Health inspection·February 8, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure: Residents Affected - Some 1. Residents were free from physical and verbal abuse when Resident 3, who had a history of hitting others and wandering, wandered around the facility, entered other resident rooms, and start altercations while unsupervised. On five separate occasions (12/26/22, 1/26/23, 2/17/23, 3/13/23, and 9/12/23) Resident 3 entered other residents ' rooms/personal space wherein she yelled and cussed at, pulled hair, slapped, and hit other residents. 2. After Resident 3 had repeatedly verbally and physically abused other residents, the facility failed to implement close supervision of the resident when wandering to prevent further incidents from occurring. 3. This continued failure to provide close supervision when Resident 3 wandered lead to a sixth incident of physical abuse on 1/13/24, when Resident 3 entered Resident 1 ' s room and started an altercation by hitting the resident ' s arms and taking the resident ' s personal items. As a result of this deficient practice, Resident 1 and other residents had the potential to experience psychosocial distress, trauma, and physical injuries. In addition, Resident 3 ' s lack of supervision while wandering placed the 58 residents on the unit at risk for further abuse. Cross reference F609 and F657. Findings: A review of the facility ' s policy titled Abuse: Prevention of and Prohibition Against revised 1/2021, defined the following: Physical Abuse includes but is not limited to hitting, slapping, pinching, and kicking . Verbal abuse includes the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability. A review of Resident 1 ' s admission Record indicated, the resident was admitted to the facility on [DATE] with diagnoses to include paralysis and weakness affecting the right side of the body following a stroke. A review of Resident 1 ' s Minimum Data Set Assessment (MDS, a comprehensive assessment) dated 12/15/23, indicated, the resident scored 15 on the brief interview of mental status (a score of 13-15 meant the resident was cognitively intact). Page 1 of 15 055182 055182 02/08/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0600 A review of Resident 2 ' s admission Record indicated the resident was admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm A review of Resident 2 ' s MDS assessment dated [DATE], indicated the resident scored 13 on the brief interview of mental status. Residents Affected - Some A review of Resident 3 ' s admission Record indicated the resident was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses to include bipolar disorder (a mood disorder characterized by depression and mania) and dementia (characterized by memory loss and lack of judgement serious enough to affect daily activities) with behavioral disturbance and psychotic (abnormal thinking and perception) disturbance. A review of the facility ' s census dated 1/23/24, indicated there were 58 residents on Resident 1, 2, and 3 ' s residential unit. A review of Resident 3 ' s interdisciplinary team (IDT) note dated 12/27/22, indicated on 12/26/22 at 4:40 P.M., .The LN [licensed nurse] heard screams coming from room [A], upon arrival found [Resident 3] standing over top of [resident in room A] hitting her while she was in her wheelchair screaming, [Resident 3] removed from the situation via staff assist placed back in her w/c [wheelchair] and taken to her room [Resident 3 ' s room]. She was yelling profanities toward LN and [Resident in room A] the whole time A review of Resident 3 ' s change of condition note dated,1/26/23, indicated at 9 P.M., . Resident in Bed C was shouting from room. Writer entered room with CNA [certified nursing assistant] in between [Resident 3 and resident in Bed C]. Separated [Resident 3] to nurses station. [Resident in Bed C] stated: [Resident 3] was mad that victim did not help her pick up an item she dropped. [Resident 3] became agitated leading to both yelling at each other resulting in [Resident 3] slapping her twice A review of Resident 3 ' s IDT note dated 2/20/23, indicated, on 2/17/23 at 7:29 P.M., . [Resident 3] entered another room that was not her assigned room. The other patient [Room F] told [Resident 3] that this was not her room and to leave. [Resident 3] became agitated and began to use profanity while talking to [Resident in Room F], [Resident 3] then stood up from her wheelchair and slapped [Resident in Room F] and then began to pull her hair . While LN was speaking to law enforcement [Resident 3] was sitting in front of the nurses station, [Resident 3] stood up from her wheelchair suddenly and hit another patient [Resident in Room G] with a closed fist on the left side of the face. Residents were immediately separated. This incident was immediately reported as well According to the same IDT note dated 2/20/23, the assistant director of nursing (ADON) interviewed the resident in Room G and that resident made the statement, ' [Resident 3] is the same patient who hit me before, I was just sitting in the nurses station and [Resident 3] suddenly stood up and hit me in my face, [Resident 3] needs to go, she cannot hit other people here, it ' s dangerous [Resident in Room G] added that she did not provoke [Resident 3] to anything A review of Resident 3 ' s IDT note dated 3/15/23, indicated on 3/13/23 at 11:15 P.M., Resident 1 stated .that at 9 P.M., [Resident 3] entered [Resident 1's] room in a wheelchair and told her ' why are you sleeping in my bed ' [Resident 1] responded, ' Get out of my room you [expletive]. ' At that time [Resident 3] approached the right side of [Resident 1 ' s] bed, stood up, and began attempting to hit her and hit her right arm 055182 Page 2 of 15 055182 02/08/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 3 ' s IDT note dated 9/13/23, indicated on 9/12/23, .Victim reported to the LN/CN [charge nurse] that her roommate [Resident 3] physically touched her, [Resident 3] noted to have some confusion, agitation, and while staff attempted to assist [Resident 3], [Resident 3] began to strike out at staff. [Resident 3] was asked what happened, stated that victim called her a vulgar name, [Resident 3] was informed that victim in non-verbal, when asked if [Resident 3] touched your roommate, [Resident 3] stated yes ' I did ' . victim was noted with redness to the right side of the chest. Redness to the left side of the face near the ear A review of Resident 3 ' s IDT note dated 1/17/24, indicated on 1/15/24 at 11:35 P.M., per LN statement of event, .[Resident 1] stated that approximately two days ago, another resident [Resident 3] came into her room and verbally threatened her and then grabbed a remote control and struck her several times on her left forearm, leaving a purple discoloration . Victim stated she spoke with [CNA 4] and said, ' call the police. ' .[Resident 1] stated, ' sometimes [Resident 3] comes into my room, and I ' ll start screaming for help and she leaves. ' On 1/24/24 at 8:45 A.M., an observation and interview was conducted with Resident 1 while inside the resident ' s room. Resident 1 was in bed wearing eyeglasses and a gown. Resident 1 stated she shared her room with Resident 2. Resident 1 stated Resident 3 often came into their room and would open their closets and touch their personal items. Resident 1 stated there were times Resident 3 would come over to her bed and hit her when she tried to stop the resident from taking her things. Resident 1 stated she would yell for staff to help and sometimes staff came and removed Resident 3 from her room. Resident 1 stated there were other times staff did not come when she called for help. Resident 1 stated this had been going on with Resident 3 for months and it was not the first time Resident 3 had hit her. Resident 1 stated on 1/13/24, Resident 3 again went into her room and came to her bed and threatened to pull off her glasses. Resident 1 stated Resident 3 took the remote control off her bed and started hitting her on the arms with it. Resident 1 stated she then grabbed a hold on Resident 3 ' s wrists to stop her from continuing to hit her. Resident 1 stated she yelled for help and CNA 4 came in and removed Resident 3 from her room. Resident 1 stated she told CNA 4 what had happened and that she wanted the police to be called. Resident 1 stated after the incident, a CN came and spoke to her (she did not recall the CN ' s name) and offered her a room change. Resident 1 stated she liked her room and did not think she should have to move. Resident 1 stated the CN told her if she did not want to change her room then she would have to deal with Resident 3 ' s behavior of going into her room. On 1/24/24 at 8:55 A.M., an interview was conducted with Resident 2 while inside the resident ' s room (shared with Resident 1). Resident 2 stated Resident 3 frequently came into their room and touched their things. Resident 2 stated Resident 3 usually would go directly to Resident 1 ' s bed and fights with [Resident 1]. Resident 2 stated Resident 1 was lying in bed and minding her own business when Resident 3 would come into their room. Resident 2 stated she did not always see what happened with her curtain closed. Resident 2 stated when Resident 3 entered their room and Resident 1 yelled for help, she would then hear slapping sounds. Resident 2 stated, I was afraid of [Resident 3] because she comes in and hits [Resident 1] and runs her wheelchair into my bed. Resident 2 stated sometimes staff came in and got Resident 3 out of their room, and other times they did not come, and they would have to wait for Resident 3 to leave on her own. On 1/24/24 at 10:07 A.M., an interview was conducted with CNA 5. CNA 5 stated Resident 3 seemed confused and often wandered into other residents ' rooms. CNA 5 stated, Everyone knows [Resident 3] does this. CNA 5 stated other residents did not like Resident 3 going into their rooms and would yell for Resident 3 to get out. CNA 5 stated when that happened, she would remove Resident 3 from the 055182 Page 3 of 15 055182 02/08/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0600 Level of Harm - Minimal harm or potential for actual harm room. CNA 5 was asked how staff prevented Resident 3 from going into other residents ' rooms, and she stated they redirected her. CNA 5 stated Resident 3 responded to redirection. CNA 5 stated if staff were not watching the resident at the time, then redirection did not prevent the resident from going into other residents ' rooms. CNA 5 stated Resident 3 ' s behavior of wandering into other residents ' rooms could cause resident altercations. Residents Affected - Some On 1/24/24 at 10:20 A.M., an observation and interview was conducted with Resident 3 while inside the resident ' s room. Resident 3 was sitting in bed staring at the corner of the room with wide eyes. Resident 3 was asked about the 1/13/24 incident. Resident 3 stated, A lady called me a [expletive] and I hit her. Resident 3 then resumed staring at the corner of the room and did not participate further with the interview. On 1/24/24 at 10:54 A.M., an interview was conducted with CNA 6. CNA 6 stated when Resident 3 started getting active, the wandering began. CNA 6 stated Resident 3 could get agitated during those times of being more