Health inspection·August 20, 2024

Windsor Elmhaven Care Center The following reflects the findings of the California Department of Public Health during the investigation of: Complaint # CA00902244 Survey Event ID: D1N611 State Citation B was written. Code of Federal Regulations, Title 42, Section §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. California Health and Safety Code, 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 5/29/24 at 1:52 p.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding abuse. The Department determined the facility failed to ensure an allegation of physical abuse was reported to the Department; when the facility failed to report Patient 1's allegation of physical abuse on 5/19/24. This failure resulted in a delay in the abuse investigation process and had the potential to affect Patient 1's physical and psychosocial well- being. During an interview on 5/29/24, at 2:35 p.m., with Patient 1, Patient 1 stated she felt scared when Certified Nurse Assistant (CNA) 3 was in the room. Patient 1 further stated CNA 3 would put soap and hot water in her eyes while she was receiving a shower. Patient 1 stated that she would feel safer if CNA 3 was not allowed in her room. During an interview on 5/29/24, at 6 p.m., with family member (FM) 1, FM 1 stated she told both the Human Resources Director and the Social Service Director about Patient 1's concerns regarding CNA 3. FM 1 further stated she had an in- person conversation with the HRD on 5/19/24 discussing Patient 1's concerns. During an interview on 5/30/24, at 3 p.m., with the Human Resources Director (HRD), the HRD stated that FM 1 expressed Patient 1's concern about CNA 3 intentionally put soap and hot water into her eyes. The HRD explained she met with FM 1 on 5/19/24 and was told about the concerns Patient 1 had. The HRD stated that she sent an email after her meeting with FM 1 on 5/19/24 to the Administrator (ADM), the Director of Staff Development (DSD), the Social Services Director (SSD), the Sub-Acute (a level of care needed by a patient who does not require hospital acute care but who requires more intensive licensed skilled nursing care than is provided to the majority of patients in a skilled nursing facility) Director, and the Corporate Human Resources contact expressing the concerns Patient 1 had shared with FM 1. The HRD further stated that leadership members of the facility talked about Patient 1's issues in a meeting on 5/20/24. During an interview on 5/30/24, at 3:10 p.m., with the SSD, the SSD stated that she and the HRD told the ADM it may not be in the best interest to have CNA 3 work with Patient 1. The SSD stated that she had talked to FM 1 about a few weeks ago. The SSD stated FM 1 told her about an incident that occurred between Patient 1 and CNA 3, where Patient 1 complained of eye irritation due to soap and hot water getting into her eyes. The SSD stated that she told the ADM to maybe have the staff scheduler take Patient 1 off from CNA 3's assignment. During an interview on 5/30/24, at 4:35 p.m., with the ADM, the ADM stated he received an email on 5/28/24 from the HRD that questioned the conduct of one of the CNAs that was giving care to Patient 1. The ADM further stated that he had not had any direct contact with FM 1. The ADM explained he should have called FM 1 and talked to Patient 1's family to see what their concerns were. The ADM stated that any allegation of abuse should be reported to the Department automatically. The ADM acknowledged that CNA 3 continued to work with Patient 1 on the dates of 5/19/24, 5/20/24, 5/25/24, and 5/26/24. The ADM further acknowledged that Patient 1 could have been affected emotionally and psychosocially from receiving care by CNA 3. Review of the facility's policy and procedure titled, "Abuse Prohibition Policy and Procedure," dated 2/23/21, in the section, "PROCESS, " indicated, "...Report allegations involving abuse (physical, verbal, sexual, mental) not later than two (2) hours after the allegation is made..." Therefore, the Department determined the facility failed to ensure an allegation of physical abuse was reported to the Department when the facility failed to report Patient 1's allegation of physical abuse on 5/19/24. This failure resulted in a delay in the abuse investigation process and had the potential to affect Patient 1's physical and psychosocial well- being. This violation had a direct or immediate relationship to the health, safety, or security of Patient 1.