Health inspection·April 14, 2023

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its own policy for investigating an abuse allegation, when a certified nurse assistant (CNA), was not suspended, pending an investigation of an alleged verbal abuse allegation for one of two resident (Resident 1), reviewed for resident abuse. Residents Affected - Few As a result, other residents were potentially at risk to be abused by the same CNA. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included Parkinson ' s disease, (a progressive disease that affects the nervous system), per the facility ' s Resident Face Sheet. On 4/3/23, Resident 1 ' s clinical record was reviewed: According to the Minimum Data Set, (a clinical assessment tool), dated 3/20/23, listed a cognitive score of 12, indicated moderately impaired cognition. The functional status of activities of daily living, indicated one person staff-assist with bed mobility, transfers, and toiletry. According to the plan of care, titled Behavioral symptoms, dated 3/18/23, interventions listed included: Emphasize rights, security and safety of all, approach calmly and unhurried, attempt to identify underlying cause, attempt to listen to resident vent anger, if they become abusive, explain to resident why you are leaving (ensuring their safety), reassure resident that needs will be met. On 4/3/23 at 10:05 A.M., an interview was conducted with the Administrator (ADM) and the Director of Nursing (DON, regarding the facility ' s self-reported incident of an alleged staff to resident verbal abuse that occurred on 3/26/23 P.M. shift (3 P.M. to 11:30 P.M.) The DON stated she received a call from the evening Resource Nurse (RN), of an allegation of CNA 1 telling Resident 1 to F--K yourself. The DON stated the decision was made to move CNA 1 to a different hallway, to finish out her shift. The DON continued, stated the RN for that shift, started to conduct an investigation and the decision was made to keep CNA 1 working. The DON stated they determined the verbal abuse had occurred and was a temporary lapse of CNA 1 ' s judgment and frustration. On 4/3/23 at 11:12 A.M., an interview was conducted with the RN. The RN stated she was informed by a licensed nurse 1 (LN 1) of something being overheard between Resident 1 and CNA 1. The RC stated she assessed Resident 1, who could not recall anything. The RN notified the DON, and the DON made the Page 1 of 2 555424 555424 04/14/2023 The Dorothy & Joseph Goldberg Healthcare Center 211 Saxony Road Encinitas, CA 92024

F 0610 decision to move CNA 1 to a different area. Level of Harm - Minimal harm or potential for actual harm On 4/3/23 at 11:41 A.M., an interview was conducted with CNA 1. CNA 1 stated she works all different shifts at the facility and had cared for Resident 1 many times, who is confused and difficult at times. CNA 1 stated Resident 1 told her to F--K off, and as she was walking out of the room, she said F--k yourself. CNA 1 stated she realized she should have just left the room sooner and told the charge nurse she was having difficulty dealing with the resident. CNA 1 stated she was able to finish her shift and she worked the next two days. Residents Affected - Few On 4/3/23 at 11:46 A.M., an interview was conducted with CNA 2. CNA 2 stated if he overheard something inappropriate between staff and a resident, he would immediately intervene and ask the staff member to leave. CNA 2 stated he would inform the charge nurse and document what he saw or heard. CNA 2 stated the facility was responsible for investigating the alleged incident and the staff should be removed from resident care, until it was determined what happened and what should be done. On 4/3/23 at 11:54 P.M., an interview was conducted with LN 2. LN 2 stated if an allegation of abuse occurred between staff and a resident, the staff member should be sent home immediately and removed from resident care. LN 2 stated the facility was required to investigate including the ADM, DON, Human Resource Officer, along with informing the physician and family. On 4/3/23 at 12:12 P.M., an observation and interview was conducted of Resident 1 as he sat in the dining room with another male resident, waiting for lunch. Resident 1 was dressed and well groomed. Resident 1 did not answer the questions asked but smiled instead. According to the facility ' s policy, titled Abuse Investigation and Reporting, dated July 2017, .4. The Administrator will suspend immediately any employee who had been accused of resident abuse, pending the outcome of the investigation . 555424 Page 2 of 2