active and did not like to be told what to do. CNA 6 stated Resident 3 would wander into other residents ' rooms and bothers people. CNA 6 stated Resident 3 needed close supervision when she was up and wandering around to prevent her from entering other residents ' rooms and so she doesn ' t get into trouble. On 1/24/24 at 12:40 P.M., another interview was conducted with Resident 1 while inside the resident ' s room. Resident 1 was lying in bed with a stuffed toy next to her pillow. Resident 1 stated when Resident 3 kept coming into her room it felt like harassment, and when Resident 3 would hit her it felt abusive. Resident 1 stated she was okay just did not want to see Resident 3 in her room again. On 1/24/24 at 12:45 P.M., an interview was conducted with LN 7. LN 7 stated Resident 3 was confused and sundowned in the afternoon (sundowning, a state of confusion occurring in the evening characterized by anxiety or ignoring directions and can lead to pacing or wandering). LN 7 stated Resident 3 wandered into other residents ' rooms. LN 7 stated she was not working during the 1/13/24 incident with Resident 3 and Resident 1. LN 7 stated days prior to the incident, she had heard Resident 1 yelling, Help! Get her out of here! and she had responded to the resident ' s room. LN 7 stated Resident 3 had been inside Resident 1 ' s room and she had to remove Resident 3 from the room. LN 7 stated it had not been the first time Resident 3 went into Resident 1 ' s room. LN 7 stated redirecting Resident 3 was not enough to prevent altercations when the resident was already inside another resident ' s room. LN 7 stated when Resident 3 was actively wandering, she needed 1:1 supervision (one staff to remain with the resident) or eyes on her so she Can ' t have the opportunity to get into someone else ' s room. LN 7 stated Resident 3 ' s wandering into other residents ' rooms could lead to resident altercations and abuse. On 1/24/24 at 1:45 P.M., an interview was conducted with the social services director (SSD). The SSD stated Resident 3 had a behavior of wandering into other residents ' rooms. The SSD stated this behavior could lead to resident-to-resident altercations and abuse. The SSD stated this was a safety concern. The SSD stated redirection would not consistently prevent Resident 3 from going into other residents ' rooms and closer supervision was needed to prevent this behavior from reoccurring. The SSD stated more should have been done to prevent Resident 3 ' s altercation with Resident 1. A review of Resident 3 ' s written care plans: 1) Resident Altercation dated 1/16/24; 2) Potential to demonstrate physical behaviors related to anger, history of harm to others, poor impulse control as evidenced by hitting others, verbal aggression cussing at others, dated 12/2/22 and revised 3/17/23; and 3) Wanderer: Resident self-propelling her wheelchair into the hallway and going inside other 055182 Page 4 of 15 055182 02/08/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0600 residents ' rooms dated 3/6/23, did not address the supervision needs of the resident when wandering. Level of Harm - Minimal harm or potential for actual harm On 1/24/24 at 2:35 P.M., a joint interview and record review was conducted with the ADON. The ADON stated Resident 3 wandered into other residents ' rooms but was redirectable. The ADON reviewed Resident 3 ' s clinical record and written care plans and stated the interventions of redirection and distraction were effective in preventing the resident from wandering into other residents ' rooms. The ADON was informed that direct care staff who were interviewed had stated close supervision, eyes on the resident, and 1:1 supervision was needed when Resident 3 was actively wandering to prevent this behavior. The ADON stated, We can ' t do that. The ADON then acknowledged the facility had the responsibility of meeting all the resident ' s needs including supervision needs. Residents Affected - Some The ADON acknowledged that redirection and distraction were not effective in preventing altercations and abuse if staff did not see the resident entering another resident ' s room. On 1/25/24 at 10:41 A.M., a telephone interview was conducted with CNA 4. CNA 4 stated she had been working on the evening of 1/13/24 and had heard Resident 1 yelling Help! and Get out! CNA 4 stated she responded to Resident 1 ' s room and found Resident 3 in there standing over Resident 1 and taking the resident ' s stuffed toy. CNA 4 stated she gave Resident 1 her stuffed toy back and removed Resident 3 from the room. CNA 4 stated Resident 1 had told her, [Resident 3] hit me, and had asked her to call the police. CNA 4 stated Resident 3 would wander into other residents ' rooms all the time and that other residents did not like it. CNA 4 further stated, As soon as you turn your back, [Resident 3] is in someone else ' s room. CNA 4 stated more supervision was needed when Resident 3 was out of bed and wandering around. On 1/25/24 at 11:10 A.M, an interview was conducted with the director of nursing (DON). The DON stated if her nurses stated that Resident 3 needed more supervision when out of bed to prevent wandering into other residents ' rooms, then that should have been provided. The DON acknowledged that redirection and distraction when Resident 3 was already inside another resident ' s room was too late and would not prevent altercations from occurring. On 2/2/24 at 7:05 A.M., a telephone interview and record review was conducted with LN 8. LN 8 stated he had gone in to assess Resident 1 on 1/15/24 around 11 P.M., and saw the resident had a small bruise on her arm. LN 8 stated he