Health inspection·December 11, 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 interview and record review, the facility failed to: Residents Affected - Few 1. Implement its Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy and procedure (P&P) by not reporting within two (2) hours of an allegation of physical abuse, for one of three sampled residents (Resident 1) to the California Department of Public Health ([CDPH] – state licensing and certification agency) and the Ombudsman (an agency who investigates, reports on, and helps settle complaints against the facility), after Resident 2 allegedly hit Resident 1 on 12/5/2024. This deficient practice resulted in the delay of investigation by the CDPH and had the potential to place Resident 1 for further abuse. Findings: During a review of Resident 1's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included unspecified dementia (a progressive state of decline in mental abilities), cerebral infarction (also known as stroke – damage to tissues in the brain due to a loss of oxygen to the area) with hemiplegia ( paralysis on one side of the body) and metabolic encephalopathy (a brain disorder that occurs when a chemical imbalance in the blood affects the brain). During a review of Resident 1's History and Physical (H&P), dated 10/25/2024, the H&P indicated, Resident 1 did not have the capacity for medical decision making. During a review of Resident 1's Minimum Data Set ([MDS] – a resident assessment tool), dated 12/6/2024, the MDS indicated, Resident 1's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 1 required moderate assistance (helper does less than half the effort) on staff with oral hygiene, upper body dressing and personal hygiene. During a review of Resident 2's admission Record, the admission Record indicated, Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2's diagnoses included encephalopathy (any disorder or damage that affects the brain's structure or function), Diabetes Mellitus ([DM] – a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension ([HTN] – high blood pressure). Page 1 of 2 055608 055608 12/11/2024 Primrose Post-Acute 515 Centinela Ave. Inglewood, CA 90302

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 2's H&P, dated 7/4/2024, the H&P indicated, Resident 2 had the capacity for medical decision making. During a review of Resident 2's MDS, dated [DATE], the MDS indicated, Resident 2's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated, Resident 2 required supervision (helper provides verbal cues as resident completes activity) on staff with oral hygiene, upper body dressing and personal hygiene. During a review of the facility's Report of Suspected Dependent Adult/Elder Abuse (SOC 341) faxed to CDPH on 12/6/2024 at 12:29 p.m., indicated the date and time of physical abuse incident occurred on 12/5/2024 at 7:30 p.m. The SOC 341 indicated during the clinical review on 12/6/2024 at around 10 a.m., the team came across a progress note written by the charge nurse stating Resident 1 was hit by Resident 2. During a review of Resident 1's Progress Notes, dated 12/5/2024 at 7:30 p.m., the Progress Notes indicated Resident 1 told the nurse she was hit by Resident 2. During a review of Resident 1's Progress Notes, dated 12/6/2024 at 5:47 p.m., the Progress Notes indicated Interdisciplinary Team ([IDT] – a group of healthcare professionals from different disciplines who work together collaboratively to develop and implement a comprehensive care plan for a patient) met to discuss Resident 1's allegation of physical abuse by Resident 2. During a telephone interview on 12/11/2024 at 1:25 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1's allegation of physical abuse she was hit by Resident 2 occurred on 12/5/2024 at around 8:00 p.m. LVN 1 stated she did not report the allegation of abuse to the Administrator (ADM) who is the abuse coordinator. LVN 1 stated the ADM was responsible in reporting any allegation of abuse to the CDPH and Ombudsman. LVN 1 stated the ADM reported the allegation of physical abuse to the CDPH on 12/6/2024. LVN 1 stated Resident 1's allegation of abuse should have been reported to the ADM, CDPH and ombudsman sooner for the safety of the resident. LVN 1 stated any allegations of abuse should be reported immediately not more than 2 hours to the ADM, CDPH, and Ombudsman. LVN 1 stated it was important to report any allegation of abuse to the CDPH in a timely manner so they could start the investigation and to protect the resident involved for further harm. During a concurrent interview and record review on 12/11/2024 at 2:22 p.m., with the ADM, the facility's undated P&P titled, Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, was reviewed. The P&P indicated, The Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: A) The state licensing/certification agency responsible for surveying/licensing the facility, B) The local/state Ombudsman Immediately is defined as A) within two hours of an allegation involving abuse or result in serious bodily injury, or B) within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. The ADM stated this was the facility's policy when it comes to abuse reporting allegation as required by State and Federal law. The ADM stated everyone is a mandated reporter when it comes to abuse. The ADM stated the facility was cited in the past by CDPH for late reporting of allegation of abuse. 055608 Page 2 of 2