Health inspection·May 16, 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 interviews and record review, the facility failed to report an alleged verbal abuse of one of three sampled residents (Resident 2) by Resident 3 within the required time frame to the State Survey Agency (SSA), Long-Term Ombudsman (LTO), and the local law enforcement (LLE). This failure had the potential to result in further abuse of Resident 2 and/or other residents related to the delayed investigation of alleged abuse and the necessary interventions to prevent abuse. Findings: 1a. During a review of Resident 2's Face Sheet (FS 1, admission record), FS 1 indicated the facility admitted Resident 2 on 11/10/2023, with multiple diagnoses including hypertensive heart disease (HHD, abnormal changes in the heart due to long-standing high pressure of the blood against the walls of the arteries), abnormalities of gait, and unsteadiness on feet. During a review of Resident 2's Minimum Data Set (MDS 1, a standardized resident assessment and care-planning tool), dated 2/16/2024, MDS 1 indicated Resident 2 had moderate impairment in cognition (ability to understand and process information). MDS 1 indicated Resident 2 required substantial/maximal assistance with toileting and personal hygiene, and bathing. MDS 1 indicated Resident 2 required partial/moderate assistance with upper body dressing, sit-to-stand, and chair/bed-to-char transfers. MDS 1 indicated Resident 2 had no physical, verbal, and other behavioral symptoms directed/not directed towards others. During a review of Resident 2's Plan of Care - Behavioral Disturbances (CP 1), revised on 5/5/2024, CP 1 indicated Resident 2 exhibited confrontational behavior toward other resident. During a review of Resident 2's Complete Interdisciplinary Notes (R2CIN 1), dated 5/6/2024 and timed at 4:45 PM, R2CIN 1 indicated Licensed Vocational Nurse 1 (LVN 1) documented that Resident 2 had a verbal altercation with Resident 3 while in the dining room. During a review of Resident 2's R2CIN 2, dated 5/7/2024 and timed at 12:37 PM, R2CIN 2 indicated Social Services Staff 1 (SS 1) communicated with LVN 1 that SS1 felt that Resident 2 was confused. [NAME] 2 indicated LVN 1 informed SS 1 that Resident 2 and Resident 3 argued again yesterday. [NAME] 2 indicated SS 1 reminded LVN 1 that anytime there is behavior incident, document and report to families. During a review of Resident 2's R2CIN 3, dated 5/7/2024 and timed at 12:45 PM, R2CIN 3 indicated the Director of Nursing (DON) notified Primary Care Provider 1 (PCP 1) of the altercation between Page 1 of 3 555085 555085 05/16/2024 Claremont Manor Care Center 621 W Bonita Ave Claremont, CA 91711

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 2 and Resident 3. [NAME] 3 indicated PCP 1 ordered labs and a psych consult (physician and resident conference aimed at gaining a deeper understanding of the resident's mental condition and treatment plan to meet mental health goals). During a review of the facility's document of Resident 2's interview (IR 1), titled Interview/Debriefing Narrative Record, dated 5/7/2024, IR 1 indicated Resident 2 stated that Resident 3 kept interrupting the Activities Director (AD) while providing activities to the residents. IR 1 indicated Resident 2 stated Resident 3 got upset and started cussing at Resident 2 and threatened to hit Resident 2. 1b. During a review of Resident 3's FS 2, FS 2 indicated the facility admitted Resident 3 on 10/19/2023 with multiple diagnoses including HHD, type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and unsteadiness on feet. During a review of Resident 3's History and Physical Examination (H&P), dated 10/21/2023, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's MDS (MDS 2), dated 4/25/2024, MDS 2 indicated Resident 3 had moderate impairment in cognition. MDS 2 indicated Resident 3 required substantial/maximal assistance with toileting hygiene, bathing, lower body dressing, and putting on/taking off footwear, and transfers. MDS 2 indicated Resident 3 had no physical, verbal, and other behavioral symptoms directed/not