Other·June 3, 2022

F609 §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. On 03/03/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint related to resident abuse. The facility failed to report to CDPH, the local Long-Term Care (LTC) Ombudsman Program (assist residents in the LTC facilities with issues related to day-to-day care, health, safety, and personal preferences), and the local law enforcement an allegation of abuse Resident 1 made against an unidentified staff. Resident 1 alleged a male staff hit the resident on the buttock on 2/18/2022, time unknown. CDPH received the notification on 2/20/22 at 5:05pm. As a result, there was a delayed investigation by CDPH and other agencies to ensure Resident 1's safety. A review of Resident 1's Admission Record indicated the facility admitted Resident 1, a 68-year-old-female, on 1/13/22 with diagnoses that included a cognitive communication deficit (difficulty with thinking and how someone uses language) and acute encephalopathy (an alteration of mental status due to systemic factors). On 3/3/22 at 9:30 a.m., during an interview, the Administrator (ADM) stated he was notified about the alleged incident of abuse on 2/20/22 at 3:48 p.m. The ADM confirmed the facility's policy was to report all allegations of abuse to CDPH, the Ombudsman Program and the local law enforcement no later than two hours after allegation is made. The ADM stated the incident of alleged abuse was not reported until the following day. On 3/14/22 at 9:20 a.m., during an interview, Registered Nurse 1 (RN 1) stated she was notified on 2/19/22, time unknown, Resident 1 alleged a male staff hit the resident's buttock, time unknown and no further description of what was used to hit her, but she did not report the incident to the ADM and the Director of Nursing (DON) until the following day 2/20/22, time unknown. A review of the facility's policy and procedures titled, "Abuse Reporting and Investigations," revised on 3/2018, indicated the Administrator or designated representative will notify within two (2) hours CDPH, the Ombudsman and Law enforcement. The Administrator or designated representative will send a written SOC 341 (Report Suspected Abuse of Dependent Adult and Elder) to the Ombudsman and Law enforcement and CDPH Licensing and Certification within two hours. The facility failed to report to CDPH, the local LTC Ombudsman Program, and the local law enforcement an allegation of abuse Resident 1 made against an unidentified staff. Resident 1 alleged a male staff hit the resident on the buttock on 2/18/2022. CDPH received the notification on 2/20/22 at 5:05pm. As a result, there was a delayed investigation by CDPH and other agencies to ensure Resident 1's safety. The above violation had a direct relationship to the health, safety, and security of Resident 1.