Health inspection·May 29, 2024

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 observation, interview, and record review, the facility failed to identify and develop a care plan for a resident at risk for abuse for one of two residents investigated. This failure meant that staff was unaware of the resident's risk for abuse and of measures to mitigate those risks. Findings: On May 9, 2024, a Health Facilities Evaluator Nurse (HFEN) entered the facility for an investigation of a Facility Reported Incident involving a physical and verbal altercation between two residents. According to the Record of Admission, undated, Resident 1 (Res 1) was admitted to the facility on [DATE], with health conditions that included: Malignant neoplasm (Cancer) of .lung; Major depressive disorder (a mood disturbance of feelings of sadness or loss of interest, that can affect how one thinks, feels, and behaves). In an interview on May 9, 2024, at 10 A.M. the Administrator (ADM) stated that Res 1 can push (mentally, psychologically, not physically) people and expects others to back down. In an interview on May 9, 2024, at 3:35 P.M. Licensed Nurse 1 (LN 1) stated: Everyone knows Res 1, I get along with him. LN 1 stated, If you meet his needs, he is reasonable. He wants what he wants, the way he wants it, and right now. In an interview on May 9, 2024, at 4:13 P.M., CNA 6 stated: I had worked with Res 1 before. CNA 6 stated that if Res 1 would mind his own business he wouldn't get as upset. CNA 6 stated Res 1 inserts himself into other interactions and will give advice to other residents and staff. Resident 2 was admitted on [DATE], for short term rehab, with health conditions that included: . orthopedic aftercare following surgical amputation; acquired absence of right leg below the knee; other abnormalities of gait and mobility (an unusual walking pattern). An interview with Resident 2 (Res 2) was held May 9, 2024, at 3:50 P.M. Res 2 summarized the incident that occurred between himself and Res 1. Res 2 stated he just pushed me over the edge, I didn't know I could get that upset anymore . On 5/9/24 at 1:10 P.M., a review of Res 1's IDT (interdisciplinary team-multiple staff with different backgrounds and skill sets, usually nursing, therapy, and social services) note dated 4/29/24, reflected that the root cause of the incident between Res 1 and Res 2 was because Res 2 felt Res 1 was Page 1 of 2 055761 055761 05/29/2024 Encinitas Nursing and Rehabilitation Center 900 Santa Fe Drive Encinitas, CA 92024

F 0656 Level of Harm - Minimal harm or potential for actual harm verbally aggressive towards staff, and another resident and himself. Res 2 felt Res 1 should have minded his own business. The IDT note reflected that Res 1 has multiple behaviors, including: showing physical aggression, accusing, cursing, threatening others, refusing care, being anxious, being agitated, speaks aggressively to staff. Residents Affected - Few The IDT note of 4/29/24 also reflected various recomnendations including staff education and revision of the care plan. One recommendation was to remind Res 1 to notify staff when others are aggressive and remove self from the situation. A record review of Res 1s Cognitive Patterns assessment, the BIMS, dated 3/26/24, reflected a score of 15 out of 15, or cognitively intact - no impairment in the ability to think, learn, remember, use judgement and make decisions. A joint interview and record review of Res 1s care plan for Risk for decline in psychosocial well being related to: Allegation of Abuse , dated 4/27/24, and Res 1s IDT note of 4/29/24 re: incident with another patient on 4/27/24, was reviewed with the facility Administrator (ADM), and the Director of Nursing (DON) on 5/9/24, at 5:28 P.M. The ADM noted that the recommendations of the IDT note were not listed on the care plan. The DON and ADM both stated the care plan as written did not include personalized interventions for Res 1 as discussed in the IDT: encouraging Res 1 to notify staff of another resident being aggressive, and to remove self from the situation. The ADM stated that the staff were looking at Res 1s history of aggression towards others, and didn't realize that Res 1 could be a victim due to his own behaviors. When questioned on how to keep Res 1 safe, the ADM stated, I've never looked at it that way. The DON stated, we look at how to keep others safe from Res 1. The ADM and DON both stated, REsident 1's care plan has no interventions in place to keep Res 1 safe from altercations, and that the care plan was not specific or personalized regarding interventions for Res 1s stated behavior problems. The facility policy Alleged or Suspected Abuse and Crime Reporting, revision dated 10/22 was reviewed with the ADM and DON on 5/9/24 at 5:28 P.M. Section 4. Prevention reflects: The facility will implement policies and procedures to prevent and prohibit all types of abuse.that achieves: .the identification, ongoing assessment, care planning for appropriate interventions, and monitoring for residents with needs and behaviors which might lead to conflict. Section 5. Identification reflects: .The facility will monitor the adequacy of assessment, care planning and monitoring of residents with needs or behaviors that may likely lead to conflict, altercation, abuse, exploitation and misappropriation and mistreatment such as: Physically aggressive or self-injurious behaviors, Verbally abusive behavior towards others, Socially inappropriate or disruptive behaviors, Wandering into the rooms or personal space of others. 055761 Page 2 of 2