asked Resident 1 what had happened, and the resident told him two days ago Resident 3 came into her room. LN 8 stated Resident 1 told him she told Resident 3 to get out and then Resident 3 had grabbed her remote and started hitting her arms and that they tussled over it. LN 8 stated Resident 3 was known to wander into other residents ' room. LN 8 ' s documentation dated 1/16/24 at 4:24 A.M., was reviewed and indicated Resident 3, .found entering the room [Room H] across from her ' s [sic] pushing her wheelchair when one resident in room began yelling at her to get out . [Resident 3] escorted back to her bed and asked not to enter other ' s rooms. Resident calm at the time, remains on q [every] 15 minute monitoring [observing the resident ' s whereabouts every 15 minutes]. LN 8 stated after Resident 1 told him of the incident with Resident 3, he had placed Resident 3 on q 15 monitoring. LN 8 stated, But it wasn ' t enough. She ' s fast and went into [Room H]. They yelled for help and to get [Resident 3] out. LN 8 stated Resident 3 needed closer supervision when she was wandering around because she bothers other residents. LN 8 then stated Resident 3 needed 1:1 supervision when wandering around but We can ' t provide that. LN 8 stated the level of supervision 055182 Page 5 of 15 055182 02/08/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 3 needed was an action that had to be made by facility leadership. LN 8 stated Resident 3 ' s unsupervised wandering could lead to incidents of resident-to-resident abuse. On 2/8/24 at 1:47 P.M., a joint interview was conducted with the facility ' s administrator (ADM), DON, and corporate clinical consultant (CCC). Resident 3 ' s incidents of verbal and physical abuse were reviewed with the ADM, DON, and CCC that occurred on 12/26/22, 1/26/23, 2/17/23, 3/13/23, 9/12/23, and 1/13/24. The ADM, DON, CCC all acknowledged the pattern of repeated abuse incidents. The ADM, DON, and CCC all stated that more should have been done to prevent Resident 3 ' s unsupervised wandering as it led to residents ' experiencing abuse. A review of the facility ' s policy titled Abuse, Resident-to-Resident revised 5/2007, indicated, It is the policy of this facility to protect residents from harm at all times. This includes protection from physical and verbal abuse from other residents A review of the facility ' s policy titled Abuse: Prevention of and Prohibition Against revised 1/2021, indicated, It is the policy of this facility that each resident has the right to be free from abuse . B. Screening (Prospective Residents) 1. Prior to admission, all prospective residents will be screened to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility. This screening will include, but not limited to: Reviewing the prospective resident ' s functional, mood and behavioral status . h. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms include, but are not limited to .ii. Wandering or elopement-type behaviors . D. Prevention .The facility will take action to protect and prevent abuse and neglect from occurring within the facility by .Assuring that residents are free from neglect by having structures and processes to provide the needed care and services to all residents, which includes, but is not limited to . Identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as: Verbally aggressive behavior, such as screaming, cursing . Physically aggressive behavior, such as hitting, kicking, grabbing . Taking, touching, or rummaging through other ' s property; Wandering into other ' s rooms/space . G. Protection .Increase supervision 055182 Page 6 of 15 055182 02/08/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

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 interview and record review, the facility failed to ensure its abuse policies were implemented when certified nursing assistant (CNA) 4 did not report Resident 1 ' s allegation of physical abuse. In addition, the facility did not report the allegation of abuse within 24 hours to the California Department of Public Health (CDPH, state survey agency that regulates nursing homes) and law enforcement entity as was mandated by law. As a result of this deficient practice, investigation into the allegation of abuse was delayed and placed residents at risk for further abuse. Cross reference F600. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include paralysis and weakness affecting the right side of the body following a stroke. A review of Resident 1 ' s Minimum Data Set Assessment (MDS, a comprehensive assessment) dated 12/15/23, indicated the resident scored 15 on the brief interview of mental status (a score of 13-15 meant the resident was cognitively intact). A review of Resident 1 ' s interdisciplinary (IDT) note dated 1/17/24, indicated on 1/15/24, .