Health inspection·June 21, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00900415. Representing the Department, HFEN #3639. A Class B Citation was written. REGULATORY VIOLATIONS: Title 44: Code of Federal Regulations. Freedom from Abuse, Neglect, and Exploitation §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. Title 22 California Code of Regulations § 72527. Patients' Rights. (a)(10) To be free from mental and physical abuse. § 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. On 5/17/2024, the California Department of Public Health (CDPH) state survey agency (SSA) made an unannounced visit to the facility to investigate resident abuse. The facility failed to implement its' policy titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" for Residents 1 and 2), by failing to report to the state survey agency (SSA) and the appropriate agencies as indicated in its policy when on: 1. 5/8/24, Resident 1 and Resident 2 were verbally aggressive to one another, calling each other derogatory names and racial slur. 2. 5/9/24, Resident 1 threw a shower sponge on Resident 2 and the shower sponge hit Resident 2's leg. Resident 2 called the police and wanted to press charges against Resident 1. 3. 5/14/24, Resident 1 alleged that Resident 2 wanted to "kill and rape" Resident 1. As a result, there was a in delay of investigation to ensure Resident 1, and Resident 2 felt safe while in the facility. 1.During a review of the Admission Record indicated the facility admitted Resident 1 on 6/17/21 and readmitted on 7/7/23 with diagnoses including anxiety and bipolar disorder (mental condition that causes extreme mood swings that include emotional highs and lows). During a review of the Minimum Data Set (MDS, standardized care and health screening tool) dated 3/11/24 indicated Resident 1 was cognitively intact. Resident 1 was dependent (helper does all the effort) with putting on/taking off footwear, toileting hygiene, substantial assistance (helper does more than half the effort) with shower/bathe self, upper/lower body dressing, partial assistance (helper does less than half the effort) with personal hygiene and set-up (helper sets up and resident completes the activity) with eating and oral hygiene. During a review of the Change in Condition Evaluation (COC) dated 5/8/24 at 4 p.m., indicated Resident 1 was verbally aggressive towards another resident (Resident 2). The COC indicated Resident 1, and Resident 2 were heard cursing at each other. Resident 1 called Resident 2 a racial slur and Resident 2 called Resident 1 a derogatory name. The Notes indicated Resident 1's primary physician was notified and gave order to monitor Resident 1. During a review of the Resident 1's COC dated 5/9/24 at 11:09 a.m., indicated Resident 1 threw object (bath sponge) on Resident 2. The COC indicated while Resident 1 was being taken out of the shower room, Resident 1 threw a shower sponge on Resident 2, who was waiting to go to the shower. The Notes indicated Resident 1's primary physician was notified and gave order to transfer Resident 1 to the general acute hospital (GACH 1) for evaluation. During a review of the Nursing Progress Note dated 5/9/24 at 6:23 p.m., indicated GACH 1 did not have a bed available for Resident 1. During a review of the Psychiatrist (medical doctor who can diagnose and treat mental, emotional, and behavioral conditions) Note dated 5/14/24 at 3:23 p.m. indicated Resident 1 is alert, but impulsive and verbally aggressive. The Notes indicated the psychiatrist had recommended medications to address Resident 1's behavior but Resident 1 refused. Resident 1 called the ombudsman yesterday (5/13/24) "reporting that she is afraid of being raped by resident (Resident 2) she assaulted". The Notes indicated Resident 1 was fabricating stories. The Notes also indicated Resident 1 was to be sent out for psychiatric evaluation but there was no bed available at the GACH 1. During a review of the Interdisciplinary Team (IDT, group of professionals from different health care discipline that bring together knowledge to help patients receive the care they need) dated 5/16/24 at 2:41 p.m., indicated the IDT met with Resident 1 regarding the incidents that happened on 5/8/24 and 5/9/24 with Resident 2. The Notes also indicated Resident 1 alleged that Resident 2 told Resident 1 that he will "kill and rape her". Resident 1 was offered room change but refused. 2. During a review of the Admission Record indicated the facility initially admitted Resident 2 on 10/28/16 and re-admitted on 11/19/21 with diagnoses including schizophrenia (mental illness that affects how a person thinks, feels, and behaves) and diabetes mellitus (group of diseases that affect how the body uses blood sugar (glucose). During a review of Resident 2's MDS dated 2/12/24 indicated Resident 2 was cognitively intact. Resident 2 was dependent with personal hygiene, putting on/off footwear, lower body dressing, shower, toileting, substantial assistance with upper body dressing and set up with eating and oral hygiene. During a review of the Resident 2's COC dated 5/8/24 at 3:30 p.m., indicated Resident 2 was verbally aggressive towards another resident (Resident 1). Resident 2 called Resident 1 a derogatory name. The COC indicated the primary physician was notified and gave order to monitor Resident 2. During a review of Resident 2's COC dated 5/9/24 at 