Health inspection·April 5, 2023

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that an allegation of abuse and or mistreatment was promptly reported to the Administrator, whom is the Abuse Coordinator, and the appropriate agencies in accordance with the facility's policy and procedure, for one of three residents (Resident 1). This failure had the potential for an allegation of abuse and or mistreatment to go uninvestigated and unreported thereby increasing the chances of harm to Resident 1. Residents Affected - Few Finding: An unannounced visit was made to the facility on March 29, 2023, at 12:05 PM to investigate a complaint regarding an allegation of resident-to-resident abuse involving Resident 1 and Resident 2. A review of Resident 1's face sheet (contains demographic information and diagnoses) indicated that Resident 1 was admitted to the facility on [DATE], with diagnoses which included: anxiety, depression, and repeated falls. During a review of the clinical record for Resident 1, the Nurses Note, dated March 19, 2023, at 4:50 AM, indicated, At 4:15 AM, CNA (Certified nursing assistant) alerted nurse that Resident 2 was missing from room and bed. After searching, Resident 2 was found naked, asleep in Resident 1's room, which is a female room. Resident 2 was confused and was unable to explain why he went to that room. Resident, 1 was in bed A and was in distress and stated that she did not feel safe in this facility. Resident 1 also stated that when Resident 2 entered her room, Resident 2 was touching her leg. During an interview and consecutive record review of Resident 1's Nurses Note with Licensed Vocational Nurse (LVN 1), on March 29, 2023, at 2:11 PM, LVN 1 stated, The resident wandered, confused into the room and was unable to state why. Resident 1 was in distress and said she did not feel safe. It says she was scared. Resident 2 was touching her leg. No one should be touched without their permission. He was naked in the bed next to her. I would not feel safe. The nurse reported the incident to the Redlands police. LVN 1 stated further, This is abuse. During an interview and consecutive record review of Resident 1's Nurses Note with Director of Staff Development (DSD), on March 29, 2023, at 2:27 PM, DSD stated, Resident 2 touched resident 1. Resident 2 was in B bed naked. Resident 1 was in distress and did not feel safe. Resident 1 said Resident 2 was touching her leg. It could be sexual, physical, or mental abuse. When the DSD was asked why it was not reported to the reporting agencies, the DSD stated, I don't know what happened. They did not report it. The DSD stated further, The next day Resident 1 sent herself to the hospital. During an interview and consecutive record review of Resident 1's Nurses Note with the Assistant Page 1 of 4 056372 056372 04/05/2023 Brookside Healthcare Center 105 Terracina Blvd. Redlands, CA 92373

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Director of Nursing (ADON), on March 29, 2023, at 3:01 PM, ADON stated, No one is to touch another resident without their permission. If that happens, you're not going to feel safe. We are to safeguard them. That is abuse. DON stated further, The Administrator was not called. They should have called the Administrator right away. They did not report it to Public Health. It is to be reported so they can check the welfare of the resident. They did not call the ombudsman. Resident 1 left after the incident that and has not returned. During an interview with the Administrator on March 26, 2022, at 3:13 PM, Administrator stated, I did not report it. I did not call the ombudsman. The nurse did not report it to me. We should have reported it. The facility did not provide documentation that stated the allegation of abuse and or mistreatment was reported to the appropriate state and federal agencies. The facility policy and procedure titled Abuse: Prevention of and Prohibition Against undated, indicated It is the policy of this facility that each resident has the right to be free from abuse . The facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse .E. Identification 1. The facility will assist staff in identifying abuse .This includes identifying the different types of abuse: mental/verbal, sexual abuse, physical abuse .Episodes of resident-to-resident altercation, willful or accidental, with or without injury; F. Investigation 1. All identified events are reported to the Administrator immediately H. Reporting/ Response 1. All allegations of abuse, neglect 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. I. Definitions: Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Mistreatment means inappropriate treatment or exploitation of a resident. Mental Abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Sexual abuse is non-consensual sexual contact of any type with a resident 056372 Page 2 of 4 056372 04/05/2023 Brookside Healthcare Center 105 Terracina Blvd. Redlands, CA 92373

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 initiate a care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) for one of three residents (Resident 1) when Resident 1 was in distress after an allegation of abuse and or mistreatment. This failure had the potential to result in the psychosocial decline when interventions were not in place after a incident of alleged abuse and/or mistreatment. Findings: An unannounced visit was made to the facility on March 29, 2023, at 12:05 PM to investigate a complaint regarding an allegation of resident-to-resident abuse involving Resident 1 and Resident 2. During a review of Resident 1's face sheet (contains demographic information and diagnoses) indicated that Resident 1 was admitted to the facility on [DATE], with diagnoses which included: anxiety, depression, and repeated falls. During a review of the clinical record for Resident 1, the electronic records indicated: 1. Nurses Note, dated March 19, 2023, at 4:50 AM, indicated, At 4:15 AM, CNA (Certified nursing assistant) alerted nurse that Resident 2 was missing from room and bed. After searching, Resident 2 was found naked, asleep in Resident 1's room, bed B, which is a female room. Resident 2 was confused and was unable to explain why he went to that room. Resident, 1 was in bed A and was in distress and stated that she did not feel safe in this facility. Resident 1 also stated that when Resident 2 entered her room, Resident 2 was touching her leg. 2. Change in Condition assessment note dated March 19, 2023, at 5:25 AM, indicated, The change in condition: distress. This started on March 19, 2023. During an interview and consecutive record review of Resident 1's Nurses Note with Licensed Vocational Nurse (LVN 1), on March 29, 2023, at 2:11 PM, LVN 1 stated, When we do a change in condition note. We then monitor the resident and do a care plan. LVN 1 stated further, the nurse did a change in condition note on March 19, 2023, but I don't see a care plan. The facility did not provide documentation that a care plan was completed for Resident 1's allegation of abuse and/or mistreatment. During an interview and consecutive record review of Resident 1's Nurses Note with the Director of Staff Development (DSD), on March 29, 2023, at 2:27 PM, DSD stated, There are no care plans for Resident 1's change in condition. We do the care plans to ensure the resident is safe while in the facility. There was no monitoring (interventions) for the change of condition. The care plan is done to reassure the resident and for their safety. The facility did not provide documentation of a care plan for resident 1's change in condition. During an interview and consecutive record review of Resident 1's medical record with Assistant Director of Nursing (ADON), on March 29, 2023, at 3:01 PM, ADON stated, There was no careplan. There was no monitoring after the incident. The facility did not provide documentation that indicated a careplan was initiated for the allegation of abuse and/or mistreatment. 056372 Page 3 of 4 056372 04/05/2023 Brookside Healthcare Center 105 Terracina Blvd. Redlands, CA 92373

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility policy and procedure titled Comprehensive Person-Centered Planning dated January 2022, indicated Policy - It is the policy of this facility that the interdisciplinary team shall develop a comprehensive [NAME] centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment 6. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment . The facility policy and procedure titled Abuse: Prevention of and Prohibition Against undated, indicated It is the policy of this facility that each resident has the right to be free from abuse . The facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse . G. Protection: 1. If an allegation of abuse is reported, discovered or suspected, the Facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation. 2. If the allegation of abuse, involves another resident, the facility will: continue to assess, monitor, and intervene as necessary to maximize resident health and safety 056372 Page 4 of 4