Health inspection·October 11, 2019

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of the facility's policy, the facility failed to implement their policy and identify an allegation of resident to resident abuse for six residents (Resident (R) 43, R61, R44, R47, R20 and R63) out of a survey sample of 17 residents. Specifically, the facility failed to report allegations of resident to resident physical abuse, within 24 hours, to the State Agency (SA) as federally mandated. Residents Affected - Few The failure to recognize abuse and immediately implement the facility's abuse prohibition policy had the potential to adversely affect all 69 resident's residing in the facility at the time of the survey. Findings include: 1. A review of R43's admission Record revealed the resident was admitted to the facility on [DATE], with a diagnosis of cerebral vascular disease. A review of R43's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 09/01/19, revealed the resident had a Brief Interview for Mental Status (BIMS) of 12 out of 15, which indicated the resident had moderate cognitive impairments. A review of an Interdisciplinary Progress Note dated 10/06/19, documented an unnamed staff member overheard R61 and R43 yelling at each other. Their wheel chair foot pedals had entangled. R61 hit R43 with her fist and contacted R43's foot. R43 then attempted to throw a cup of water at R61. Both residents were immediately separated from each other. The responsible parties for both residents were notified of the incident. The progress noted revealed the staff member faxed the report to the ombudsman. A review of a social service's Progress Note for R43, dated 10/07/19, revealed the Interdisciplinary Team (IDT) met to discuss the resident to resident incident which occurred on 10/06/19. The progress note revealed R43 was sitting in the lobby of the facility when R61 went up to her and ran her wheel chair into R43's right leg and then hit R43's left leg twice which resulted in R43 throwing water onto R61. Both residents were separated immediately. The residents' representatives were notified, and the progress note also mentioned the ombudsman was notified. R43 sustained two bruises on her left leg as a result of this encounter. 2. A review of R61's admission Record revealed the resident was admitted to the facility on [DATE], with a diagnosis of unspecified dementia with behavioral disturbances. Page 1 of 5 055640 055640 10/11/2019 Grass Valley Healthcare Center 355 Joerschke Dr Grass Valley, CA 95945

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of R61's quarterly MDS assessment, with an ARD of 09/15/19, had a BIMS of six out of 15, which indicated the resident was severely cognitively impaired. A review of a social service's Progress Note for R61, dated 10/07/19, revealed the IDT met to discuss the resident to resident incident which occurred on 10/06/19. The progress note revealed R43 was sitting in the lobby of the facility when R61 went up to her and ran her wheel chair into R43's right leg and then hit R43's left leg twice which resulted in R43 throwing water onto R61. Both residents were separated immediately. The residents' representatives were notified, and the progress note also mentioned the ombudsman was notified. R43 sustained two bruises on her left leg as a result of this encounter. A review of a document titled, Report of Suspected Dependent Adult/Elder Abuse dated 10/06/19, revealed the incident between R43 and R61. This document identified the ombudsman was notified by fax of this incident. There was no evidence to show the SA had been notified of the allegation of a resident to resident abuse. 3. A review of R44's admission Record revealed the resident was admitted to the facility on [DATE] with a diagnosis of anxiety disorder. A review of R44's significant change MDS assessment dated [DATE], had a BIMS of 15 out of 15 which indicated R44 was fully cognitively aware. A review of a nursing Progress Note for R44, dated 09/06/19, revealed R44 was in the lobby of the facility and R47 came up to R44 and punched R44's right upper arm. Both residents were immediately separated by staff. 4. A review of R47's admission Record revealed the resident was admitted to the facility on [DATE] with a diagnosis of unspecified dementia with behavioral disturbances. A review of R47's quarterly MDS assessment dated [DATE], had a BIMS of seven out of 15 which indicated the resident was severely cognitively impaired. A review of the nursing Progress Notes for R47, dated 09/06/19, revealed R47 was attempting to get around R44, and when R44 would not move, R47 punched her. Both residents were immediately separated by staff. A review of a document titled, Report of Suspected Dependent Adult/Elder Abuse dated 09/06/19, revealed the incident between R47 and R44. This document identified the ombudsman was notified by fax of this incident. There was no evidence to show the SA had been notified of the allegation of a resident to resident abuse. 5. A review of R20's Face Sheet revealed the resident was admitted to the facility on [DATE], with a diagnosis of dementia with behavioral disturbances and major depressive disorder. A review of R20's significant change MDS assessment, dated 09/22/19, revealed the resident had a Brief Interview for Mental Status (BIMS) of 5, which indicated the resident was severely cognitively impaired. A review of R63's Face Sheet revealed the resident was admitted to the facility on [DATE], with a 055640 Page 2 of 5 055640 10/11/2019 Grass Valley Healthcare Center 355 Joerschke Dr Grass Valley, CA 95945

