Health inspection·January 13, 2024

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 and record review, the facility failed to report a verbal abuse allegation made by one of four sampled residents (Resident 3) against a Certified Nursing Assistant (CNA 1) to the required agencies, including California Department of Public Health, Long Term Care Ombudsman and Local Law Enforcement agency. This failure resulted in facility not responding to abuse allegation appropriately and placed Resident 3 at risk for experiencing further unreported abuse. Findings: During a review of Resident 3 ' s admission Record printed on 1/12/24, the record indicated Resident 3 was admitted to the facility on [DATE] and discharged on 12/8/23. During a review of Resident 3 ' s Minimum Data Set (MDS, an assessment used to plan care), the assessment indicated Resident 3 had a BIMS (a tool used to assess a resident ' s level of awareness and thinking) score of 13 out of 15, indicating Resident 3 was cognitively intact and was able to make his needs known and understood. During a phone interview with CNA 1 on 1/12/24 at 12:04 p.m., CNA 1 stated on 11/16/23, the Director of Staff Development (DSD) told him that a complaint was made against him for being loud with a resident [Resident 3] and that he could not care for Resident 3 any further that night. During a concurrent interview and record review with Director of Nursing (DON 2, who was the assigned director for the facility) on 1/12/24 at 1:11 p.m., Resident 3 ' s nursing progress notes dated 11/16/23 and timed 6:50 p.m. was reviewed. Resident 3 ' s nursing progress note written by Licensed Vocational Nurse (LVN) 1, indicated the following: [Family Representative-FR 1] expressed frustration, first starting off with whoever the CNA that was in there with her dad is ' very rude and disrespectful ' . Said he was yelling at her father .She requested that the CNA be switched [due to] him being ' disrespectful ' and ' cursing at her father ' . Made arrangements to change CNA. After [FR 1] left and situation was de-escalated (sic), I went to tell the Team lead on shift of the situation. The DON 2 stated only if the allegation was determined to be credible, the facility would immediately report to the California Department of Public Health and the Long-Term Care Ombudsman. The DON 2 stated she was aware of the situation on 11/16/23 and told FR 1 that she would follow up on the allegation. The DON 1 then stated since that was her last day prior to her vacation, she personally did not complete a follow up for this incident and notify any agencies of verbal abuse allegation by Resident 3 against CNA 1. Page 1 of 4 056381 056381 01/13/2024 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0609 Level of Harm - Minimal harm or potential for actual harm During an interview with the Director of Nursing (DON 1, who was assisting the facility on as needed basis) on 1/12/24 at 12:41 p.m., the DON 1 stated for all staff to resident verbal abuse allegations, the facility was expected to notify the state public health department, the ombudsman, and file an SOC 341 form (a form used to report witnessed or suspected abuse to state and federal agencies) after interviewing the resident, the family, and the staff. Residents Affected - Few During an interview with DON 1 and DON 2 on 1/12/24 at 1:53 p.m., the DON 1 stated that the usual reporting timeframe for abuse allegation was within 24 hours, and that any allegation involving injury would be reported within two hours. The DON 2 stated the facility ' s abuse coordinator was the Administrator (ADM) and would usually email her the abuse investigation report if he conducted the investigation. The ADM was unavailable for an interview during the investigation. During an interview on 1/12/24 at 2:26 p.m., the DON 2 stated she could not find any email from the ADM regarding verbal abuse allegation investigation summary/ report for Resident 3 against CNA 1. During an email communication with the Long-Term Care Ombudsman on 1/17/2024, the Ombudsman indicated that there was no record of the facility reporting the verbal abuse allegation by Resident 3 against CNA 1 to the Ombudsman ' s office. During a review of the facility ' s policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, dated September 2022, the P&P indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported, and the administrator . 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; c) The resident ' s representative; d) Adult protective services (where state law provides jurisdiction in long-term care); e) Law enforcement officials; f) The resident ' s attending physician; and g) The facility ' s medical director .The facility ' s P&P further indicated, ' 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 056381 Page 2 of 4 056381 01/13/2024 Delta View Post Acute 1210 A Street Antioch, CA 94509

