and the State Agency. The ADM stated an allegation could be true or false, however, the allegation needed to be reported so a thorough investigation could be conducted internally and by the State Agency. A review of the facility's policy and procedure (P&P) titled, "Abuse- Reporting & Investigations", revised 3/2018, indicated regarding allegations of abuse with no serious bodily injury, the Administrator or designated representative would notify, via telephone and written form, the State Agency, ombudsman, and the police department within two hours. The facility failed to: 1. Report abuse allegations to the, CDPH, ombudsman, and the police department when Resident 88's RP 1 informed RN 1 that CNA 2 said hurtful things to Resident 88. 2. Report abuse allegations to the State Agency, ombudsman, and the police department when Resident 259 informed LVN 3 that CNA 2 made him feel uncomfortable during a bed bath. These failures resulted in a delay of an onsite inspection by the State Agency and had the potential for potential ongoing abuse. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of residents 259, 88 and other residents in the facility.