F 0607 diagnosis of dementia without behavioral disturbances. Level of Harm - Minimal harm or potential for actual harm 6. A review of R63's quarterly MDS assessment, dated 07/21/19, revealed the resident had a Brief Interview for Mental Status (BIMS) of 13, which indicated the resident was cognitively intact. Residents Affected - Few A review of a Progress Note dated 09/29/19, revealed that R20 was witnessed to stand up beside his bed, reach out to R63 and R63 slapped his hand out of the way before the staff member could get to R20. Both residents were immediately separated from each other. No injuries were noted either R20 or R63. The responsible parties for both residents were notified of the incident. A review of the facility investigation form indicated the incident happened on 09/29/19. The facility responded appropriately by separating the two residents from each other and each residents' representative, and physician, was notified of the resident to resident incident. The local long-term care ombudsman was notified however, the facility did not report the incident to the state survey agency as indicated in their abuse policy and procedure. A review of a Progress Note dated 10/05/19, revealed that R20 was being assisted in the merry walker (an ambulation device that is a walker/chair combination. It allows a person, who would normally be placed in a wheelchair, to be able to walk independently and safely), when R20 reached over roommates' bed (R63) and slapped R63's hand. Both residents were immediately separated from each other. No injuries were noted to either R20 or R63. The responsible parties for both residents, and physician, were notified of the incident. A review of the facility's investigation form indicated the incident happened on 10/05/19. The facility responded appropriately by separating the two residents from each other and each residents' representative, and physician, was notified of the resident to resident incident. The local long-term care ombudsman was notified however, the facility did not report the incident to the state survey agency as indicated in their abuse policy and procedure. During an interview with the Administrator on 10/10/19 at 2:40 PM, the Administrator confirmed she was the facility's abuse coordinator. She confirmed she only notified the ombudsman and not the State Agency on all resident to resident abuse allegations. The Administrator stated the reason she did not notify the SA was because each of the residents had a diagnosis of dementia and there was no intent to harm the other resident. A review of a facility policy titled, Abuse Investigation and Reporting dated as revised 07/17, revealed, .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) will be reported immediately to the Administrator, and shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. 055640 Page 3 of 5 055640 10/11/2019 Grass Valley Healthcare Center 355 Joerschke Dr Grass Valley, CA 95945

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, record review, the facility failed to ensure all allegations of suspected abuse were reported immediately, but not later than 24 hours after the allegation was made, for resident to resident altercations which involved six residents (Resident (R) 43, R61, R44, R47, R20 and R63). This failure had the potential to impede the safety and protection of the facility's residents. Findings include: Review of the facility policy titled, Abuse Investigation and Reporting dated as revised 07/17, revealed, .All alleged violations involving abuse.will be reported by the facility Administrator, or-his/her designee immediately, and to the following persons or agencies as required by law or regulation.The State licensing/certification agency responsible for surveying/licensing the facility. Record reviews during the survey process revealed six Residents were involved in incidents of potential resident to resident abuse that were not reported to the state survey agency as required. Please refer to

F607 for the details of these incidents. 1. A review of R43's admission Record revealed the resident was admitted to the facility on [DATE], with a diagnosis of cerebral vascular disease. 2. A review of R61's admission Record revealed the resident was admitted to the facility on [DATE], with a diagnosis of unspecified dementia with behavioral disturbances. 3. A review of R44's admission Record revealed the resident was admitted to the facility on [DATE] with a diagnosis of anxiety disorder. 4. A review of R47's admission Record revealed the resident was admitted to the facility on [DATE] with a diagnosis of unspecified dementia with behavioral disturbances 5. A review of R20's Face Sheet revealed the resident was admitted to the facility on [DATE], with a diagnosis of dementia with behavioral disturbances and major depressive disorder. 6. A review of R63's Face Sheet revealed the resident was admitted to the facility on [DATE], with a diagnosis of dementia without behavioral disturbances. During an interview with the Administrator on 10/11/19 at 8:18 AM, she stated she attempted to keep up with the regulatory requirements. The Administrator stated her expectation from staff was to separate the residents immediately from each other, the nurse was to assess the residents, and to speak with the residents about the incident. The Administrator stated she expected all staff to follow the abuse prevention policies. On 10/11/19 at 8:44 AM, the Administrator presented a document titled California Legislative Information.Article 3 Mandatory and Nonmandatory Reports of Abuse [15630-15632].If the suspected abuse does not result in serious bodily injury.a written report shall be made to the local ombudsman, the corresponding licensing agency.within 24 hours of the mandated reporter observer, obtaining knowledge 055640 Page 4 of 5 055640 10/11/2019 Grass Valley Healthcare Center 355 Joerschke Dr Grass Valley, CA 95945

F 0609 Level of Harm - Minimal harm or potential for actual harm of, or suspecting the physical abuse.When the suspected abuse is allegedly caused by a resident with a physician's diagnosis of dementia, and there is no serious bodily injury.the reporter shall report to the local ombudsman. It was brought to the attention of the Administrator that the state statutes contradicted the federal requirements. Residents Affected - Few 055640 Page 5 of 5