Other·July 10, 2019

F000 INITIAL COMMENTS

F000 DEFICIENCY) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of facility reported incident #CA00534528. Representing the Department of Public Health: Health Facilities Evaluator Nurse, 36586 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility.

F225 SS=D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. 555153 06/18/2019 FAIR OAKS HEALTHCARE CENTER 11300 Fair Oaks Boulevard Fair Oaks, CA 95628 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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 longterm care facilities) in accordance with State law through established procedures. (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. This REQUIREMENT is not met as evidenced 555153 06/18/2019 FAIR OAKS HEALTHCARE CENTER 11300 Fair Oaks Boulevard Fair Oaks, CA 95628 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE by: Based on interview and record review, the facility failed to report an allegation of staff abuse within 24 hours as required, when the Certified Nursing Assistant (CNA 1), who witnessed the alleged abuse by CNA 2, did not report it to the facility. This failure resulted in a five day delay of the investigation and had the potential to leave Resident 1 in harm for those five days. Findings: Resident 1 was admitted to the facility in December of 2016 with diagnoses of chronic kidney failure, nausea and vomiting, pathological fractures and altered mental status. Resident 1's Psycho Social Assessment, dated 5/9/17, indicated Resident 1 had a BIMS of 6 (Brief Interview for Mental Status, 15-question evaluation of mental processes including perception, memory, judgment and reasoning; ideal score is 15) and physician orders stipulated resident did not have capacity to make healthcare decisions. During an interview on 5/17/17 at 9:00 a..,the Director of Nursing (DON) stated, on 5/3/17, CNA 1, who is a mandated reporter, observed CNA 2 being "rough" with Resident 1 after she vomited. CNA 1 then told CNA 3 of the witnessed alleged abuse. CNA 3 gave the Unit Manager (UM) a letter on 5/8/17 listing complaints about CNA 2. The UM did not open the letter until 5/8/17 at which time the allegation of abuse was reported. The department was notified on 5/8/17 at end of business. During an interview on 5/17/17 at 9:30 a.m., the UM confirmed receiving the letter and the 555153 06/18/2019 FAIR OAKS HEALTHCARE CENTER 11300 Fair Oaks Boulevard Fair Oaks, CA 95628 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE time line stated by the DON. She further stated CNA 2 was a good CNA and was well liked by the residents. There have been no disciplinary issues with CNA 2. During an interview with CNA 2, on 5/17/17 at 4:00 p.m., CNA 2 stated she was not angry at Resident 1 but surprised at the amount of vomit that was present. CNA 1 was interview on 5/18/17 at 2:10 p.m. and stated on 5/3/17 she heard loud talking coming from Resident 1's room and went into the room and observed CNA 2 "being rough with Resident 1." CNA 1 stated she told CNA 3 what was observed and was told "She always rough with patients." CNA 1 stated she did not report the incident to any supervisors. CNA 1 further stated the DON, Administrator (ADM) and the UM spoke to her after CNA 3 reported the incident. "I had to fill out the SOC341." During a concurrent observation and interview with Resident 1 on 5/19/17 at 10:00 a.m., Resident 1 was observed resting quietly in bed, no apparent signs of distress. When asked if Resident 1 knew who CNA 2 was, Resident 1 did not recall who CNA 2 was or any incident involving a CNA. Review of Resident 1's electronic medical record reveal social services checks after the alleged incident with no problems. The document titled Care plan was updated noting the alleged abuse. Review of the facility policy titled Elder and Dependent Adult Suspected Abuse & Reporting last revision dated 1/6/17 stipulated "...Community staff, volunteers, and students shall be advised of the policy and procedure during orientation, as well as the penalties for failing to report such incidences... will e 555153 06/18/2019 FAIR OAKS HEALTHCARE CENTER 11300 Fair Oaks Boulevard Fair Oaks, CA 95628 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE educated on the community's policies and procedures regarding abuse prevention and reporting... They are provide information on how, and to whom, they may report... Reporting requirements - all suspected/ alleged or witnessed abuse... shall be immediately reported verbally and /or in writing to the mandated reporter's immediate supervisor and the Administrator and/ or his/her designee and the Dir. of Nursing. All suspected/ alleged or witnessed physical abuse that does not result in serious bodily injury shall be reported by telephone within in 24 hours to the local law enforcement agency AND within 24 hours the SOC341 written report shall be made to the Long Term Care Ombudsman, local law enforcement and the licensing agency (CDPH) [California Department of Public Health]..."