Health inspection·June 26, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review, the facility failed to complete and ensure prompt efforts were made to resolve grievance verbalized by residents to the facility and keep resident appropriately apprised of progress towards resolution for one of three sampled residents (Resident 1). In addition, the facility failed to issue a written grievance decision to Resident 1, in accordance with the facility's policy on Grievance/Concern. This deficient practice increased the risk for negative psychosocial impact on Resident 1's quality of life. Findings: A review of Resident 1's admission Record indicated the facility readmitted the resident on 7/19/2022, with diagnoses of paraplegia (paralysis that occurs in the lower half of the body), Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A review of Resident 1's History and Physical Examination dated 7/21/2022, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, an assessment and screen tool) dated 11/01/2022, indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight bearing support) one person physical assist for bed mobility, dressing ,toilet use and personal hygiene. During an interview in Resident 1's room on 6/26/23 at 11:12 AM, Resident 1 stated he spoke with the Social Service Director (SSD) and the Director of Staffing Development (DSD) about his concerns (on 5/9/23) regarding Certified Nursing Assistant (CNA) 1 being assigned to him as his regular CNA. Resident 1 stated he told the SSD and DSD that he did not want CNA 1 being assigned as his primary CNA or come into his room, as he feels fearful for his safety and fears retaliation from CNA 1 because he reported the lack of competent care being provided to him by CNA 1. A review of Resident 1's Progress notes indicated the following information: 1. On 5/09/23, the notes indicated that SSD and DSD went to Resident 1's room and spoke with Resident 1 and Resident 1 verbalized he did not want CNA 1 being assigned to him. SSD and DSD informed Resident 1 that CNA 1 would be assigned to him with a second staff member present for the safety of the staff due to Resident 1's verbal threats to call the California Department of Public Health (CDPH). Page 1 of 2 555081 555081 06/26/2023 Del Mar Convalescent Hospital 3136 North Del Mar Avenue Rosemead, CA 91770

F 0585 2. On 6/08/23, the notes indicated Resident 1 refused to have CNA 1 assigned to him. Level of Harm - Minimal harm or potential for actual harm 3. On 6/15/23, the notes indicated SSD and DSD went to speak to Resident 1 because Resident 1 insisted he did not want CNA1 assigned to him. The DSD told Resident 1 he needs to wait due to his request. Residents Affected - Few During a concurrent interview and record review of the facility's Grievance Log with the SSD on 6/26/2023 at 1:15 PM, the SSD stated she could not find documented evidence that grievances were logged for Resident 1 for the months of April, May or June 2023 or that a written grievance resolution was provided to Resident 1. The SSD stated a grievance is when a resident and/or family member complains about something. The SSD stated sometimes residents would tell their concerns to nurses or CNAs. The SSD stated she also conducts room rounds and wouls start a grievance process for any residents who have concerns but had not completed one for Resident 1's verbal concern regarding CNA 1. The SSD stated once a grievance was made, they would notify whichever department it concerns, investigate, and notify the resident and/or family member of the resolved response. The SSD stated the Social Services Department is responsible for filling out the legal document for the resident's grievance. A review of the facility's policy and procedure titled Grievance/Complaint Procedures, with a revision date of November 2016 indicated the following information: 1. Any resident, his or her representative, family member, or appointed advocate may file a grievance or complaint alleging discrimination in treatment, medical care, and behavior of other residents or staff members, without fear of threat or reprisal in any form. The facility's policy indicated grievances and or complaints may be submitted orally (spoken) or in writing and anonymously. The facility's policy indicated the Administrator has designated the facility's Social Service Designee (SSD) as the Grievance Official, who is responsible for overseeing the grievance process, receiving and tracking grievances though to their conclusion that included issuing written grievance decisions to the resident. 555081 Page 2 of 2