Other·December 18, 2023

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00866799. Representing the California Department of Public Health: Health Facilities Evaluator Nurse: 09848, A Class "B" Citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations: F609 Freedom from Abuse, Neglect, and Exploitation §483.12(c) (1) (4) 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: § 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 11/3/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding employee to resident abuse. The facility failed to implement its' policy and procedures titled, "Abuse Investigation and Reporting," by failing to report an alleged abuse incident to the State Survey Agency (SSA), the local Ombudsman (examines complaints from people who resides in skilled Nursing Facilities who feel they have been unfairly treated by facility staff) and law enforcement for Resident 1. As a result, there was a delay of an onsite inspection by the SSA to rule out abuse placing Residents 1 and other residents at risk for further abuse. A review of Resident 1's Admission Record indicated Resident 1 was originally admitted to the facility on 10/18/2022, with diagnoses including aftercare following surgery of the digestive tract, delayed milestone in childhood (developmentally delayed), difficulty walking, and generalized muscle weakness. A review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 10/18/2023, indicated Resident 1 was alert and oriented, with unclear speech able to understand and usually understood. Requiring total assistance from staff with activities of daily living (ADLs-bed dressing, eating, toilet use, and personal hygiene). During an interview and a concurrent record review with the Director of Nursing (DON), on 11/3/2023 at 3:50 the DON stated the mother of Resident 1 complained that Resident 1 stated a male nurse picked him up and threw him back in bed hurting his back and neck on 10/16/2023 at around 5am. The DON informed Resident 1's mother that she would investigate and let her know of the results of the investigation. The DON further stated they assessed Resident 1, interviewed staff, and investigated it as a complaint investigation not an abuse. The DON further confirmed and stated the alleged abuse incident was not reported to the State Agency (SA), police or the Ombudsman. The DON stated the facility should have reported to the proper authorities as indicated in the facility's policy and procedures regarding abuse investigation and reporting. A review of the facility 's policy and procedures (P&P), titled, "Abuse Investigation and reporting," revised 7/2023, indicated the facility will ensure that all alleged violations by anyone are reported to the administrator or his / her designee, to the following persons or agencies the State licensing / certification agency responsible for surveying / licensing the facility; the local Ombudsman; the Resident's representative (Sponsor) of Record; Law enforcement officials and the Resident's Attending Physician. An alleged violation abuse, neglect, mistreatment, will be reported immediately, but not later than: violations involving abuse are reported immediately, but not later than 2 hours if involve abuse OR has resulted in serious bodily injury, or 24 hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. The facility failed to implement its' policy and procedures titled, "Abuse Investigation and Reporting," by failing to report an alleged abuse incident to the SSA, the local Ombudsman, and law enforcement for Resident 1. As a result, there was a delay of an onsite inspection by the SSA to rule out abuse placing Residents 1 and other residents at risk for further abuse. The above violation had a direct relationship to the health, safety, and security of Resident 1.