Health inspection·June 7, 2023

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Based on interviews and record reviews, the facility failed to implement its policies and procedures on abuse and ensure that one of three sampled residents, Resident 1, was free from mental abuse (Mental abuse is the use of threats, verbal insults, and other more subtle tactics to control a person's way of thinking. This form of abuse is especially disturbing because it is tailored to destroy self-esteem and confidence and undermine a personal sense of reality or competence) and mistreatment (a cruel, unkind, or unfair way of treating a person), when the door to Resident 1's room was deliberately closed by Licensed Nurse A, while Resident 1 requested for staff assistance. This failure, which was witnessed by Management Staff B on 12/24/22, at around 2:30 p.m., resulted in anxiety (Anxiety refers to the apprehensive anticipation of future danger or misfortune accompanied by a feeling of distress, sadness, or somatic (relating to the body) symptoms of tension) as evidenced by Resident 1 calling out in distress, and physical harm to Resident 1, as evidenced by shortness of breath and low oxygen level that required hospitalization. Findings: During an interview on 1/10/23, at 3:15 p.m., with Certified Nursing Assistant C (CNA C), she stated she worked the afternoon shift of 12/24/22. CNA C stated that at around 2:30 p.m., Resident 1 was calling for help and Licensed Nurse A shut the door of his room because Resident 1 had an infection. CNA C stated that at 3 p.m., she heard Resident 1 screaming for help, like someone was being murdered. CNA C stated that Licensed Nurse A slammed the door of Resident 1's room without asking him what he needed. CNA C stated that at around 3:10 p.m., Licensed Nurse A responded to Resident 1's calls for help and he was having a panic attack and his O2 (oxygen) at 85% (A normal level of oxygen is usually 95% or higher). During an interview on 1/10/23, at 3:25 p.m., with CNA D, she stated at around 2 p.m., while Licensed Nurse E and Licensed Nurse A were doing the change of shift report, Resident 1 started to scream in distress. CNA D stated that Resident 1 liked to keep his door open because he was claustrophobic (a person with extreme fear or irrational fear of confined spaces). CNA D stated that she and other aides would like to check on Resident 1, but Licensed Nurse A kept them from doing it. CNA D stated that Licensed Nurse E did not restrict the morning CNA'S from going into Resident 1's room and left the room door open. CNA D stated she left the facility at 3 p.m., and Resident 1 was still screaming inside the room while the door was shut. During an interview on 3/13/23, at 3:35 p.m., with Licensed Nurse A, she stated she could not remember if Licensed Nurse E told her what precaution (e.g. Contact Precaution- Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission; Droplet Precaution- Use Droplet Precautions for patients known or suspected to be infected Page 1 of 8 056483 056483 06/07/2023 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0600 Level of Harm - Actual harm Residents Affected - Few with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking; Airborne Precaution- Use Droplet Precautions for patients known or suspected to be infected with pathogens (organisms that can cause disease) transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking) Resident 1 should be on. Licensed Nurse A stated that she informed Resident 1 that she would close his door for now. Licensed Nurse A stated after she received report that Resident 1 was on contact precaution and not on droplet or airborne precaution, she opened Resident 1's door. Licensed Nurse A stated that Resident 1 was screaming at her because she closed his door. Licensed Nurse A stated that staff were hearing Resident 1 screaming in his room to have the door opened after she closed it. Licensed Nurse A stated that at 6:30 p.m., Resident 1's oxygen level dropped to 80%. Licensed Nurse A stated that Resident 1 declined to be transferred to the hospital but later agreed and was transferred. During an interview on 3/13/23, at 4:05 p.m., with the Administrator/Owner, she stated she investigated the incident regarding Licensed Nurse A and Resident 1. She stated Licensed Nurse A was not placed on suspension because there was no incident. The Administrator stated Licensed Nurse A opened the door after the change of shift when she confirmed that the isolation precaution was just contact and not droplet precaution. During an interview on 3/14/23, at 1:16 p.m., with Management Staff B, he stated he was on his way back to the kitchen when he passed by Resident 1's room and the door to his room was open. Management Staff B stated that he saw Resident 1 raised his hand to get his attention. Management Staff B stated that he peeked into Resident 1's room and observed that he was in a bad shape, health wise. Management Staff B stated that Resident 1 had a mask for his oxygen, which Resident 1 removed temporarily, and told him he needed CNA D. Management Staff B stated he talked to Licensed Nurse E informing her that Resident 1 was looking for CNA D. Management Staff B stated that Licensed Nurse E told him that CNA D