Health inspection·September 30, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that one of three residents (Resident 1) was monitored following an allegation of physical abuse. Residents Affected - Few This failure had the potential to affect Resident 1 ' s emotional and psychosocial wellbeing. Findings: On September 10, 2024 at 9:00 a.m., an unannounced visit to the facility was conducted to investigate an allegation of physical abuse. On September 10, 2024, Resident 1 ' s medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included left shoulder osteoarthritis (a disease where the tissues [a group of cells] of the joints break down overtime.) A review of Resident 1 ' s History and Physical, dated August 22, 2024, indicated, Resident 1 had mental capacity. A review of Resident 1 ' s Minimum Data Set (MDS - an assessment tool), dated August 26, 2024, indicated Resident 1 had a Brief Interview for Mental Status (tool used to assess a resident's cognitive function) score of 15 (cognitively intact). A review of Resident 1 ' s eINTERACT Change of Condition Evaluation, dated August 26, 2024, indicated, .Caregiver .alleged CNA handled resident roughly during transfer causing moderate to severe pain in the left shoulder . Further review of Resident 1's progress notes from August 26 to August 29, 2024, indicated there was no documented evidence Resident 1 was monitored after the physical abuse allegation. On September 10, 2024, at 10:10 a.m., during a concurrent interview and review of Resident 1 ' s progress notes with License Vocational Nurse (LVN) 1, he stated, Resident 1 ' s caregiver alleged CNA 1 was rough and caused pain to resident during a transfer on August 26, 2024. LVN 1 further stated the process for abuse monitoring requires that the resident involved be monitored for 72 hours after the abuse incident or allegation to observe for any psychosocial effect, emotional distress, behavioral changes , or delayed physical injuries. LVN 1 stated, Resident 1 was not monitored for 72 hours after the alleged physical abuse. LVN 1 further stated, Resident 1 should have been monitored for any emotional distress or any behavior changes. Page 1 of 2 555247 555247 09/30/2024 Rancho Mirage Health and Rehabilitation Center 39950 Vista Del Sol Rancho Mirage, CA 92270

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On September 10, 2024, at 10:45 a.m., during a concurrent interview and review of Resident 1 ' s progress notes with the Director of Nursing (DON), she stated, Resident 1 was not monitored after the alleged physical abuse incident on August 26, 2024. The DON stated a resident involved in an abuse allegation needs to be monitored for 72 hours to detect any negative effects on the resident. The DON further stated, it is important to monitor the resident after an abuse allegation to assess for any emotional or psychosocial effects and latent physical injuries. The DON stated her expectation is for nursing to conduct 72-hour monitoring and documentation of the resident involved after an abuse incident or allegation. The DON further stated, Resident 1 should have been monitored for any emotional distress, and or latent bodily injuries. On September 10, 2024, at 1:20 p.m., during an interview with the DON, she stated the facility does not have a specific policy related to 72-hour monitoring. The DON further stated it is the facility ' s standard practice to monitor residents every shift for 72 hours after any abuse allegations, and the monitoring is documented in the resident ' s medical records. 555247 Page 2 of 2