[Resident 1] stated that approximately two days ago [1/13/24], another resident [Resident 3] came into her room and verbally threatened her and then grabbed a remote control and struck her on her left forearm, leaving a purple discoloration .Victim stated she spoke with [CNA 4] and said ' call the police ' On 1/24/24 at 8:45 A.M., an interview was conducted with Resident 1 while inside the resident ' s room. Resident 1 stated on 1/13/24, Resident 3 went into her room and came to her bed and threatened to pull off her glasses. Resident 1 stated Resident 3 took the remote control off her bed and started hitting her on the arms with it. Resident 1 stated she then grabbed a hold on Resident 3 ' s wrists to stop her from continuing to hit her. Resident 1 stated she yelled for help and CNA 4 came in and removed Resident 3 from her room. Resident 1 stated she told CNA 4 what had happened and that she wanted the police to be called. On 1/25/24 at 10:41 A.M., a telephone interview was conducted with CNA 4. CNA 4 stated she had been working on the evening of 1/13/24 and had heard Resident 1 yelling Help! and Get out! CNA 4 stated she responded to Resident 1 ' s room and found Resident 3 in there standing over Resident 1 and taking the resident ' s stuffed toy. CNA 4 stated she gave Resident 1 her stuffed toy back and removed Resident 3 from the room. CNA 4 stated Resident 1 had told her, [Resident 3] hit me, and had asked her to call the police. CNA 4 stated she did not report that Resident 1 told her Resident 3 had hit her because she did not witness it herself. CNA 4 stated hitting was considered abuse. CNA 4 then stated, It ' s my fault. I should have reported what [Resident 1] said. On 1/25/24 at 11 A.M., an interview was conducted with CNA 9. CNA 9 stated all allegations of abuse had to be reported. CNA 9 stated abuse did not have to be witnessed to be reported. CNA 9 stated 055182 Page 7 of 15 055182 02/08/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few allegations of abuse had to be reported immediately to the charge nurse, director of nursing (DON), and administrator (ADM). On 1/25/24 at 11:05 A.M., an interview was conducted with CNA 10. CNA 10 stated, You have to listen to your patient. If they tell you, they were abused you have to report it immediately. [NAME] ' t wait. CNA 10 further stated, You don ' t have to witness it to report it. Just report it. It ' s not your job to investigate or believe it. On 1/25/24 at 11:10 A.M., an interview was conducted with the DON. The DON stated CNA 4 should have immediately reported Resident 1 ' s allegation that Resident 3 had hit her. The DON stated the incident and allegation between Resident 1 and Resident 3 occurred on 1/13/24, and it should have been reported the day it happened. The DON acknowledged Resident 1 had to again report the incident to staff on 1/15/24. The DON stated the facility ' s reporting of Resident 1 ' s allegation of abuse on 1/15/24 was not timely. On 2/2/24 at 7:05 A.M., a telephone interview was conducted with licensed nurse (LN) 8. LN 8 stated he had gone in to assess Resident 1 on 1/15/24 around 11 P.M., and saw the resident had a small bruise on her arm. LN 8 stated he asked Resident 1 what had happened, and the resident told him two days ago Resident 3 came into her room. LN 8 stated Resident 1 told him she told Resident 3 to get out and then Resident 3 had grabbed her remote and started hitting her arms and that they tussled over it. LN 8 stated he reported Resident 1 ' s allegation on 1/15/24 when the resident told him about it because it was an allegation of abuse. LN 8 stated he asked CNA 4 what had happened on 1/13/24. LN 8 stated CNA 4 did not tell him that Resident 1 had alleged she was hit. LN 8 stated CNA 4 should reported Resident 1 ' s allegation of abuse on 1/13/24 when she first had knowledge of it. LN 8 stated, You don ' t have to see it to report the resident ' s allegation. On 2/8/24 at 8:50 A.M., an interview was conducted with the ADM. The ADM stated staff had to report all allegations of abuse immediately to their supervisor or the ADM. The ADM stated staff did not have to witness the abuse to report it. The ADM stated Resident 1 ' s allegation of abuse had not been reported timely and this was not done according to her expectations. On 2/8/24 at 10:10 A.M., a joint interview and record review was conducted with the ADM. CNA 4 ' s employee training titled Abuse, Neglect, and Exploitation in the Elder Care Setting completed on 10/12/23, was reviewed. The ADM stated this training included reporting of abuse allegations and was assessed with a post test. On 2/8/24 at 12:55 P.M., a telephone interview was conducted with LN 11. LN 11 stated she was working on 1/13/24 and had been assigned to provide care to Resident 1 and Resident 3. LN 11 stated CNA 4 had not informed her of any altercation between the residents, nor of any allegation of abuse. LN 11 stated CNA 4 should have told her of Resident 1 ' s allegation of abuse so she could have reported it on 1/13/24 when it happened. On 2/8/24 at 1:47 P.M., a joint interview was conducted with the facility ' s ADM, DON, and corporate clinical consultant (CCC). The ADM and CCC both stated the facility ' s abuse policies had not been implemented related to abuse reporting. The CCC stated Resident 1 ' s allegation of abuse had not been reported to CDPH timely. A review of the facility ' s policy titled Abuse, Resident-to-Resident revised 5/2007, indicated, .5. Immediately notify the administrator and the director of nursing . 7. Notify the family/guardian, 055182 Page 8 of 15 055182 02/08/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0609 physician, and state agency(ies) as required Level of Harm - Minimal harm or potential for actual harm A review of the facility ' s policy titled Abuse: Prevention of and Prohibition Against revised 1/2021, indicated, .H. Reporting/Response 1. All allegations of abuse .should be reported immediately to the administrator. 