will not be able to go to Resident 1's room at that time because she was in the Red Zone (isolated area for Covid positive residents). Management Staff B stated that another nurse, Licensed Nurse A held his arm and guided him towards the room of Resident 1. Management Staff B stated Licensed Nurse A told him, This is how to take care of that, and said bye to Resident 1, while Licensed Nurse A closed Resident 1's door abruptly. Management Staff B stated he reported the incident to the Management Staff F because Licensed Nurse A's conduct surprised him, because it lacked respect to Resident 1 and Licensed Nurse A did not ask Resident 1 what he needed. During a follow-up interview on 3/17/23, at 2:34 p.m., with CNA D, she stated she informed Licensed Nurse A that Resident 1's door did not need to be closed because he was on contact precaution only. CNA D stated that Licensed Nurse A closed the door of Resident 1 before getting the shift report from Licensed Nurse E. During a review of Resident 1's clinical record on 6/2/23, at 11 a.m., Resident 1's Progress Notes, dated 12/23/22, at 1:45 p.m., authored by Licensed Nurse G, indicated that Resident 1 was re-admitted to the facility after a stay at a local hospital where he was treated for UTI (Urinary Tract (The series of organs in the urinary system in which urine is formed and excreted) Infection). Licensed Nurse G indicated on the progress notes that Resident 1 was alert and oriented x4 (alert and oriented to person, place, time, and event) and was placed on contact isolation (precaution). Licensed Nurse G indicated on the progress note that Resident 1 was ordered oxygen at three (3) liters per minute to maintain an oxygen saturation (the amount of oxygen you have circulating in your blood) level above 90%. On 12/24/22, at 6:40 p.m., a progress note authored by Licensed Nurse A indicated, Resident (Resident 1) was sent to the hospital because his oxygen kept dropping. His O2 (oxygen) on 3L (three liters) was only 83%. On 12/26/22, at 1:23 a.m., a progress note entry authored by Licensed Nurse 056483 Page 2 of 8 056483 06/07/2023 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0600 H indicated, Resident (Resident 1) passed away at hospital on night of 12/25/22. Level of Harm - Actual harm A review of Resident 1's Hospital Progress Notes, dated 12/28/22, at 3:55 p.m., indicated Resident 1 passed away on 12/25/22, at 10:37 p.m., at the hospital's ICU (Intensive Care Unit). The progress note indicated that Resident 1's cause of death was Sepsis (Sepsis occurs when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body. This can cause a cascade of changes that damage multiple organ systems, leading them to fail, sometimes even resulting in death. Symptoms include fever, difficulty breathing, low blood pressure, fast heart rate, and mental confusion. Treatment includes antibiotics and intravenous (within a vein) fluids). Residents Affected - Few During an interview on 6/2/23, at 12:30 p.m., with the Director of Nursing (DON), he stated that he was not at the facility when the incident between Licensed Staff A and Resident 1 happened. The DON stated he learned about the incident from CNA D. The DON stated that Management Staff B was aware of what had happened. The DON stated that he was not a part of the staff that investigated the incident. The DON stated that the facility did not have a single person who acted as the abuse coordinator, but all suspected abuse would be reported to the Administrator. The DON stated that the Administrator at that time was the owner of the facility. During an interview with Licensed Nurse E on 6/2/23, at 3 p.m., she stated she was the AM (morning) nurse on 12/24/22. Licensed Nurse E stated she remembered giving shift report to Licensed Nurse A and she mentioned to Licensed Nurse A that Resident 1 had an infection that was contagious. Licensed Nurse E stated that Licensed Nurse A went to Resident 1's room and closed the door. Licensed Nurse E stated that she informed Licensed Nurse A that Resident 1's room did not need to be closed. Licensed Nurse E stated that during her morning shift on 12/24/22, Resident 1's room door remained open. Licensed Nurse E stated she continued to give report to Licensed Nurse A after Licensed Nurse A closed Resident 1's door. Licensed Nurse E stated that she left the facility at around 3 p.m. Licensed Staff E stated when she passed by Resident 1's room on her way out of the facility, she heard Resident 1 calling for help while his door was closed. Licensed Nurse E stated that there was another resident, Resident 2, who was across the hallway who looked perplexed as he was hearing the calls for help from Resident 1. During an interview on 6/2/23, at 3:35 p.m., with Resident 2, he stated that he remembered Resident 1 calling for help. Resident 2 stated he could not see if the door to Resident 1's room was closed, but he could definitely hear him calling out for help. Resident 2 stated that Resident 1 did not usually call for help. Resident 2 stated he was not sure how long Resident 1 was calling for help before somebody came to help him. During an interview on 6/2/23, at 4:24 p.m., with Management Staff F, she stated Management Staff B reported the incident to her on 12/26/22. Management