Health inspection·March 7, 2025

F609 42 CFR §483.12(b) The facility must develop and implement written policies and procedures that: (b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. 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. 22 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. An unannounced visit was conducted by the California Department of Public Health on 2/5/2025 at 6 AM to investigate a facility reported incident (FRI) and a complaint regarding an allegation of employee to resident physical abuse (inflicting physical injury such as hitting and slapping) made by Resident 1. The facility failed to report an allegation of physical abuse within two hours to local police department, state survey agency (CDPH) and ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) after the allegation of physical abuse was made by Resident 1. This resulted in delayed reporting which could have resulted in ongoing abuse, leading to physical, emotional, or psychological (mental or emotional) harm to Resident 1. A review of Resident 1’s Admission Record indicated Resident 1, a 79-year-old-female, was admitted to the facility on 10/1/2020 and re-admitted on 10/6/2024, with diagnoses including metabolic encephalopathy (ME, occurs when problems with your metabolism cause brain dysfunction) and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). A review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool), dated 1/13/2025, indicated Resident 1 was moderately impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. 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 oral hygiene, upper body dressing, roll left and right, sit to lying, sit to stand, chair/ bed-to-chair transfer, toilet transfer, walk 10, 50, and 150 feet and required partial/ moderate assistance (Helper does less than half the effort, helper lifts, hold, or supports trunk or limbs but provides less than half the effort) in toileting hygiene, shower/ bathe self, lower body dressing, putting on and taking off footwear, personal hygiene and tub/ shower transfer. During an observation on 2/5/2025 at 6:11 AM, Resident 1 was observed in bed sleeping. Resident 1 was observed with a greenish colored discoloration to the back of Resident 1’s right hand. A review of Resident 1’s Change of Condition (COC) notes, dated 1/23/2025, timed at 6:25 AM, indicated Resident 1 had a skin dislocation to the back of the resident’s right hand. The COC indicated that according to Resident 1, the dislocation was from a blood draw done on 1/22/2025. During an interview with Certified Nursing Assistant 1 (CNA 1) on 2/5/2025 at 6:20 AM, CNA 1 stated she was with Resident 1 on 1/22/2025 when Resident 1 refused blood draw. During an interview with CNA 3 on 2/5/2025 at 7:01 AM, CNA 3 stated that on Thursday (1/23/2025) morning (time not specified), CNA3 saw Licensed Vocational Nurse 1 (LVN 1) come out from Resident 1’s room. CNA3 stated LVN 1 looked stressed. CNA3 stated after LVN 1 came out of Resident 1’s room, LVN 1 told CNA3 that Resident 1 accused CNA 1 of hurting her. During an observation on 2/5/2025 at 7:21 AM, Resident 1 was observed in bed awake but refused to discuss the abuse allegation against CNA1. During an interview with the Director of Nursing (DON) on 2/5/2025 at 8:49 AM, the DON stated that on Thursday (1/23/2025) morning at 7AM, LVN 1 assessed Resident 1’s skin discoloration on the right hand. The DON stated on 1/23/2025 at 3:45PM, the DON also assessed Resident 1’s right hand which was swollen and with reddish discoloration. The DON added that according to Resident 1, it happened during transfer but could not identify the staff. During an interview with the DON on 2/5/2025 at 9:09 AM, the DON stated, “We need to report abuse allegation within 2 hours per our policy. If abuse incident was not reported on time, we might have delay in care, and there will be delay of investigation. We need to make sure the resident was safe.” During an interview with the Director of Staff Development (DSD) on 2/5/2025 at 10:04 AM, DSD stated, “If we cannot report within 2 hours, there is a possibility that the resident involved might get abused. The resident might feel scared and there will be a possible issue of resident safety.” During an interview with the DON on 2/5/2025 at 10:06 AM, the DON stated she received a text message from LVN 1 on 1/23/2025 at 9:15 AM that Resident 1 had informed LVN 1 regarding allegation of being hit by CNA (CNA1) on Wednesday (1/22/2025) morning. The DON stated, “It was my fault, I was not reading the text carefully. I must have misread it.” The DON stated she should have reported the allegation of abuse right away, conduct the investigation and ensure the resident involved was safe. The DON stated Resident 1’s abuse allegation against CNA1 was reported to the California Department of Public Health (CDPH) on 1/23/25 at 5 PM (more than 24 hours from time of alleged abuse report). During an interview with LVN 1 on 2/5/2025 at 10:50 AM, LVN 1 stated “On 1/23/2025, Thursday morning before resident (Resident 1) went for dialysis (process of removing waste products and excess fluid from the body), I took the resident’s vital signs on the right arm because she has a left arm arteriovenous shunt (AVS, is the most commonly used vascular access in resident’s receiving regular hemodialysis [a machine filters wastes, salts and fluid from the blood when the kidneys are no longer healthy enough to work adequately]). I saw a discoloration to the back of the resident’s (Resident 1) right hand.” LVN 1 stated, “I sent a text message to the DON on Thursday morning after 8 AM and was able to speak with the DON at 9 AM about the resident’s (Resident 1) hand discoloration.” During an interview with LVN 1 on 2/5/205 at 11:01 AM, LVN 1 did not give any information regarding Resident 1’s allegation of abuse against CNA 1 but stated, “If there is an allegation of abuse, we should report it as soon as possible to the DON. We should also inform the physician and Responsible Party. The DON will follow up with the other stuff needed to be submitted such as reporting the abuse to the agencies.”. A review of the facility’s Policy and Procedure (P&P) titled, “Abuse Prevention and Management,“ revised 5/30/2024, indicated the facility will report all allegations of abuse and criminal activity as required by law and regulations to the appropriate agencies. Reports of resident abuse, mistreatment, neglect, exploitation, injuries of unknown source and any suspicion of crimes are promptly reported and thoroughly investigated. The P&P indicated the Administrator, or designated representative will notify law enforcement, by telephone immediately, or as soon as practicably possible, but no longer than 2 hours of an initial report and send a written SOC 341 report (report of suspected dependent adult/elder abuse) to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within 2 hours. The facility failed to report an allegation of physical abuse within two hours to local police department, state survey agency, and ombudsman after the allegation of physical abuse was made by Resident 1. This resulted in delayed reporting which could have resulted in ongoing abuse, leading to physical, emotional, or psychological (mental or emotional) harm to Resident 1. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.