2. Allegations of abuse . will be reported outside the facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations Residents Affected - Few 055182 Page 9 of 15 055182 02/08/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident ' s (Resident 3) written care plan for wandering behavior was implemented when incidents of wandering and what diversional activity was attempted were not consistently documented. As a result, the facility could not track Resident 3 ' s incidents of wandering and what diversional activity may or may not have been effective. Cross reference F600 and F609. Findings: A review of Resident 3 ' s admission Record indicated the resident was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses to include bipolar disorder (a mood disorder characterized by depression and mania) and dementia (characterized by memory loss and lack of judgement serious enough to affect daily activities) with behavioral disturbance and psychotic (abnormal thinking and perception) disturbance. A review of Resident 3 ' s written care plan for Wanderer: Resident self-propelling wheelchair into the hallway and going into other residents ' rooms, dated 3/6/23 and revised 1/24/23 indicated, .Document wandering behavior and attempted diversional interventions . On 1/24/24 at 8:45 A.M., an interview was conducted with Resident 1 while inside the resident ' s room. Resident 1 stated Resident 3 often came into her room and would open her closets and touch her personal items. Resident 1 stated there were times Resident 3 would come over to her bed and hit her when she tried to stop the resident from taking her things. Resident 1 stated she would yell for staff to help and sometimes staff came and removed Resident 3 from her room. Resident 1 stated there were other times staff did not come when she called for help. Resident 1 stated this had been going on with Resident 3 for months and it was not the first time Resident 3 had hit her. Resident 1 stated on 1/13/24, Resident 3 again went into her room and came to her bed and threatened to pull off her glasses. Resident 1 stated Resident 3 took the remote control off her bed and started hitting her on the arms with it. Resident 1 stated she then grabbed a hold on Resident 3 ' s wrists to stop her from continuing to hit her. Resident 1 stated she yelled for help and certified nursing assistant (CNA) 4 came in and removed Resident 3 from her room. A review of Resident 1 ' s interdisciplinary (IDT) note dated 1/17/24, indicated on 1/15/24, .[Resident 1] stated that approximately two days ago [1/13/24], another resident [Resident 3] came into her room and verbally threatened her and then grabbed a remote control and struck her on her left forearm, leaving a purple discoloration .Victim stated she spoke with [CNA 4] and said ' call the police ' .[Resident 1] stated, ' sometimes [Resident 3] comes into my room, and I ' ll start screaming for help and she leaves. ' On 1/24/24 at 12:45 P.M., an interview was conducted with LN 7. LN 7 stated Resident 3 wandered into other resident ' s rooms. LN 7 stated she was not working during the 1/13/24 incident with Resident 3 and Resident 1. LN 7 stated days prior to the incident, she had heard Resident 1 yelling, Help! Get her out of here! and she had responded to the resident ' s room. LN 7 stated Resident 3 had been inside Resident 1 ' s room and she removed Resident 3 from the room. LN 7 stated it had not been the first time Resident 3 went into Resident 1 ' s room. 055182 Page 10 of 15 055182 02/08/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/25/24 at 8:25 A.M., a joint interview and record review was conducted with LN 7. LN 7 stated she did not know the exact dates when she found or was aware Resident 3 had wandered into Resident 1 ' s room or other resident rooms. LN 7 stated she had not documented when this had happened or what diversional interventions were attempted. LN 7 reviewed Resident 3 ' s written care plan for Wanderer: Resident self-propelling wheelchair into the hallway and going into other residents ' rooms, dated 3/6/23 and revised 1/24/23, .Document wandering behavior and attempted diversional interventions . LN 7 stated the care plan had not been implemented and should have been. LN 7 further stated the monitoring of that intervention was not in the medication administration record, which would prompt the LN to document that behavior. On 1/25/24 at 11:10 A.M., an interview was conducted with the director of nursing (DON). The DON stated Resident 3 ' s written care plan for Wanderer: Resident self-propelling wheelchair into the hallway and going into other residents ' rooms, dated 3/6/23 and revised 1/24/23 with intervention, .Document wandering behavior and attempted diversional interventions . had been in place since 3/6/23 despite a revision date of 1/24/23. The DON stated licensed nurses should have been consistently documenting each episodes Resident 3 had of wandering and what diversional activities were attempted. On 2/8/24 at 12:55 P.M., a telephone interview was conducted with LN 11. LN 11 stated she was working on 1/13/24 and had been assigned to provide care to Resident 1 and Resident 3. LN 11 stated CNA 4 had not informed her of any altercation between the residents, nor of any allegation of abuse. LN 11 stated CNA 4 should have told her of Resident 1 ' s allegation of abuse so she could have reported it and documented the incident. A review of the facility ' s policy titled Care Planning/ Care Conference reviewed 9/13/23 did not provide guidance related to care plan implementation. 