Staff F stated she informed Management Staff B that his report should be in writing. Management Staff F stated that Management Staff B gave his account of the incident on 12/26/22. Management Staff F stated that she reported the incident to the administrator via phone call and it was investigated by the Administrator. Management Staff F stated it was not reported to the Ombudsman or to the State. A review of Resident 1's History and Physical (H&P) from the hospital, dated 12/25/22, at 11:57 a.m., indicated, Resident 1's chief complaint was SOB (Shortness of Breath) and Anxiety. The H&P did not indicate that Resident 1 had an active problem with anxiety disorder. The H&P indicated that Resident 1 was prescribed Lorazepam (Lorazepam is a medication that treats anxiety) 1 mg (milligram) IV (intravenous) Q2H (every two hours) for anxiety, and/or restlessness, and/or worried expression on 056483 Page 3 of 8 056483 06/07/2023 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0600 face, PRN (as needed). Level of Harm - Actual harm A review of Resident 1's Order Summary Report, dated 12/1/22 - 12/31/22, indicated he did not have a medical diagnosis of Anxiety nor was he taking any medications for anxiety. Residents Affected - Few A review of a facility document titled, Staff Complaint/Grievance Form, dated 12/26/22, indicated that a complaint/grievance was communicated by Management Staff B and Licensed Nurse I, concerning another staff, Licensed Nurse A. The document indicated that Management Staff B was concerned that Licensed Nurse A did not provide enough attention to address Resident 1's needs, by closing the door. The document indicated Licensed Nurse I complained that Licensed Nurse A ignored Resident 1's needs, did not pay enough attention to assess Resident 1, and caused his death. The document indicated that the department affected by the complaint/grievance was the Nursing department. During a follow-up interview on 6/5/23, at 2:55 p.m., with the Administrator, she stated that she did not report the complaint allegations of Management Staff B and Licensed Nurse I to the Ombudsman or the State because Licensed Staff A was justified in closing the door of Resident 1 because of infection precaution. The Administrator stated that the allegation of Licensed Staff I regarding Licensed Staff A not providing enough attention to assess Resident 1 and caused his death was absurd because Licensed Staff I was not even on duty that day and her complaint was hearsay. The Administrator stated that she and Management Staff F investigated the complaints. When the Administrator was asked why the DON was not involved in the investigation because on the complaint/grievance form, the department affected by the complaint/grievance was the Nursing department, she stated the DON was involved with the investigation. When the Administrator was asked why Licensed Staff A was not placed on suspension pending the investigation, she stated because Resident 1 was transferred to the hospital and had passed away. A review of a facility policy and procedure (P&P) titled, Abuse Prevention Program, dated 11/30/2017, indicated, Abuse, neglect, abandonment, isolation, financial abuse, will not be tolerated in this facility at any time. It is the policy of this facility to take every proactive measure to prevent the occurrence of abuse to any resident. Under Prevention, the P&P indicated, Administrative staff, Nursing supervisors/Charge Nurses are responsible for directing, supervising, and evaluating all resident care activities within their respective departments or assigned units on a daily basis. A review of a facility document titled, Abuse Investigation and Reporting Policy, dated 11/30/17, indicated, All reports of resident abuse, neglect, exploitation, misrepresentation of resident property, mistreatment, and/or injuries of unknown source (abuse) shall be promptly reported to the local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Under Procedure: Role of the Administrator: The P&P indicated: 1. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 4. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect, exploitation, or mistreatment is prevented. 056483 Page 4 of 8 056483 06/07/2023 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

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. Based on interviews and record reviews, the facility failed to implement its policies and procedures on abuse investigation and reporting and ensure that an allegation of abuse and mistreatment of one of three sampled residents, Resident 1, was reported to the appropriate agencies and within the mandated timeframes by a covered individual (owner, operator, employee, manager, agent, or contractor of the facility). This failure had the potential to result in further abuse and mistreatment of Resident 1, or other residents of the facility that could negatively affect their health and well-being. Findings: During an interview on 1/10/23, at 3:15 p.m., with Certified Nursing Assistant C (CNA C), she stated she worked the afternoon shift of 12/24/22. CNA C stated that at around 2:30 p.m., Resident 1 was calling for help and Licensed Nurse A shut the door of his room because Resident 1 had an infection. CNA C stated