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 thoroughly investigate a verbal abuse allegation by one of four sampled residents (Resident 3) against Certified Nursing Assistant (CNA 1). Facility did not remove CNA 1 from resident care areas and did not complete and/or report the results of investigation to California Department of Public Health (CDPH) within 5 working days of the incident. Residents Affected - Few This failure resulted in facility not responding to abuse allegation appropriately and placed Resident 3 and other residents residing at the facility at risk for experiencing further unreported abuse. Findings: During a review of Resident 3 ' s admission Record printed on 1/12/24, the record indicated Resident 3 was admitted to the facility on [DATE] and discharged on 12/8/2023. During a review of Resident 3 ' s Minimum Data Set (MDS, an assessment used to plan care), the record indicated Resident 3 had a BIMS (a tool used to assess a resident ' s level of awareness and thinking) score of 13 out of 15, indicating Resident 3 was cognitively intact and was able to make his needs known and understood. During a phone interview with CNA 1 on 1/12/24 at 12:04 p.m., CNA 1 stated on 11/16/23, the Director of Staff Development (DSD) told him that a complaint was made against him for being loud with a resident [Resident 3] and that he could not care for Resident 3 any further that night. He further stated he continued to work with other assigned residents that night but did not care for Resident 3 any further. During a review of facility ' s document titled Detail Time and Job (a document indicating when and for how long a staff member worked), the record indicated that CNA 1 started his shift on 11/16/2023 at 6:54 a.m, ended his shift at 11:16 p.m. with two lunch breaks in between. During a concurrent interview and record review with Director of Nursing (DON 2, who was the assigned director for the facility) on 1/12/24 at 1:11 p.m., Resident 3 ' s nursing progress notes dated 11/16/23 was reviewed. Resident 3 ' s nursing progress note, written by Licensed Vocational Nurse (LVN) 1 dated 11/16/23 and timed 6:50 pm, indicated the following: [Family Representative-FR 1] expressed frustration, first starting off with whoever the CNA that was in there with her dad is ' very rude and disrespectful ' . Said he was yelling at her father .She requested that the CNA be switched [due to] him being ' disrespectful ' and ' cursing at her father ' . Made arrangements to change CNA. After [FR 1] left and situation was de-escalated (sic), I went to tell the Team lead on shift of the situation. DON 2 stated there was no indication in the record that an investigation was completed. During an interview with DON 1 (who was assisting the facility on as needed basis) and DON 2 on 1/12/24 at 1:53pm, DON 1 stated the facility policy was to immediately send any staff member who is accused of abuse home and that it didn ' t matter if allegation was proven or not. DON 1 stated the facility should investigate by speaking to the resident(s), family member(s), and staff member(s) involved in the incident for the safety of staff and for the safety of residents. DON 1 stated most investigations were done in coordination between the DON and Administrator (ADM). DON 1 and DON 2 confirmed that neither of them had done an investigation , and they also confirmed that the Director of 056381 Page 3 of 4 056381 01/13/2024 Delta View Post Acute 1210 A Street Antioch, CA 94509

F 0610 Level of Harm - Minimal harm or potential for actual harm Staff Development (DSD) did not do an investigation for the allegation of verbal abuse to Resident 3 by CNA 1. DON 1 and DON 2 stated the facility ' s abuse coordinator was the Administrator (ADM) and would usually email them the abuse investigation report if he conducted the investigation. The ADM was unavailable for an interview during the investigation. Residents Affected - Few During an interview on 1/12/24 at 2:26 p.m., the DON 2 stated she could not find any email from the ADM regarding verbal abuse allegation investigation summary/report for Resident 3 against CNA 1. During an interview with Licensed Vocational Nurse (LVN) 1 on 1/16/2024 at 1:33pm, she stated she spoke with FR 1, who said she got a report from Resident 3 that CNA 1 yelled at him. LVN 1 stated she went into Resident 3 ' s room and FR 1 assisted with translating from English to Spanish to ask Resident 3 what happened. She then reported the incident to her supervisor, Registered Nurse (RN) 1. She further stated the situation felt it may have qualified as verbal abuse. She further stated the facility ' s policy was to send any staff member accused of abuse home and complete an investigation to then inform the public health department, ombudsman, and local police. She did not in this instance because had never heard anything bad about the CNA, so she was unsure what to do. During an interview with RN 1 on 1/17/2024 at 3:32pm, she stated she received a report from LVN 2 that there was complaint regarding CNA 1. She stated LVN 1 reported she de-escalated the situation of alleged verbal abuse to Resident 3 by CNA 1. RN 1 stated she removed the CNA from working with Resident 3, checked in with CNA 1 to make sure he was fit for work, allowed CNA 1 to continue working with other residents, and informed DON 2. RN 1 states she did not call FR 1 or interview Resident 3 or CNA 1 because LVN 1 told her she had de-escalated the situation. She further stated it is important to complete a full and thorough investigation to make sure that residents are protected from further abuse and that if the abuse is not investigated, it may not be reported and no followup will be completed. During a review of the facility ' s policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, dated September 2022, the record indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported, and the individual conducting the investigation as a minimum: a) reviews the documentation and evidence; b) reviews the resident ' s medical record to determine the resident ' s physical and cognitive status at the time of incident and since the incident; c) observes the alleged victim, including his or her interactions with staff and other residents; d) interviews the person(s) reporting the incident; e) interviews any witnesses to the incident; f) interviews the resident (as medically appropriate) or the resident ' s representative; g) interviews the resident ' s attending physician as needed to determine the resident ' s condition; h) interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i) interviews the resident ' s roommate, family members, and visitors; j) interviews other residents to whom the accused employee provides care or services; k) reviews all events leading up to the alleged incident; and l) documents the investigation completely and thoroughly. 056381 Page 4 of 4