055182 Page 11 of 15 055182 02/08/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise/update Resident 3 ' s written care plan to provide close supervision when the resident was wandering around the facility after Resident 3 had incidents of entering other residents ' rooms that resulted in resident-to-resident altercations. As a result of this deficiency, Resident 3 continued to wander into other residents ' rooms and those residents experienced abuse or were at risk for experiencing abuse. Cross reference F600. Findings: A review of Resident 3 ' s admission Record indicated the resident was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses to include bipolar disorder (a mood disorder characterized by depression and mania) and dementia (characterized by memory loss and lack of judgement serious enough to affect daily activities) with behavioral disturbance and psychotic (abnormal thinking and perception) disturbance. A review of Resident 3 ' s interdisciplinary team (IDT) note dated 12/27/22, indicated on 12/26/22 at 4:40 P.M., .The LN [licensed nurse] heard screams coming from room [A], upon arrival found [Resident 3] standing over top of [resident in room A] hitting her while she was in her wheelchair screaming, [Resident 3] removed from the situation via staff assist placed back in her w/c [wheelchair] and taken to her room [Resident 3 ' s room]. She was yelling profanities toward LN and [Resident in room A] the whole time A review of Resident 3 ' s change of condition note dated 1/26/23, indicated at 9 P.M., . Resident in Bed C was shouting from room. Writer entered room with CNA [certified nursing assistant] in between [Resident 3 and resident in Bed C]. Separated [Resident 3] to nurses station. [Resident in Bed C] stated: [Resident 3] was mad that victim did not help her pick up an item she dropped. [Resident 3] became agitated leading to both yelling at each other resulting in [Resident 3] slapping her twice A review of Resident 3 ' s IDT note dated 2/20/23, indicated on 2/17/23 at 7:29 P.M., . [Resident 3] entered another room that was not her assigned room. The other patient [Room F] told [Resident 3] that this was not her room and to leave. [Resident 3] became agitated and began to use profanity while talking to [Resident in Room F], [Resident 3] then stood up from her wheelchair and slapped [Resident in Room F] and then began to pull her hair . While LN was speaking to law enforcement [Resident 3] was sitting in front of the nurses station, [Resident 3] stood up from her wheelchair suddenly and hit another patient [Resident in Room G] with a closed fist on the left side of the face. Residents were immediately separated. This incident was immediately reported as well According to the same IDT note dated 2/20/23, the assistant director of nursing (ADON) interviewed the resident in Room G and that resident made the statement, ' [Resident 3] is the same patient who hit me before, I was just sitting in the nurses station and [Resident 3] suddenly stood up and hit me in my face, [Resident 3] needs to go, she cannot hit other people here, it ' s dangerous [Resident in Room G] added that she did not provoke [Resident 3] to anything A review of Resident 3 ' s IDT note dated 3/15/23, indicated on 3/13/23 at 11:15 P.M., Resident 1 stated .that at 9 P.M., [Resident 3] entered her room in a wheelchair and told her ' why are you 055182 Page 12 of 15 055182 02/08/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sleeping in my bed ' [Resident 1] responded, ' Get out of my room you [expletive]. ' At that time [Resident 3] approached the right side of [Resident 1 ' s] bed, stood up, and began attempting to hit her and hit her right arm A review of Resident 3 ' s IDT note dated 1/17/24, indicated on 1/15/24 at 11:35 P.M., per LN statement of event, .[Resident 1] stated that approximately two days ago [1/13/24], another resident [Resident 3] came into her room and verbally threatened her and then grabbed a remote control and struck her several times on her left forearm, leaving a purple discoloration . Victim stated she spoke with [CNA 4] and said, ' call the police. ' .[Resident 1] stated, ' sometimes [Resident 3] comes into my room, and I ' ll start screaming for help and she leaves. ' On 1/24/24 at 8:45 A.M., an interview was conducted with Resident 1 while inside the resident ' s room. Resident 1 stated she shared her room with Resident 2. Resident 1 stated Resident 3 often came into their room and would open their closets and touch their personal items. Resident 1 stated there were times Resident 3 would come over to her bed and hit her when she tried to stop the resident from taking her things. Resident 1 stated she would yell for staff to help and sometimes staff came and removed Resident 3 from her room. Resident 1 stated there were other times staff did not come when she called for help. Resident 1 stated this had been going on with Resident 3 for months and it was not the first time Resident 3 had hit her. Resident 1 stated on 1/13/24, Resident 3 again went into her room and came to her bed and threatened to pull off her glasses. Resident 1 stated Resident 3 took the remote control off her bed and started hitting her on the arms with it. Resident 1 stated she then grabbed a hold on Resident 3 ' s wrists to stop her from continuing to hit her. Resident 1 stated she yelled for help and CNA 4 came in and removed Resident 3 from her room. On 1/24/24 at 10:07 A.M., an interview was conducted with CNA 5. CNA 5 stated Resident 3 seemed confused and often wandered into other residents ' rooms. CNA 5 stated, Everyone knows [Resident 3] does this. CNA 5 stated other residents did not like Resident 3 going into their rooms and would yell for Resident 3 to get out. CNA 5 stated when that happened, she would remove Resident 3 from the room. CNA 5 was asked how staff prevented Resident 3 from going into other residents ' rooms, and she stated they redirected her. CNA 5 stated Resident 3 responded to redirection. CNA 5 stated if staff were not watching the resident at the time, then redirection did not prevent the resident from going into other residents ' rooms. On 1/24/24 at 10:54 A.M., an interview was conducted with