Health inspection·February 4, 2025

The following reflects the findings of the California Department of Public Health (Department) during the investigation of a complaint. Complaint number: CA00930284. A Class B citation was issued. Regulatory Violations Freedom from Abuse, Neglect, and Exploitation §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; 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. On 11/26/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident neglect. The facility failed to ensure Resident 1 was free from physical abuse (an act where one person uses their body to inflict intentional harm or injury upon another person) from staff by failing to acknowledge and investigate allegations, assess monitor, and implement allegations of Resident 1 being slapped by Certified Nursing Assistant (CNA) 1 As a result, there is a potential to result in the continued physical abuse to Resident 1 and residents in the facility. During a review of Resident 1's admission record indicated Resident 1 was initially admitted to the facility on 12/22/2021 and was readmitted on 3/6/2023 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (HTN-high blood pressure). During a review of a history and physical (H&P-a term used to describe a physician's examination of a patient. In an H&P, the physician obtains a thorough medical history from the patient, performs a physical examination, and then documents their findings) dated 1/19/2024 indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 8/22/2024, indicated Resident 1 had moderate cognitive impairments (a stage of cognitive decline where a person has significant difficulty with complex tasks and may become confused about their surroundings). The same MDS indicated Resident 1 was mostly depended on staff for most of his Activities of Daily Living such as: (ADLs- routine tasks/activities such as bathing, dressing, toileting hygiene). During a review of Resident 4's admission record indicated Resident 4 was admitted to the facility on 3/20/2024 with diagnoses which including depression, acute kidney failure (the rapid [less than 2 days] loss of your kidneys' ability to remove waste and help balance fluids and electrolytes in your body), and generalized muscle weakness (a decrease in muscle strength that can make it difficult to move your body). During a review of Resident 4's H&P indicated Resident 4 had the capacity to make decisions. During a review of Resident 4's MDS dated 11/20/2024, the MDS indicated Resident 4 was cognitively intact (mental action or process of acquiring knowledge and understanding). The same MDS indicated Resident 4 required between partial/maximal assistance and staff dependency for ADLs. During an interview with Resident 1 on 11/26/24 at 1:05 pm, Resident 1 stated, "That CNA just came in and slapped me." During an interview with Resident 4 on 11/26/24 at 11:31 am, Resident 4 stated that CNA 1 (whom she had identified in the hallway) came in to perform some personal care a few weeks ago (did not remember exact date) for Resident 1. Resident 4 stated that CNA 1 came to their room, went to Resident 1's side of the room, closed the privacy curtain and heard a "slap sound," then heard Resident 1 ask why CNA 1 had slapped her. During an interview with CNA 2 on 11/26/23 at 2:54 pm, CNA 2 stated that on 11/9/2024 while passing lunch trays in the room that is adjacent to Resident 1's room, she heard a "slap" sound and heard Resident 1 scream. CNA 2 stated that she noticed that CNA 2 was in Resident 1's room with Resident 1. CNA 2 stated that she reported the incident to Registered Nurse (RN) 1. During an interview with RN 1 on 11/26/24 at 3:12 pm, RN 1 stated that CNA 1 reported the "slap" incident which was then reported to the Director of Nursing (DON). RN 1 admitted and stated the slap incident should have been reported as suspected abuse, investigated, reported to the police, ombudsman as well as Department of Public Health. RN 1 stated that the implications of not reporting may result in continued abuse. During an interview with the Social Services Director (SSD) on 11/26/24 at 3:36 pm, the SSD stated the incident with Resident 1 should have been suspected as physical abuse even though it was not witnessed based on the information provided. SSD acknowledged that the incident should have been reported because it needs to be investigated. During an interview with the Facility Administrator (FA), the FA stated that he was aware about that Resident 1 had alleged that she was slapped. The FA stated that nursing had assessed, and incident investigated but was unable to provide documented evidence of the investigation. FA stated that he thought that the designee (DON) had investigated the incident. FA admitted that he was the abuse coordinator. During a review of a Policy and Procedures (P&P) titled "Abuse Prevention Program - Abuse Prohibition," revised 5/2024 indicated, "The facility shall uphold resident's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Facility shall ensure thorough and extensive investigation of different types of incidents including but not limited to those that may constitute abuse, and identification of a staff member, who would be responsible for the initial reporting, investigation of alleged violations and reporting of results to facility administrator and/or facility abuse coordinator, who shall, in return, report such incident to required agencies. a) Facility administrator shall be responsible for appointing staff member(s) who would be responsible for the initial reporting and investigation of alleged. Necessary steps are to be taken to prevent reoccurrence of violations which may include in service training, suspension of involved individuals, or other measures as appropriate." The facility failed to ensure Resident 1 was free from physical abuse from staff by failing to acknowledge and investigate allegations, assess monitor, and implement allegations of Resident 1 being slapped by CNA 1. As a result, there is a potential to result in the continued physical abuse to Resident 1 and residents in the facility. The above violation had a direct relationship to the health, safety, or security of all the residents in the facility.