Health inspection·September 21, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a repeated resident to resident altercation, for one of three sampled residents (Resident 2) when Resident 2 had been placed on 1:1 (one-to-one) monitoring (one-to-one monitoring uses continuous staff observation to safeguard patients judged likely to harm themselves or others) and the monitor stepped away from Resident 2 leaving him unattended. This failure had the potential to cause Resident 2 to begin an altercation with another resident. Findings: An unannounced visit was made to the facility on September 19, 2023, at 10:28 AM, to investigate a facility reported incident regarding a resident-to-resident altercation. A review of Resident 2's face sheet (a document that gives a summary of resident information), undated, indicated an admission date of August 25, 2023, with diagnoses that included: psychosis (a mental disorder characterized by a disconnection from reality), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizoaffective disorder (a mental illness that affects thoughts, mood and behavior), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During an interview with the Administrator (Admin) on September 19, 2023, at 11:03 AM, the Admin stated the incident happened when both Resident 1 and Resident 2 were waiting to go out to the smoking patio. The Admin stated Resident 2 had been speaking in a very loud voice and Resident 1 asked him to be quiet which triggered Resident 2 to assault Resident 1. Staff intervened quickly and neither resident sustained injury. The Admin stated the facility was working on placement in another facility for Resident 2 as his unpredictable and aggressive behavior was escalating towards other residents and staff. The Admin stated Resident 2 had received a psychiatric evaluation and the physician had changed some of Resident 2's medications. The Admin stated Resident 2 would stay on 1:1 monitoring until appropriate placement had been secured. During an observation and interview with a Minimum Data Set Coordinator (MDS Coord) and Resident 2 on September 19, 2023, at 11:58 AM, The MDS Coord walked down the hallway towards the nursing station. The MDS Coord. pointed to Resident 2 and stated, That is [name of Resident 2] walking toward us. Resident 2 was independently and rapidly walking down the hallway. There was no 1:1 monitor following Resident 2. The MDS Coord. stated he did not know where the 1:1 monitor was. Resident 2 stopped walking and came very close and stated very loudly, What questions?! What questions?! My psychiatrist told me I don't have to answer any questions! Resident 2 was asked if he was doing OK. Resident 2 Page 1 of 2 555521 555521 09/21/2023 Rancho Mesa Care Center 9333 LA Mesa Dr Alta Loma, CA 91701

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few turned away and continued walking down the hallway and shouted, No! No! No! Resident 2 was followed, and Resident 2 ended up at the front office and spoke briefly with an Activities Director (AD) and then turned and walked back down the hallway unmonitored. During an interview with the Activities Director (AD) and MDS Coord on September 19, 2023, at 12:06 PM, The AD stated she had been assigned the 1:1 monitoring duty for Resident 2. The AD stated she understood she needed to always maintain a line of sight on Resident 2. The AD stated she had passed off the duty to a Director of Staff Development (DSD) so she could come to the front office and make popcorn. The MDS Coord stated neither the AD nor DSD had been with Resident 2 when Resident 2 was observed walking down the hallway. During an interview with the DSD on September 19, 2023, at 12:16 PM, The DSD stated the AD had not passed off the 1:1 monitoring duty for Resident 2 until she had been questioned about it. The DSD stated he understood that during a 1:1 monitoring one must always remain within a line of sight of the resident. During an interview with the Admin and Director of Nursing (DON) on September 19, 2023, at 12:21 PM, The Admin and DON stated during a 1:1 monitoring of a resident a line of sight must be always maintained. The Admin and DON stated the AD had not maintained the line of sight for Resident 2's monitoring. A review of the facility's policy and procedure titled, 1:1 SUPERVISION/ SITTERS, undated, indicated, PURPOSE: 1. To assist residents who need additional supervision . POLICY: . Sitters must agree to comply with the facility sitter 1:1 supervision policy approved by the facility. 2. Sitters Responsibilities: . 4. Accompanying the resident to the bathroom if the resident is able to ambulate independently. 5. Notifying facility's staff of any resident's needs. D. The sitter will notify the facility staff when taking a break or when the sitter will be away from the resident during his/ her work shift. G. Sitter(s) must report to nurse supervisor/ charge nurse when coming on and going off duty. 555521 Page 2 of 2