that at 3 p.m., she heard Resident 1 screaming for help, like someone was being murdered. CNA C stated that Licensed Nurse A slammed the door of Resident 1's room without asking him what he needed. CNA C stated that at around 3:10 p.m., Licensed Nurse A responded to Resident 1's calls for help and he was having a panic attack and his O2 (oxygen) at 85% (A normal level of oxygen is usually 95% or higher). During an interview on 1/10/23, at 3:25 p.m., with CNA D, she stated at around 2 p.m., while Licensed Nurse E and Licensed Nurse A were doing the change of shift report, Resident 1 started to scream in distress. CNA D stated that Resident 1 liked to keep his door open because he was claustrophobic (a person with extreme fear or irrational fear of confined spaces). CNA D stated that she and other aides would like to check on Resident 1, but Licensed Nurse A kept them from doing it. CNA D stated that Licensed Nurse E did not restrict the morning CNA'S from going into Resident 1's room and left the room door open. CNA D stated she left the facility at 3 p.m., and Resident 1 was still screaming inside the room while the door was shut. During an interview on 3/13/23, at 3:35 p.m., with Licensed Nurse A, she stated she could not remember if Licensed Nurse E told her what precaution (e.g. Contact Precaution- Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission; Droplet Precaution- Use Droplet Precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking; Airborne Precaution- Use Droplet Precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking) Resident 1 should be on. Licensed Nurse A stated that she informed Resident 1 that she would close his door for now. Licensed Nurse A stated after she received report that Resident 1 was on contact precaution and not on droplet or airborne precaution, she opened Resident 1's door. Licensed Nurse A stated that Resident 1 was screaming at her because she closed his door. Licensed Nurse A stated that staff were hearing Resident 1 screaming in his room to have the door opened after she closed it. Licensed Nurse A stated that at 6:30 p.m., Resident 1's oxygen level dropped to 80%. Licensed Nurse A stated that Resident 1 declined to be transferred to the hospital but later agreed and was transferred. During an interview on 3/13/23, at 4:05 p.m., with the Administrator/Owner, she stated she investigated the incident regarding Licensed Nurse A and Resident 1. She stated Licensed Nurse A was not placed on suspension because there was no incident. The Administrator stated Licensed Nurse A opened 056483 Page 5 of 8 056483 06/07/2023 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the door after the change of shift when she confirmed that the isolation precaution was just contact and not droplet precaution. During an interview on 3/14/23, at 1:16 p.m., with Management Staff B, he stated he was on his way back to the kitchen when he passed by Resident 1's room and the door to his room was open. Management Staff B stated that he saw Resident 1 raised his hand to get his attention. Management Staff B stated that he peeked into Resident 1's room and observed that he was in a bad shape, health wise. Management Staff B stated that Resident 1 had a mask for his oxygen, which Resident 1 removed temporarily, and told him he needed CNA D. Management Staff B stated he talked to Licensed Nurse E informing her that Resident 1 was looking for CNA D. Management Staff B stated that Licensed Nurse E told him that CNA D will not be able to go to Resident 1's room at that time because she was in the Red Zone (isolated area for Covid positive residents). Management Staff B stated that another nurse, Licensed Nurse A held his arm and guided him towards the room of Resident 1. Management Staff B stated Licensed Nurse A told him, This is how to take care of that, and said bye to Resident 1, while Licensed Nurse A closed Resident 1's door abruptly. Management Staff B stated he reported the incident to the Management Staff F because Licensed Nurse A's conduct surprised him, because it lacked respect to Resident 1 and Licensed Nurse A did not ask Resident 1 what he needed. During a follow-up interview on 3/17/23, at 2:34 p.m., with CNA D, she stated she informed Licensed Nurse A that Resident 1's door did not need to be closed because he was on contact precaution only. CNA D stated that Licensed Nurse A closed the door of Resident 1 before getting the shift report from Licensed Nurse E. During an interview on 6/2/23, at 12:30 p.m., with the Director of Nursing (DON), he stated that he was not at the facility when the incident between Licensed Staff A and Resident 1 happened. The DON stated he learned about the incident from CNA D. The DON stated that Management Staff B was aware of what had happened. The DON stated that he was not a part of the staff that investigated the incident. The DON stated that the facility did not have a single person who acted as the abuse coordinator, but all suspected abuse would be reported to the Administrator. The DON stated that the Administrator at that time was the owner of the facility. During an interview with Licensed Nurse E on 6/2/23, at 3 p.m., she stated she was the AM (morning) nurse on 12/24/22. Licensed Nurse E stated she remembered