Health inspection·October 24, 2024

42 CFR §483.12 Freedom from abuse, neglect, and exploitation. (b) The facility must implement written policies and procedures that: (2) Establish policies and procedures to investigate any such allegations (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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. 22CCR §72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be implemented to ensure that patient related goals and facility objectives are achieved. The California Department of Public Health (CDPH) received a complaint on 9/12/2024, regarding quality of care and quality of life concerns. 9/26/2024 at 8:40 a.m., an unannounced visit was conducted at the facility to investigate the allegations. The facility failed to: 1). Investigate Resident 1's allegation that on 5/28/2024, during the night shift (time not specified), a Certified Nurse Assistant (CNA 2) punched Resident 1, that resulted in a bruise (an area of discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels) on Resident 1's left cheek near the left eye. 2). Provide the State Survey Agency a written report of the findings for the investigation of an allegation of abuse within five (5) working days for Resident 1. These failures had the potential to result in unidentified abuse for Resident 1 and other residents in the facility. A review of Resident 1's Admission Record, indicated Resident 1 was an 80-year-old male, admitted to the facility on 9/2/2022. Resident 1's diagnoses included Stage 4 pressure ulcer (full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones) on the sacral (tail bone) region and urinary tract infection ([UTI] an infection in any part of the urinary system). A review of Resident 1's Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 6/6/2024, indicated Resident 1 could understand and be understood by others, indicated Resident 1 required a two or more person's assist with activities of daily living (ADLs) such as eating, oral hygiene, toileting hygiene, shower, dressing, personal hygiene, and bed mobility. The MDS indicated Resident 1 had a Stage 4 pressure ulcer. A review of Resident 1's "History and Physical" (H&P) dated 8/11/20204 indicated Resident did not have the capacity to understand and make decisions. A review of Resident 1's clinical records for May 2024 did not indicate documentation regarding the allegation the Certified Nurse Assistant (CNA) 2 punched Resident 1 on the left cheek near the left eye on 5/28/2024, night shift (time not specified) was investigated. During a phone interview on 9/30/2024 at 1:20 p.m. with the Caretaker, the Caretaker stated she visited Resident 1 on 5/29/2024 (time not indicated) and observed Resident 1's left cheek near the left eye had skin discoloration. The Caretaker stated Resident 1 told her (Caretaker) that CNA 2 punched Resident 1, on 5/28/2024 (time not specified) at night shift, leaving a bruise on Resident 1's left cheek near the left eye. The Caretaker stated she called the Social Service Assistant (SSA) to Resident 1's room on 5/29/2024 and reported to SSA that Resident 1 was punched on the left side of the face by a CNA. During an interview on 9/30/2024 at 2:51 p.m. with the SSA, the SSA stated the Caretaker reported to her (SSA) that CNA 2 punched Resident 1's left cheek near the left eye on 5/28/2024, during night shift (time not specified). The SSA stated she spoke to Resident 1 and Resident 1 denied being punched by a CNA or CNA 2. The SSA stated she failed to report the abuse allegation to the CDPH within two hours to ensure proper investigation was conducted and to prevent further abuse. During an interview with the Admin on 10/1/2024 at 2:30 pm., the Admin stated the abuse allegation was not investigated because the SSA did not report the allegation of abuse that happened on 5/28/2024 (night shift) to her (Admin). A review of the facility's Operational Manual- Abuse & Neglect titled "Abuse-Reporting and Investigations," dated 1/3/2024, indicated all allegations of abuse, or mistreatment, should be reported to the Administrator or designated representative immediately (right away). The manual indicated, when the Administrator or designated representative received the report of an incident or suspected incident of resident abuse, or mistreatment, the Administrator, or designated representative, will initiate an investigation immediately (right away). The manual indicated if the suspected perpetrator was an employee, the Administrator or designated representative should remove the employee immediately from the care of the resident and immediately suspend the employee pending the outcome of the investigation on accordance with the facility policies. The facility failed to: 1). Investigate Resident 1's allegation that a CNA2 punched Resident 1, on 5/28/2024 night shift (time not specified), that resulted in a bruise (an area of discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels) on Resident 1's left cheek near the left eye. 2). Provide the State Survey Agency a written report of the findings for the investigation of an allegation of abuse within 5 working days for an incident of physical abuse for Resident 1. These failures had the potential to result in unidentified abuse for Resident 1 and other residents in the facility. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of residents.