Health inspection·April 18, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1. Their abuse policy and procedure accurately reflect the correct reporting time frames and the abuse allegation was reported to the state, Ombudsman (a person who investigates, reports on, and helps settle complaints) and local police enforcement immediately, but no later than 2 hours after the allegation is made for one out of four sampled residents (Resident 1). This failure had the potential to result to ongoing abuse which could cause Resident 1 to feel angry, depressed and scared. Findings: During a review of Resident 1's face sheet (demographics), it indicated Resident 1 was [AGE] years old, initially admitted to the facility on [DATE]. Her diagnoses included Congestive Heart Failure (CHF, A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), Dysphagia (difficulty swallowing) and Stage 4 pressure sore (most severe type of pressure ulcer, indicating the pressure injury is very deep, reaching into muscle and bone and causing extensive damage) on her sacrum, a large, triangle-shaped bone in the lower spine that forms part of the pelvis (the lower part of the trunk). Her Minimum Data Sheet assessment (MDS, a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems) dated 2/23/23, Brief Interview of Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents), indicated Resident 1 had moderately impaired cognition. Resident 1 was totally dependent on 1 to 2 staff for her Activities of Living (ADL's, activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Resident 1 received nutrition via Gastrostomy tube (GT, a tube inserted through the belly that brings nutrition directly to the stomach) During an interview on 3/27/23 at 2:30 p.m., the Administrator verified he received a report from staff on 3/23/23, night shift, about an alleged incident between Resident 1 and her son. The Administrator stated, it was reported to him on 3/23/23 that Resident 1's son was unsafely handling Resident 1 during turning and repositioning, while Resident 1 was lying flat on the bed with her tube feeding running and Resident 1's son was observed to be tugging on her blanket harshly while repositioning her. The Administrator stated that at this time, he did not feel the son's action towards Resident 1 was abusive in nature hence no report was made until the morning of 3/24/23 when a staff reported another incident where Resident 1's son was attempting to change her shirt while she was inappropriately positioned, the privacy curtain was opened, and Resident 1 was exposed. The Administrator stated this prompted him to report an alleged abuse on 3/24/23. During an interview on 3/27/23 at 2:53 p.m., Unlicensed Staff A stated staff should report to the Page 1 of 3 055014 055014 04/18/2023 Fairfield Post-Acute Rehab 1255 Travis Blvd Fairfield, CA 94533

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few manager immediately if a resident was yelling stop repeatedly, appears to be in pain or being cared for harshly in anyway as this could be an abusive situation that needed further investigation. Unlicensed Staff A stated if an alleged abuse was not reported immediately, it could result to continued abuse, resident would feel unhappy, hopeless, scared, and angry. Unlicensed staff A stated, all abuse allegations had to be reported to the state, the Ombudsman, and the law enforcement within 24 hours upon learning of the incident. During an interview on 3/27/23 at 3:02 p.m., Unlicensed Staff B stated, allegation of abuse should be reported immediately. Unlicensed Staff B stated hearing a resident yelling stop repeatedly or observing a harsh care being provided to a resident need to be reported immediately because that could be an indication of abuse. When asked what immediately meant, Unlicensed Staff B stated, I'm not really sure but I think all abuse allegations need to be reported within 24 hours. Unlicensed Staff B stated, if abuse allegations were not reported immediately, resident would not be safe. Unlicensed Staff stated, residents could get injured and experience emotional distress. Unlicensed Staff B stated, resident would end up feeling angry and scared. During an interview on 3/27/23 at 3:28 p.m., Licensed Staff C stated, all abuse allegations would need to be reported to the state, Ombudsman, and the law enforcement, immediately within 24 hours. Licensed Staff C stated he did not know which document he needed to fill out when reporting abuse to the state, the ombudsman, and the law enforcement agency. Licensed Staff C stated if a resident was yelling stop continuously and complaining of pain or if staff observed someone treating a resident harshly in any way, this could mean it was an abusive situation that would need further investigation and would need to be reported immediately. Licensed Staff C stated residents' safety was a top priority. Licensed Staff C stated, if an abuse allegation was not reported immediately, it could result to resident feeling alone, scared, depressed and angry. Licensed Staff C stated failure to report an abuse allegation immediately could result to further abuse. During an interview on 3/27/23 at 4:07 p.m., Licensed Staff D stated, if there was an abuse allegation, staff would need to fill out SOC 341. Licensed Staff D stated, all abuse allegations had to be reported to the state, Ombudsman, and local enforcement agency within 2 hours. Licensed Staff D stated, if a resident was being treated harshly in anyway, it could mean an abuse is going on and would need to investigate further. Licensed Staff D stated, residents' safety was always the priority. Licensed Staff D stated, if an abuse allegation was not investigated and reported timely, the abuse could continue. Licensed Staff D stated this could result to resident feeling angry and scared. Licensed Staff D stated, resident will not trust staff thinking staff did not do anything to help them anyway. During a concurrent interview and nursing note dated 3/23/23 9:30 p.m., record review on 3/27/23 at 4:51 p.m. the Director of Nursing (DON) verified that on the evening of 3/23/23, she was notified by Unlicensed Staff E regarding an incident involving Resident 1 and her son. The DON stated she could not recall the details of the call but was concerned on how Resident 1's son was treating the staff versus on how Resident 1's son was providing care for her. The DON stated she was not worried about Resident 1 when she received the report regarding an incident between Resident 1 and her son, but more so on Resident 1's son behavior towards the staff. The DON stated Licensed Staff E had concerns, among others, about Resident 1's son caring for her. The DON verified the nursing note on 3/23/23 9:32 p.m., indicated Resident 1's son was unsafely handling her while being repositioned in bed, flat on the bed, with GT feeding running . son was tugging the bedsheet harshly while repositioning her. When asked if this could be considered an alleged abuse situation, the DON stated it was hard to say. When asked if Resident 1's son tugging on Resident 1's sheets harshly while repositioning her 055014 Page 2 of 3 055014 04/18/2023 Fairfield Post-Acute Rehab 1255 Travis Blvd Fairfield, CA 94533

F 0609 Level of Harm - Minimal harm or potential for actual harm and Resident 1's son unsafe handling while repositioning her could be considered an abuse, thus needing to be investigated and reported immediately, the DON stated it was a tricky question. The DON stated, based on the facility policy, the facility met the abuse reporting time frame since they had reported the abuse allegation within 24 hours anyway. The DON stated abuse that resulted to an injury would be reported within 2 hours. Residents Affected - Few During a telephone interview on 3/29/23 at 3:04 p.m., Unlicensed Staff E verified that on the night of 3/23/23, she had reported to the DON and the Administrator, an incident involving Resident 1 and her son. Unlicensed Staff E stated the call was prompted because she felt the situation was abusive in nature. Unlicensed Staff E stated, the situation did not feel right, the way Resident 1's son was caring for her. During a review of the facility's policy and procedure (P&P), titled Fairfield Post Acute Rehab Policy and Procedure- Nursing Administration, Residents Rights section, Abuse Prevention revised 12/2021, the P&P indicated, all alleged incidents of abuse are to be reported to the state immediately or within 24 hours .allegation of resident abuse, neglect, misappropriation of resident property or injury of unknown source will be reported within 24 hours to the appropriate state agency, the Department of health and the Ombudsman. A review of the Federal Regulation 609, 42 CFR 483.12(c) indicated all alleged violations should be reported immediately but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury. 055014 Page 3 of 3