Health inspection·September 20, 2024

Code of Federal Regulations, Title 42, Section CFR §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. California Code of Regulations, Title 22, Section 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 8/8/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding resident abuse and resident rights. As a result of the investigation, the CDPH determined the facility failed to report an allegation of abuse involving Resident 1 to the California Department of Public Health (the Department), the Ombudsman, and the local law enforcement within two hours in accordance with the facility's policy and procedure (P&P) titled, "Abuse, Neglect and Exploitation," dated 12/19/2022. This failure violated Resident 1’s rights, had the potential to compromise Resident 1’s safety, and could subject Resident 1 to potential further abuse. A review of Resident 1's Admission Record indicated the facility admitted Resident 1, a 75-year-old female, to the facility on 12/29/2023, with diagnoses including metabolic encephalopathy, type 2 diabetes mellitus, and dementia. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/2/2024, indicated Resident 1 had severely impaired cognitive skills. The MDS indicated Resident 1 required setup or clean-up assistance from staff for eating and personal hygiene. During an interview on 8/7/2024 at 9:40 a.m., Resident 1's Responsible Party (RP) stated on the morning of 7/4/2024, unable to recall time, Resident 1 informed RP that a resident (unidentified) at the facility punched Resident 1 in the face earlier that morning. RP stated RP informed a nurse at the facility. RP stated RP did not remember who the nurse was. During an interview on 8/8/2024 at 11:18 a.m., Resident 1 stated there was a time at the facility (unable to recall date and time) when a “woman” (unidentified) hit Resident 1 on Resident 1's right shoulder. Resident 1 stated Resident 1 responded by hitting the woman. Resident 1 stated Resident 1 told RP about the incident. During an interview on 8/8/2024 at 12:35 p.m., the Administrator (ADM) stated RP informed the ADM that someone hit Resident 1's shoulder. The ADM stated the ADM did not report the allegation of someone hitting Resident 1 on the shoulder to the Department and other officials because the ADM determined it was not possible that someone had hit Resident 1 on the shoulder. During an interview on 8/8/2024 at 1:03 p.m., the Director of Nursing (DON) stated sometime in the previous month, Resident 1 informed the DON that "a guy” (unidentified) tried to "pat" Resident 1 on the arm and that Resident 1 "hit the guy back." A review of the facility's P&P titled, "Abuse, Neglect and Exploitation," dated 12/19/2022, indicated the facility designated an Abuse Prevention Coordinator in the facility who was responsible for reporting allegations of suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. The P&P indicated reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involved abuse or result in serious bodily injury. The facility failed to report an allegation of abuse involving Resident 1 to the Department, the Ombudsman, and the local law enforcement within two hours in accordance with the facility's P&P titled, "Abuse, Neglect and Exploitation," dated 12/19/2022. This failure violated Resident 1’s rights, had the potential to compromise Resident 1’s safety, and could subject Resident 1 to potential further abuse. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.