Health inspection·November 20, 2024

Garden City Healthcare Center The following reflects the findings of the California Department of Public Health during a Recertification Survey and one Facility Reported Incident #CA00926741. Survey Event ID: 6PKA11 State Citation B was written Code of Federal Regulations, Title 42, Section §483.12 483.12(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 10/21/24 at 8:00 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to conduct a recertification survey and investigate one Facility Reported Incident regarding abuse. The Department determined the facility failed to ensure allegations of abuse were reported to the state survey agency after the allegations of abuse were witnessed by staff and reported to facility administration involving Resident 32, Resident 38, Resident 25, and Resident 311, when; 1. Resident 32 and Resident 38 engaged in sexual activity, but neither Resident 32 or Resident 38 had the decision-making capacity (the ability of a patient to understand the benefits and risks of, and the alternatives to, a proposed treatment or intervention) to consent to the sexual activity; and, 2. Resident 311 was involved in a verbal altercation, which included threats of physical violence and racial derogatory remarks, with her roommate, Resident 25, in their room, on 10/6/24. 1. Review of Resident 32's "ADMISSION RECORD", indicated Resident 32 was admitted to the facility with diagnoses which included cerebral infarction (blood supply to brain is blocked or reduced and can cause brain cell damage), hypertension (heart has to work harder to pump blood), and myocardial infarction (a type of heart attack when your heart's need for oxygen cannot be met). Resident 32's admission record had a Resident Representative (RP, a person who makes decisions for another) identified as RP 2. Review of Resident 32's "Order Summary Report" (a document which includes all medication, tests, and non-medication orders), dated 9/26/24, indicated, " ...Resident is not capable of Understanding Rights, Responsibilities, And Informed Consent [process of communication between you and your health care provider that often leads to agreement or permission for care, treatment, or services]. ..." Review of Resident's 32's Cognitive Impairment Care Plan (a plan of care that outlines a patient's care needs related to understanding and thought), dated 5/15/23, indicated, " ... [Resident 32] exhibits cognitive loss... Monitor for changes in cognitive status. Observe for indicators of clinical changes ... behavior changes. Notify physician if occurs ..." Review of Resident 32's "Case Management" progress note, dated 6/28/24, written by the SSD, indicated, " ...A female resident [Resident 38] and this patient [Resident 32] have openly expressed their relationship and love for each other ...Both residents express their decision to engage in sexual relations and intimate experiences such as holding hands, snuggling, kissing, and fondling ... " Review of Resident 32's "Nurse's Note," dated 9/7/24, indicated, " ...[Resident 32] found with [Resident 38] having sex in female resident room [a shared female bed room]. after separating the two residents, both residents refused medication and assessments ..." During a phone interview on 10/22/24, at 12:14 p.m., RP 2 stated (Resident 32) had a girlfriend (Resident 38), and she was dragging him around all over the facility. RP 2 stated (Resident 32) would lay down in her [Resident 38's] bed but she was unsure if it was still going on as this was a few months ago. RP 2 stated when visiting, she saw (Resident 32) with his pants off, wearing no undergarments, and he was laying in (Resident 38's) bed. RP 2 stated she told him to go to his room. RP 2 stated the night Licensed Nurse (LN) told her he was always in (Resident 38's) room. RP 2 stated at night an LN would call her on the phone at 9:00 p.m. or 10:00 p.m. and inform her he would not leave (Resident 38's) room and would ask RP 2 for help in getting him to leave her room. RP 2 stated she was not aware of (Resident 32) and (Resident 38) engaging in any type of sexual behavior and the SSD had never informed her of this. RP 2 stated (Resident 32) was not able to consent to sexual touching due to his dementia. RP 2 stated she would have wanted to be informed by the facility and she stated she would not want him to engage in sexual activity with (Resident 38) or any other residents. Review of Resident 38's "ADMISSION RECORD," indicated, Resident 38 was admitted to the facility with diagnoses including dementia, bipolar disorder (mental health condition which causes extreme mood swings), obsessive compulsive disorder (lasting and unwanted thoughts that keep coming back or urges or images that are intrusive and cause distress or anxiety), anxiety disorder (excessive fear or worry about a specific situation), depression (affects how you feel, think and behave and can lead to a variety of emotional and physical problems), attention-deficit hyperactivity disorder (combination of persistent problems, such as difficulty sustaining attention, hyperactivity and impulsive behavior), and herpes viral vesicular dermatitis (a skin infection caused by a virus and spread by skin-to-skin contact). Review of Resident 38's "Order Summary Report," indicated physician orders written on 4/26/24, as follows, " ...Resident does not have the capacity to make her own decisions related to: DEMENTIA, MAJOR NEUROCOGNITIVE DISORDER [the ability to think and reason] DUE TO MULTIPLE ETIOLOGIES [decreased mental function and loss of ability to do daily tasks] ..." Review of Resident 38's "Nurse's Note," dated 5/30/24, indicated, " ...Resident noted with unappropriated [sic] sexual behavior. Found performing sexual act with male patient in his room. Staffing intervened and separated both patients. SBAR [Situation, Background, Assessment, and Recommendation-a method used to communicate important information] sent to MD [medical doctor]. Social service ...and Ombudsman aware ..." Review of the clinical record did not indicate further communication with Resident 38's medical doctor. During a concurrent interview and observation on 10/22/24, at 8:23 a.m., Resident 32 stated he did not know what day or year it was and stated since his stroke he had become forgetful. Resident 32 stated he cannot remember anything, and RP 2 made all his decisions for him. Resident 32 stated he had a girlfriend but could not remember her name and stated her room was close to his room, but he cannot recall what room she was in. Resident 32 stated he visits with her in the hallway, and he "does" not visit with her in her room nor was she allowed to visit him in his room. During a concurrent interview and record review on 10/22/24, at 1:52 p.m., the Administrator (ADM) stated Resident 38 and Resident 32 had taken a liking to each other and had established an intimate relationship. The ADM stated his understanding was the relationship included holding hands, kissing, and potentially a sexual relationship. The ADM stated Resident 32's RP was not okay with the sexual relationship. In a record review of Resident 38's clinical record, the ADM confirmed Resident 38 did not have capacity to make medical decisions. In a record review of Resident 32 and Resident 38's clinical record, the ADM confirmed there were currently no safeguards in place to prevent Resident 32 and Resident 38 from engaging in sexual contact. The ADM stated the risk to residents if safeguards were not in place to prevent sexual activity was for unwanted sexual contact and other behaviors and stated their sexual contact could be considered sexual abuse. 2. Review of Resident 25's "ADMISSION RECORD", indicated, Resident 25, was admitted to the facility in the summer of 2024, with diagnoses including but not limited to anxiety disorder (excessive fear or worry about a specific situation), and depression (affects how you feel, think and behave and can lead to a variety of emotional and physical problems). Review of Resident 311's "ADMISSION RECORD," indicated, Resident 311 was admitted to the facility on 10/1/24, with diagnoses including but not limited to, bipolar disorder (mental health condition which causes extreme mood swings), anxiety disorder, and major depressive disorder. In a concurrent observation and interview on 10/21/24, at 11:56 a.m., Resident 311 stated she had an altercation recently with a roommate and was upset because of the way staff handled the situation and felt like they were discriminating against her. Resident 311 stated during the altercation, Resident 25 had called her a "dirty [racial slur, an insulting remark]" and she had told staff this, including the Case Manager (CM 1). Resident 311 stated the (CM 1) told her if she did not move out of her room she would call the police on her. Resident 311 stated (CM 1) told her if she was not happy with her care she could leave the facility. In a concurrent interview and record review on 10/24/24, 12:19 p.m., LN 7 stated she was Resident 311's and Resident 25's LN on 10/6/24, when CNA 4 alerted her there was a verbal altercation occurring between the two residents in their room. LN 7 stated Resident 25 was threatening to go outside and fight Resident 311. LN 7 stated Resident 311 asked Resident 25 to just leave her alone and stated Resident 311 had felt threatened by Resident 25. LN 7 stated Resident 311 stated she did not feel safe. LN 7 stated the manager on duty for the facility that day was the Registered Dietician (RD) and she called her to speak with Resident 311. LN 7 stated Resident 311 told the RD she felt like staff was being discriminatory towards her because she was expected to change rooms and Resident 25 was not. Through review of Resident 311's clinical record, LN 7 confirmed she did not write a nursing note in her chart and stated she was not sure why she did not do it and stated she must have gotten busy. LN 7 stated it was important to document the incident in Resident 311's clinical record for patient care and to help advise