directed towards others. During a review of Resident 3's Plan of Care - Behavioral Disturbances (CP 2), revised on 5/5/2024, CP 2 indicated Resident 3 had a behavior of cursing and was abusive towards another resident. During a review of Resident 3's [NAME] 1 (R3CIN 1), dated 5/5/2024 and timed at 3 PM, R3CIN 1 indicated LVN 1 documented that Resident 3 had a verbal altercation with Resident 2 while in the dining room. R3CIN 1 indicated Resident 3 was cussing at resident and saying ' F*** your mom. You bi***. I am going to kick you a**.' During a review of the facility's document of Resident 3's interview (IR 2), titled Interview/Debriefing Narrative Record, dated 5/7/2024, IR 2 indicated Resident 3 stated Resident 2 started raising her voice and told Resident 3 she was not supposed to take a picture. IR 2 indicated Resident 2 used profanity on Resident 3, so Resident 3 responded, Fuck you or I will kick your ass. During an interview on 5/16/2024 at 10:40 AM, AD stated on 5/5/2024 at around 3:05 PM while the facility was celebrating Cinco de Mayo, Resident 3 requested AD to take a photo of Resident 3 with another resident. AD stated Resident 2 told Resident 3 not to disrupt the activities. AD stated Resident 3 responded, You don't tell me what to say, then the argument started. AD stated AD witnessed Resident 3 verbalizing profanities towards Resident 2. AD stated he separated the residents immediately and continued with the activities until 4 PM/4:15 PM on 5/5/2024. AD stated he did not report the incident to any Charge Nurse, Registered Nurse (RN) Supervisor, or the Abuse Coordinator. During an interview on 5/16/2024 at 2:29 PM, LVN 1 stated LVN 1 did not witness the altercation between Resident 2 and Resident 3. LVN 1 stated LVN 1 overheard from other staff members that Resident 3 was brought out of the activities room because Resident 3 needed to be separated from Resident 2 due to an argument they had while in the activities room with the other residents. LVN 1 stated SS 1 approached him on 5/6/2024 and asked him what happened on 5/5/2024. LVN 1 stated he spoke to AD on 555085 Page 2 of 3 555085 05/16/2024 Claremont Manor Care Center 621 W Bonita Ave Claremont, CA 91711

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 5/6/2024 at the end of the shift (approximately 3 PM) to inquire about the incident details on 5/5/2024 between Resident 2 and Resident 3. During an interview on 5/16/2024 at 2:50 PM, RN 1 stated any alleged abuse, including verbal abuse, must be reported to the SSA, LTO, and LLE within 2 hours. RN 1 stated it was necessary to investigate the incident timely to prevent the recurrence of any abuse incident and to prevent any further abuse or injury of any resident/s. During an interview on 5/16/2024 at 3:32 PM, the Administrator stated the alleged abuse was reported to the agencies on 5/7/2024 (more than 24 hours after the incident occurred). During a review of the facility's policy and procedure (P&P), titled Adult Abuse, dated 4/2018, the P&P indicated the following: 1. The facility must enforce a non-tolerance of any form of behavior that might be construed as abuse by any individual, family member, staff member, visitor, volunteer, student, or other person, including resident-to-resident abuse of any type. 2. Abuse is the willful (deliberate action) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. 3. Verbal abuse refers to any use of oral, written, or gestured language that includes threats and/or disparaging and derogatory terms. 4. Any person having information, either by direct observation or by report, of any act or suspected act that may be considered to be a form of abuse, is responsible for reporting the information immediately to the individual's department head or Administrator, or their designee, regardless of the time of day. 5. Anyone who is an owner, operator, employee, manager, agent, or contractor of the facility who has observed, suspects, or has knowledge of an allegation of abuse must report to SSA, LTO, LLE, and the Administrator immediately but not later than 2 hours. 555085 Page 3 of 3