11:40 a.m., indicated Resident 2 was "hit on his leg with an object (shower sponge) by another resident (Resident 1) while Resident 2 was waiting to go in the shower room. Resident 2 denied pain and had no bleeding or bruises after assessment. Resident 2's primary physician was notified and gave order to continue to monitor Resident 2. During a review of Resident 2's Nursing Progress Note dated 5/9/24 at 1:40 p.m., indicated Resident 2 called the police. The Notes indicated the police came and spoke to Resident 2. Resident 2 wanted Resident 1 to move to another facility. During a review of the IDT Note dated 5/17/24 at 10:25 a.m., indicated IDT met with Resident 2. The Notes indicated Resident 2 was informed of Resident 1's allegation that Resident 1 will "rape and kill" Resident 1. The Notes indicated Resident 2 denied Resident 1's allegation. During an interview on 5/17/24 at 10:30 a.m., Resident 1 stated Resident 2 told her that Resident 2 will "rape and kill me". Resident 1 further stated Resident 2 called her derogatory names and he was "tormenting me". Resident 1 stated she did not feel safe in the facility. During an interview on 5/17/24 at 10:50 a.m., Resident 2 stated Resident 1 called him a racial slur. During an interview on 5/17/24 at 11 a.m., LVN 1 stated Resident 1 and Resident 2 were yelling and "cussing at each other". LVN 1 also stated Resident 1 threw shower sponge on Resident 2 on 5/9/24. Resident 1's psychiatrist was notified and gave order to transfer Resident 1 to the hospital for psychiatric evaluation but Resident 1 refused. LVN 1 stated Resident 2 was upset and called the police to press charges against Resident 1. LVN 1 stated she notified the director of nursing (DON). LVN 1 stated she did not hear Resident 2 tell Resident 1 that he will "kill and rape" Resident 1. During an interview on 5/17/24 at 11:25 a.m., the social service designee (SSD) stated Resident 1 and Resident 2 are calling each other derogatory names and racial slur. SSD stated there were two incidents and both incidents were not reported to the SSA. SSD stated, "we did not report because it is more on the behavior of the residents." During an interview on 5/17/24 at 12:02 p.m., the director of staff development (DSD) stated for verbal altercation and resident to resident altercation any physical violence and threat of harm should be reported within two hours. During an interview on 5/17/24 at 12:11 p.m., the DON stated the facility did not report the incidents to the SSA when Resident 1 and Resident 2 cursed at each other and Resident 1 making the allegation that Resident 2 will "rape and kill" Resident 1. DON also stated there were verbal exchange and cursing at each other. DON stated Resident 1's allegation that Resident 2 will "rape and kill" Resident 1 was not witnessed by any of the staff of the facility. DON stated, "we did not report because we think it is more on their behavior problems". During an interview on 5/17/24 at 2:47 p.m. with the administrator (ADM) in the presence of the DON, the ADM stated Resident 1 and Resident 2's yelling and cursing at each other and Resident 1's allegation that Resident 2 will "rape and kill" Resident 1 were not reportable. ADM stated staff were present and did not hear Resident 2 state that he will "rape and kill" Resident 1. ADM stated Resident 1 had history of fabricating stories. During a review of the facility Policy titled Resident-to-Resident Altercations revised on 1/31/24 indicated facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors or to the staff. The Policy indicated report incidents, findings and corrective measures to appropriate agencies as outlined in the facility's abuse reporting policy. During review of the facility Policy titled "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" reviewed on 1/31/24 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 for all investigations are documented and reported. The Policy indicated the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. the state licensing/certification agency responsible for surveying/licensing the facility. b. The local/state ombudsman c. The resident's representative d. Adult Protective services (where state law provides jurisdiction in long-term care) e. law enforcement officials f. The resident's attending physician g. The facility medical director. The same Policy indicated immediately is defined as within two hours of an allegation involving abuse or result in bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. The facility failed to implement its' policy titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" for Residents 1 and 2), by failing to report to the state survey agency (SSA) and the appropriate agencies as indicated in its policy when on: 1. 5/8/24, Resident 1 and Resident 2 were verbally aggressive to one another, calling each other derogatory names and racial slur. 2. 5/9/24, Resident 1 threw a shower sponge on Resident 2 and the shower sponge hit Resident 2's leg. Resident 2 called the police and wanted to press charges against Resident 1. 3. 5/14/24, Resident 1 alleged that Resident 2 wanted to "kill and rape" Resident 1. As a result, there was a in delay of investigation to ensure Resident 1 and Resident 2 felt safe while in the facility. The above violation had a direct relationship to the health, safety, and security of Resident 1 and Resident 2.