Health inspection·September 4, 2024

The following reflects the findings of the California Department of Public Health (Department) during the investigation of a complaint. Complaint number: CA00911816. A Class B citation was issued. Regulatory Violations: 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation 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. 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. 22 CCR 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. On 7/30/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding an allegation of resident-to-resident abuse. The facility failed to ensure Resident 2 did not physically abused Resident 1 by hitting Resident 1 on her left arm so hard that Resident 1 verbalized experiencing pain. This deficient practice resulted in Resident 1 experiencing pain and there was a delay of an onsite inspection by CDPH to ensure the safety of the Resident 1 and to ensure all abuse was investigated. During a review of Resident 1's Face sheet (Admission Record), indicated Resident 1 was re-admitted to the facility on 6/27/2024, with a diagnoses of acute kidney failure (when your kidneys suddenly stop working properly), and essential hypertension (a type of high blood pressure that occurs when there is no identifiable cause). During a review of Resident 1's History and Physical (H&P) dated 6/29/2024, indicated Resident 1 had the capacity for medical decision making. During a review of Resident 2's Face Sheet, indicated Resident 2 was admitted to the facility on 6/7/2023 with diagnoses including dementia (impaired thinking, remembering, or reasoning that can affect a person's ability to function safely) and essential hypertension. During a review of Resident 2's H&P dated 7/16/2023, indicated Resident 2 did not have the capacity to understand and make decisions. During an interview on 7/30/2024 at 10:17 am, Resident 1 stated that on 7/19/2024, Resident 2 was attempting to unplug her (Resident 1)'s television (TV). Resident 1 stated she told Resident 2 to stop unplugging the TV and that's when Resident 2 hit Resident 1's left arm so hard that a blood vessel appeared and experienced pain on Resident 1's arm. Resident 1 stated she was mad (upset/angry). Resident 1 stated the staff came in the room right away and separated her and Resident 2. During an interview on 7/30/2024 at 11:46 am with Administrator, the Administrator was working on 7/19/2024, at approximately 2 pm., the day of the alleged incident between Resident 1 and Resident 2. The Administrator stated Resident 1's Certified Nursing Assistant (CNA) informed her of the incident between Resident 1 and Resident 2. The Administrator stated Resident 2 reported the incident with Resident 1 to the Director of Staff Development (DSD) and that the DSD informed the Administrator of the incident right away. The Administrator stated she should have reported the incident between Resident 1 and Resident 2 to CDPH within 2 hours. During an interview on 7-30-24 at 12:38 pm, with the Director of Nursing (DON), the DON stated the Administrator notified her of the incident between Resident 1 and Resident 2. The DON stated Resident 1 told the DON that Resident 2 was touching and changing the TV channel, and Resident 1 told Resident 2 to stop and that was when Resident 2 hit Resident 1. The DON stated she immediately moved Resident 2 to another room. The DON stated, "abuse is supposed to be reported to CDPH within 2 hours." During an interview on 7/30/2024 at 1:38 pm, the License Vocational Nurse 1 (LVN 1), stated the DSD reported to LVN 1 the alleged incident between Resident 1 and Resident 2 and instructed the DSD to report the incident to the Administrator right away. LVN 1 stated abuse, "is supposed to be reported to CDPH within 2 hours." The facility did not report the physical abuse incident happened on 7/19/2024 to the department. During a review of the facility's policy and procedures titled "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating" revised on 3/2023, indicated, "All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting allegations to the Administrator and Authorities: 3. "Immediately" is defined as a. Within two hours of an allegation involving abuse or result serious bodily injury; or f. Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury." The facility failed to ensure Resident 2 did not physically abused Resident 1 by hitting Resident 1 on her left arm so hard that Resident 1 verbalized experiencing pain. This deficient practice resulted in Resident 1 experiencing pain and there was a delay of an onsite inspection by CDPH to ensure the safety of the Resident 1 and to ensure all abuse was investigated. This violation had a direct relationship to the health, safety, and security of Resident 1.