Health inspection·October 8, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm 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: Residents Affected - Few 1.Implement its abuse Policy and Procedure (P&P) titled, Abuse Investigation and Reporting which indicated an allegation of abuse would be reported immediately to the State Licensing/Certification Agency immediately, but no later than two hours. This deficient practice had the potential for a delay in the investigation of the state agency and placed Resident 1 and other residents at risk for further abuse. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including heart failure (heart disorder which causes the heart to not pump the blood efficiently), end stage renal disease ([ESRD] irreversible kidney failure), and hypertension ([HTN] high blood pressure). During a review of Resident 1 ' s History and Physical (H&P) dated 3/1/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 9/3/2024, the MDS indicated Resident 1 had no cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 required partial/moderate assistance (staff does less than half the effort) for Activities of Daily living (ADLs) such as lower body dressing, personal hygiene, and transfers (ability to transfer to and from the bed or chair). During a review of Resident 1 ' s SBAR ([Situation Background, Assessment, Recommendation) Communication Form (a communication tool used by healthcare workers when there is a change in condition among the residents) dated 10/1/2024, the SBAR indicated (on 10/1/2024) at approximately 12:25 a.m., Resident 2 hit Resident 1 on both of his cheek with closed fists. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), diabetes (a disorder characterized by difficulty in blood sugar control and wound healing) and HTN. During a review of Resident 2 ' s H&P dated 7/30/2024, the H&P indicated Resident 2 had the Page 1 of 2 055608 055608 10/08/2024 Primrose Post-Acute 515 Centinela Ave. Inglewood, CA 90302

F 0609 capacity to make medical decisions. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 had moderate cognitive impairment. The MDS indicated Resident 2 required partial/moderate assistance from staff for ADLs such as oral hygiene, dressing and transfers. Residents Affected - Few During a review of Resident 2 ' s SBAR dated, 10/1/2024, the SBAR indicated (on 10/1/2024)12:25 a.m. at approximately 12:25 a.m., Resident 2 physically assaulted his roommate (Resident 1). During an interview on 10/8/2024 at 10:52 a.m. with Resident 2, Resident 2 stated (on 10/1/2024), Resident 1 punched him while lying in bed for refusing to turn the television off. During a concurrent record review and interview on 10/8/2024 at 1:55 p.m. with the Director of Nursing (DON), the facility ' s Report of Suspected Dependent Adult/Elder Abuse fax submitted to the State Agency was reviewed. The DON stated the Charge Nurse (unnamed) notified her regarding the altercation between Resident 1 and Resident 2 on 10/1/2024 at around 12:00 a.m. The DON stated the report was sent to the State Agency on 10/1/2024 at 2:02 p.m. The DON stated the abuse incident should have been reported to the State Agency within 2 hours however was not done because she wanted to investigate first. During an interview on 10/8/2024 at 2:50 p.m. with the Administrator (ADM), the ADM stated the DON informed him of the abuse incident on 10/1/2024 at 2:50 a.m. The ADM stated, per policy, abuse should be reported (to the State Agency) within 2 hours however was delayed because they were gathering statements and nurses may not be aware they could complete the report. The ADM also stated abuse should be reported timely to ensure residents were safe. During a review of the facility ' s P&P titled, Abuse Investigation and Reporting, dated 7/2017, the P&P indicated all reports of resident abuse, neglect, exploitation, mistreatment shall be promptly reported to local, state, and federal agencies. The P&P indicated all alleged violations involving abuse would be reported by the facility Administrator, or his/her designee to the State Licensing/Certification Agency, local/state Ombudsman, law enforcement immediately, but no later than two hours. 055608 Page 2 of 2