other staff, including LNs of the event. LN 7 stated the RD placed a message out to alert administration of the altercation between the residents and stated this was important because she did not want Resident 311 and Resident 25 to hurt each other or lead to a physical altercation. In an interview on 10/24/24, at 1:51 p.m., CNA 4 stated on 10/6/24, which was a Sunday, she walked in Resident 311's room and witnessed her and roommate, Resident 25, engaged in an altercation. CNA 4 stated Resident 25 was upset there was a smell of Resident 311's commode (a portable toilet) and gave Resident 311 a pack of briefs (disposable underwear for lack of control of the bowel and bladder). CNA 4 stated Resident 311 called Resident 25 a (derogatory name) and stated she did not want the briefs and tried to give them back to Resident 25. CNA 4 stated they were using violent words towards each other and threatening each other. CNA 4 stated they were telling each other they were going to meet outside with boys to take care of the situation, so she called LN 7 for assistance. CNA 7 stated LN 7 entered the room and Resident 311 and Resident 25 continued to threaten each other. CNA 7 stated Resident 311 stated it was not fair they were asking her to change rooms and felt staff were siding with Resident 25. In a concurrent interview and record review on 10/24/24, at 2:04 p.m., the ADM stated he was aware of Resident 311 and her roommate, Resident 25, were not getting along. The ADM stated he had spoken to the SSD regarding the altercation that occurred in their room on 10/6/24, since most issues regarding conflicts amongst residents go through the SSD. The ADM stated the expectation was if there was an altercation between two residents which included fighting and threatening of each other then they determine if the situation needs to be investigated or reported to the state agency. The ADM stated it was important to investigate resident to resident altercations for resident safety and to have resolution between the residents. The ADM stated he was notified using "tiger texts" phone messaging regarding both Resident 311 and Resident 25, since the altercation occurred on the weekend. The ADM stated his understanding of the altercation was the residents had an argument over the smell of the commode and Resident 311 agreed to move to another room. The ADM stated typically there would have been an IDT collaboration meeting to ensure there was a multidisciplinary approach. The ADM stated there should have been monitoring of the residents, including 72-hour charting by staff. The ADM stated this would have been effective to ensure whatever actions taken were effective for the residents involved in the altercation. Through record review of Resident 311's clinical record, the ADM confirmed, there was no follow-up or investigation into the altercation which occurred between Resident 311 and Resident 25 nor was the altercation reported to the state agency. During a review of a facility policy and procedure (P&P) titled "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," revised 4/2021, the document indicated, " ...Residents have the right to be free abuse ...This includes but is not limited to ...verbal, mental, sexual or physical abuse ...Identify and investigate all possible incidents of abuse ...mistreatment ...Investigate and report any allegations within timeframes required by federal requirements ...Protect residents from further harm during investigations ..." During a review of a facility policy and procedure (P&P) titled "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating," revised 9/2022, the document indicated, " ...All reports of resident abuse ...neglect, exploitation ...of resident are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings are documented and reported ...If resident abuse, neglect, exploitation ...the suspicion must be reported immediately to the administrator and to other officials according to state law ...The administrator or the individual making the allegation immediate reports his or her suspicion to the following persons or agencies ...The stated licensing/certification agency responsible for surveying/licensing the facility ...The local/state ombudsmen ...The resident's representative ...Adult protective services ...Law enforcement officials ...The resident's attending physician ...The facility medical director ..."Immediately" is defined as ... within two hours of an allegation involving abuse ...within 24 hours of an allegation that does not involve abuse ...Verbal/written notices to agencies are submitted via special carrier, fax, email, or by telephone ...Upon receiving any allegation of abuse, neglect, exploitation ...the administrator is responsible for determining what actions (if any) are needed for the protection of residents ..." During a review of a facility policy and procedure (P&P) titled "Dementia Clinical Protocol,", revised 3/2017, the document indicated, " ...The staff and physician will review the current physical,