Health inspection·September 28, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 and implement policies and procedures for an allegation of abuse when: the alleged perpetrator returned to work and continued to enter the alleged victim's (Resident 5) room. Residents Affected - Few This failure had the potential for Resident 5 to be vulnerable and exposed to the alleged perpetrator. Findings: Resident 5 was admitted to the facility on [DATE] with diagnoses including aphasia (language disorder affecting how to communicate) following other cerebrovascular disease (group of conditions affecting blood flow and blood vessels in the brain) and need for assistance with personal care according to the facility's admission Record. An interview was conducted on 9/25/23, at 10:24 A.M. with Resident 5. Resident 5 was sitting in a wheelchair in her room and nodded when asked if she had any concerns with the facility staff. Resident 5 frowned and stated in a loud voice, A man, terrible person, grabbed . Resident 5 had difficulty completing sentences but kept repeating he was a terrible person. Resident 5 stated she screamed and yelled when she saw the man. During a review of Resident 5's clinical record titled Progress Notes (PN) dated 9/18/23, the PN indicated a licensed nurse (LN) documented Resident 5 complained about a nurse who stood in between Resident 5's bed and her roommate (Resident 1) on 9/17/23. The PN indicated, Resident told the nurse to move away and leave the room .resident explained sticking her left arm out towards nurse to move away and the resident claims the nurse hit her left arm 2 separate times. An interview was conducted with LN 2 on 9/25/23, at 4:31 P.M. LN 2 stated he did not work 9/18/23 and 9/19/23. LN 2 stated he returned to work on 9/20/23 and was assigned to Resident 5's roommate in bed B (Resident 1). On 9/20/23 evening shift, LN 2 stated Resident 5 and Resident 1 was heard yelling at each other. LN 2 stated he went into the room to ask Resident 1 what happened, then LN 2 and another CNA separated the beds further away. LN 2 further stated Resident 5 saw him at the other room and told him to go away. An interview was conducted with the Administrator (Admin) on 9/26/23, at 11:07 A.M. The Admin stated she was not aware of LN 2 being assigned in Resident 5's room. The Admin stated she would not have assigned LN 2 in Resident 5's room because this would upset Resident 5. Page 1 of 2 555545 555545 09/28/2023 The Cove at LA Jolla 7160 Fay Avenue LA Jolla, CA 92037

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's Investigative Summary, dated 9/22/23, the Investigative Summary indicated LN 2 as the suspected abuser and was suspended pending investigation was returned to work on 9/20/23. A review of the facility's undated policy and procedure (P&P) titled, Resident Rights Abuse: Prevention of and Prohibition Against was conducted. The P&P indicated, .G. Protection 1. If an allegation of abuse . is reported, discovered or suspected, the Facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation .Make room or staffing changes . to protect the resident (s) from the alleged perpetrator . 555545 Page 2 of 2