CNA 6. CNA 6 stated when Resident 3 started getting active, the wandering began. CNA 6 stated Resident 3 could get agitated during those times of being more active and did not like to be told what to do. CNA 6 stated Resident 3 would wander into other residents ' rooms and bothers people. CNA 6 stated Resident 3 needed close supervision when she was up and wandering around to prevent her from entering other residents ' rooms and so she doesn ' t get into trouble. On 1/24/24 at 12:45 P.M., an interview was conducted with LN 7. LN 7 stated Resident 3 was confused and sundowned (sundowning, a state of confusion occurring in the evening characterized by anxiety or ignoring directions and can lead to pacing or wandering) in the afternoon. LN 7 stated Resident 3 wandered into other resident ' s rooms. LN 7 stated she was not working during the 1/13/24 incident with Resident 3 and Resident 1. LN 7 stated days prior to the incident, she had heard Resident 1 yelling, Help! Get her out of here! and she had responded to the resident ' s room. LN 7 stated Resident 3 had been inside Resident 1 ' s room and she removed Resident 3 from the room. LN 7 stated it had not been the first time Resident 3 went into Resident 1 ' s room. LN 7 stated redirecting Resident 3 was not enough to prevent altercations when the resident was already inside another resident ' s 055182 Page 13 of 15 055182 02/08/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0657 Level of Harm - Minimal harm or potential for actual harm room. LN 7 stated when Resident 3 was actively wandering, she needed 1:1 supervision (one staff to remain with the resident) or eyes on her so she Can ' t have the opportunity to get into someone else ' s room. LN 7 stated Resident 3 ' s wandering into other residents ' rooms could lead to resident altercations and abuse. LN 7 further stated Resident 3 ' s increased supervision needs to prevent wandering into other residents ' rooms should have been included in the resident ' s written care plan. Residents Affected - Few A review of Resident 3 ' s written care plans: 1) Resident Altercation dated 1/16/24; 2) Potential to demonstrate physical behaviors related to anger, history of harm to others, poor impulse control as evidenced by hitting others, verbal aggression cussing at others, dated 12/2/22 and revised 3/17/23; and 3) Wanderer: Resident self-propelling her wheelchair into the hallway and going inside other residents ' rooms dated 3/6/23, did not address the supervision needs of the resident when wandering. On 1/24/24 at 1:45 P.M., an interview was conducted with the social services director (SSD). The SSD stated Resident 3 had a behavior of wandering into other residents ' rooms. The SSD stated this behavior could lead to resident-to-resident altercations and abuse. The SSD stated this was a safety concern. The SSD stated redirection would not consistently prevent Resident 3 from going into other residents ' rooms and closer supervision was needed to prevent this behavior from reoccurring. The SSD stated more should have been done to prevent Resident 3 ' s altercation with Resident 1. The SSD further stated increased supervision when Resident 3 was wandering should have been included on the resident ' s care plan. On 1/24/24 at 2:35 P.M., a joint interview and record review was conducted with the ADON. The ADON stated Resident 3 wandered into other residents ' rooms but was redirectable. The ADON reviewed Resident 3 ' s clinical record and written care plans and stated the interventions of redirection and distraction were effective in preventing the resident from wandering into other residents ' rooms. The ADON was informed that direct care staff who were interviewed had stated close supervision, eyes on the resident, and 1:1 supervision was needed when Resident 3 was actively wandering to prevent this behavior. The ADON stated, We can ' t do that. The ADON then acknowledged the facility had the responsibility of meeting all the resident ' s needs including supervision needs. The ADON acknowledged that redirection and distraction were not effective in preventing altercations and abuse if staff did not see the resident entering another resident ' s room. On 1/25/24 at 11:10 A.M, an interview was conducted with the director of nursing (DON). The DON stated if her nurses stated that Resident 3 needed more supervision when out of bed to prevent wandering into other residents ' rooms, then that should have been provided. The DON acknowledged that redirection and distraction when Resident 3 was already inside another resident ' s room was too late and would not prevent altercations from occurring. A review of the facility ' s policy titled Care Planning/ Care Conference reviewed 9/13/23, indicated, .4. Revision and update of care plan should transpire to accommodate resident needs A review of the facility ' s undated policy titled Dementia Care, .3. Develop individualized interventions related to the resident ' s symptomology and rate of progression A review of the facility ' s policy titled Abuse: Prevention of and Prohibition Against revised 1/2021, indicated, . Identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as: Verbally 055182 Page 14 of 15 055182 02/08/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0657 Level of Harm - Minimal harm or potential for actual harm aggressive behavior, such as screaming, cursing . Physically aggressive behavior, such as hitting, kicking, grabbing . Taking, touching, or rummaging through other ' s property; Wandering into other ' s rooms/space . G. Protection .Increase supervision Residents Affected - Few 055182 Page 15 of 15