Incident investigation·March 27, 2024

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Gregory Case. Today's visit was in response to two (2) LIC624 Incident Reports, which Licensee self-submitted to the CCLD San Diego Regional Office (both were received on 02/09/2024). According to the LIC624s: On 02/06/2024, facility management first became aware of allegations of Staff #1’s (S1’s) mistreatment of residents. Specifically, it was alleged that S1 handled Resident #1 (R1) roughly during personal care and that S1 intentionally gave Resident #2 (R2) a cold shower. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. Upon receiving these allegations, Licensee immediately suspended S1’s employment pending further investigation. During today’s visit, LPA performed a brief facility tour and welfare check on select residents in care. LPA collected copies of and reviewed pertinent care and personnel records, as well as handwritten and signed statements from staff (which Licensee’s collected during its own internal investigation). LPA also independently interviewed multiple relevant staff. [CONTINUED ON LIC 809-C, 1 of 2] [CONTINUED FROM LIC 809] According to R1’s Facesheet and LIC602 Physician’s Report (dated 08/28/2023), R1’s diagnoses included Dementia and “hemiplegia and hemiparesis following cerebral infarction [i.e., stroke].” R1’s Service Agreement with Licensee (i.e., care plan) showed that they required assistance of two (2) staff with incontinence care and dressing, among other needs. According to R2’s Facesheet and LIC602 Physician’s Report (dated 07/24/2023), R2’s diagnoses included Dementia. R1’s Service Agreement with Licensee showed that they required staff assistance with bathing, among other needs. According to R3’s Facesheet and LIC602 Physician’s Report (dated 02/01/2023), R3’s diagnoses included Dementia and Insomnia. Records showed that R1 had lived at the facility since 06/04/2022, while S1 had worked at the facility since 12/07/2022. Staff interviews widely corroborated that R1 experienced limited flexibility in their legs due to their underlying condition. Sometime between late January and early February 2024, there was an occasion when S1 quickly/forcefully opened R1’s legs while they attempted to provide incontinence care to R1, causing R1 to cry out in pain. This was witnessed by Staff #2 (S2) the only other person in the room at that time. Staff #3 (S3) and Staff #4 did not witness the above incident, but each described a separate occasion where they witnessed S1 refuse to provide personal care to S1 (for which other facility staff had to step in to help S1). According to records and staff interviews, during the same general time frame: There was a day when S1 gave R2 a shower using cold water. After R2 yelled out in protest, S2 intervened to pause the shower until the water could be warmed up. The cold shower incident was witnessed by both S2 and S3. Lastly, there was a morning when S2 saw S1 exit R3’s bedroom. S1 told S2 that R3 refused to get up out of bed. When S2 went into R3’s bedroom, they found R3 curled up in bed cold, with their blankets on the floor and their bedroom window left open. S3 was on duty at the time, and while they did not personally enter R3’s bedroom, they corroborated that S2 expressed to them that same day their concern about what they witnessed. [CONTINUED ON LIC 809-C, 2 of 2] [CONTINUED FROM LIC 809-C, 1 of 2] Due to their baseline memory loss, R1, R2, and R3 were unable to be interviewed. Personnel records showed: S1’s employment at the facility was suspended starting 02/06/2024. S1’s employment was subsequently involuntarily terminated on the basis that Licensee’s investigation concluded S1 had participated in “Patient Abuse/Neglect.” Per records, Licensee reported the respective incidents involving S1 against R1 and R2 to CCLD, the local Long Term Care Ombudsman Program (LTCOP), local law enforcement, and those residents’ responsible persons (RPs), as was required. However, Licensee did not submit a written report to the Department describing the alleged incident involving S1 and R3, as was required, despite gaining constructive knowledge of this latter allegation on 02/06/2024. Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). Since one of the deficiencies is a repeat violation within a twelve (12) month period of time, a civil penalty of $250 was also assessed (refer to the LIC421-FC). Plan of Corrections were jointly developed with the Licensee. An exit interview was conducted with Case, to whom a copy of this report, the LIC 809-D, the LIC421-FC, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.