giving shift report to Licensed Nurse A and she mentioned to Licensed Nurse A that Resident 1 had an infection that was contagious. Licensed Nurse E stated that Licensed Nurse A went to Resident 1's room and closed the door. Licensed Nurse E stated that she informed Licensed Nurse A that Resident 1's room did not need to be closed. Licensed Nurse E stated that during her morning shift on 12/24/22, Resident 1's room door remained open. Licensed Nurse E stated she continued to give report to Licensed Nurse A after Licensed Nurse A closed Resident 1's door. Licensed Nurse E stated that she left the facility at around 3 p.m. Licensed Staff E stated when she passed by Resident 1's room on her way out of the facility, she heard Resident 1 calling for help while his door was closed. Licensed Nurse E stated that there was another resident, Resident 2, who was across the hallway who looked perplexed as he was hearing the calls for help from Resident 1. During an interview on 6/2/23, at 3:35 p.m., with Resident 2, he stated that he remembered Resident 1 calling for help. Resident 2 stated he could not see if the door to Resident 1's room was closed, but he could definitely hear him calling out for help. Resident 2 stated that Resident 1 did not usually call for help. Resident 2 stated he was not sure how long Resident 1 was calling for help before somebody came to help him. 056483 Page 6 of 8 056483 06/07/2023 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/2/23, at 4:24 p.m., with Management Staff F, she stated Management Staff B reported the incident to her on 12/26/22. Management Staff F stated she informed Management Staff B that his report should be in writing. Management Staff F stated that Management Staff B gave his account of the incident on 12/26/22. Management Staff F stated that she reported the incident to the administrator via phone call and it was investigated by the Administrator. Management Staff F stated it was not reported to the Ombudsman or to the State. A review of a facility document titled, Staff Complaint/Grievance Form, dated 12/26/22, indicated that a complaint/grievance was communicated by Management Staff B and Licensed Nurse I, concerning another staff, Licensed Nurse A. The document indicated that Management Staff B was concerned that Licensed Nurse A did not provide enough attention to address Resident 1's needs, by closing the door. The document indicated Licensed Nurse I complained that Licensed Nurse A ignored Resident 1's needs, did not pay enough attention to assess Resident 1, and caused his death. The document indicated that the department affected by the complaint/grievance was the Nursing department. During a follow-up interview on 6/5/23, at 2:55 p.m., with the Administrator, she stated that she did not report the complaint allegations of Management Staff B and Licensed Nurse I to the Ombudsman or the State because Licensed Staff A was justified in closing the door of Resident 1 because of infection precaution. The Administrator stated that the allegation of Licensed Staff I regarding Licensed Staff A not providing enough attention to assess Resident 1 and caused his death was absurd because Licensed Staff I was not even on duty that day and her complaint was hearsay. The Administrator stated that she and Management Staff F investigated the complaints. When the Administrator was asked why the DON was not involved in the investigation because on the complaint/grievance form, the department affected by the complaint/grievance was the Nursing department, she stated the DON was involved with the investigation. When the Administrator was asked why Licensed Staff A was not placed on suspension pending the investigation, she stated because Resident 1 was transferred to the hospital and had passed away. A review of a facility document titled, Abuse Investigation and Reporting Policy, dated 11/30/17, indicated, All reports of resident abuse, neglect, exploitation, misrepresentation of resident property, mistreatment, and/or injuries of unknown source (abuse) shall be promptly reported to the local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Under Procedure: Role of the Administrator: The P&P indicated: 1. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 4. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect, exploitation, or mistreatment is prevented. Under Reporting, the P&P indicated: 1. All mandated reporters (covered Individuals), are required by law to report incidents of known or suspected abuse in two ways: 1) by telephone immediately or as soon as practically possible, to 056483 Page 7 of 8 056483 06/07/2023 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the local ombudsman or local law enforcement agency and CDPH (California Department of Public Health), and 2) by written report, Department of Social Services Form (SOC Form 341), Report of Suspected Dependent Adult/Elder Abuse sent within two (2) working days to CDPH. 12. Administrator shall report all incidents of alleged abuse or suspected abuse to CDPH within 24 hours and the results of the investigation to DHS (Department of Health Services) withing 5 working days of the incident, and if alleged violation is verified, appropriate action must be taken. 056483 Page 8 of 8