Health inspection·November 7, 2024

F609 Code of Federal Regulations, Title 42, Section FCR§ 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. §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. California Code of Regulations, Title 22, Section CCR§ 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 9/27/2024 at 9 AM, the California Department of Public Health (the Department) conducted an unannounced visit to the facility to investigate a complaint regarding resident abuse. The facility failed to follow the facility's policy and procedure (P&P) titled, "Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment," when the facility failed to report an allegation of abuse to the Department regarding Resident 1. As a result of the failure Resident 1's rights were violated and there was a potential to compromise Resident 1's safety. Additionally, the failure could have subjected Resident 1 to potential further abuse. Findings: A review of Resident 1's Admission Record (AR) indicated Resident 1 was an 84-year-old female and was admitted to the facility on 5/21/2024. The AR indicated diagnoses that included other cervical disc degeneration (a condition affecting the neck's spinal discs which can lead to neck pain, headaches, and other symptoms) unspecified cervical region (made up of the cervical spine, which is the first seven vertebrae in the spine), dysphagia (difficulty swallowing), oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), and anxiety disorder (mental health condition that cause uncontrollable and excessive feelings of fear or worry). A review of Resident 1's History and Physical Examination (H&P), dated 6/18/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/25/2024, indicated Resident 1 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated, Resident 1 required partial/moderate assistance (helper does less than half the effort) for toileting hygiene, upper and lower body dressing, and putting on/taking off footwear. The MDS indicated, Resident 1 required partial/moderate assistance for rolling left and right in bed (the ability to roll from lying on back to left and right side and return to lying on back on the bed). A review of Resident 1's untitled care plan (CP), initiated on 8/27/2024, indicated Resident 1 had a potential for a psychosocial well-being problem related to an incident (unspecified) on 8/27/2024. The CP interventions included for staff to monitor Resident 1 for signs of mental anguish or emotional distress for 72 hours. A review of Resident 1's As Needed (PRN) Skin Evaluation (SE), dated 8/27/2024, timed at 10:37 AM, indicated Resident 1's skin assessment was done. The SE indicated, no new skin issues were noted. The SE indicated, Resident 1 had no bruising, no discoloration, no signs of trauma, and no redness noted. The SE indicated, Resident 1's skin was intact. A review of Resident 1's Condition Monitoring (CM), dated 8/28/2024, timed at 11:27 PM, indicated, the date of original condition being monitored was 8/27/2024. The CM indicated, Resident 1 was verbally abusive towards staff. A review of Resident 1's medical chart, there was no Nurse's Note or CM regarding any allegation of abuse involving Resident 1 and facility staff. During an interview on 9/27/2024 at 4:28 PM with the Administrator (ADM), the ADM stated Licensed Vocational Nurse (LVN) 2 and Certified Nursing Assistant (CNA) 1 alleged that the Activities Supervisor (AS) placed the AS's hands on Resident 1's shoulders and LVN 1 force fed medications down Resident 1's throat. The ADM stated the Director of Nursing (DON) did a full body assessment on Resident 1, including checking Resident 1's mouth. The ADM stated AS and LVN 1 were suspended during the investigation. The ADM stated the ADM considered these incidents as accusations of abuse. The ADM stated it was the ADM's job to do a thorough investigation when there was an allegation of abuse. The ADM stated the facility's abuse policy indicated to report all alleged violations no later than two hours if it included abuse or serious bodily injury or 24 hours if it did not involve abuse or serious bodily injury. The ADM stated the abuse allegations should have been reported to the Department. The ADM stated residents could be at risk for abuse when allegations of abuse were not reported. A review of the facility's P&P titled, "Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment," revised December 2023, indicated the definition of an "alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property." The P&P indicated, "In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: a. 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 two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily or not later than twenty-four (24) hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury." The P&P indicated, "Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to: The Administrator of the Facility, The State Survey Agency, and Adult Protective Services (as appropriate). The facility failed to follow the facility's P&P titled, "Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment," when the facility failed to report an allegation of abuse to the Department for Resident 1. As a result of the failure Resident 1's rights were violated and there was a potential to compromise Resident 1's safety. Additionally, the failure could have subjected Resident 1 to potential further abuse. The above violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.