Health inspection·June 21, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five sampled residents, Resident 1, was free from abuse when Resident 1 expressly stated to Certified Nursing Assistant (CNA) 1 not to check his brief (product used to absorb urine) on 6/7/24. CNA 1 checked Resident 1's brief twice without his permission and in the process physically touched Resident 1's genitals (sexual organs located outside the body). These failures resulted in not honoring Resident 1's expressed refusal of care and could be considered physical and sexual abuse. Resident 1 felt violated, angry, humiliated, and disrespected. Findings: During a review of Resident 1's admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included Acquired Absence of Right Leg Below Knee (cutting off leg below the knee), End Stage Renal Disease (a medical condition in which a person's kidneys stop working on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment dated 6/15/24, it indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment, 99 severely impaired). The BIMS assessment indicated Resident 1 was cognitively intact. During an interview on 6/21/24 at 11:24 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 refused care throughout the night and in the morning on 6/7/24. CNA 1 stated around 6 a.m. on 6/7/24 she asked Resident 1 if she could check his brief (product used to absorb urine) and he told her no he just needed to get up. CNA 1 stated she tapped his brief with the back of her hand and Resident 1 told her don't do that . CNA 1 stated she told LVN 1 and the LVN 1 directed her to inform Assistant Director of Nursing (ADON) 1, CNA 1 stated ADON 1 instructed her to provide a written statement. CNA 1 stated she did not honor Resident 1's wishes when she checked Resident 1 brief after he had said no. During a concurrent observation and interview on 6/21/24 at 12:25 p.m. with Resident 1, in Resident 1's room, Resident 1 was lying in bed. Resident 1 stated on 6/7/24 CNA 1 asked if he was wet. Page 1 of 7 555652 555652 06/21/2024 Willow Creek Healthcare Center 650 W. Alluvial Clovis, CA 93611

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1 stated he told CNA 1 he was not wet and did not need his brief changed. Resident 1 stated CNA 1 then grabbed the brief where his genitals were with the palm of her hand and shook his genitals. Resident 1 stated he pushed CNA 1's hand away and with his arm, and told her she could not do that to him. Resident 1 stated, CNA 1 told him she was trained to check his brief and grabbed and shook his genitals a second time. Resident 1 stated he again pushed CNA 1's arm away. Resident 1 then told CNA 1 to get out of the room. Resident 1 stated he told the Licensed Vocational Nurse (LVN) 1 that lady (CNA 1) violated me, and I don't appreciate it . Resident 1 stated LVN 1 said he would talk to CNA 1. Resident 1 stated he felt awful, mad, and violated . During an interview on 6/21/24 at 1:23 p.m. with LVN 1 , LVN 1 stated Resident 1 told him on 6/7/24 he did not want CNA 1 to provide him care because she was rough . LVN 1 stated he did not question what Resident 1 meant by rough and thought it was rough in general. LVN 1 stated he never discussed looking into why. LVN 1 stated he did not chart that CNA 1 was rough with Resident 1. LVN 1 stated on 6/7/24 he told CNA 1 he would be switching her assignments and CNA 1 was agreeable with the plan. LVN 1 stated he did not document he switched CNA 1 from caring for Resident 1 or why. LVN 1 stated about a week later Resident 1 wanted to know if CNA 1 was still working at the facility. LVN 1 stated when he told Resident 1 CNA 1 was still working at the facility Resident 1 asked to speak to Assistant Director of Nursing (ADON) 2 to discuss the incident on 6/7/24. LVN 1 stated he was made aware of Resident 1's 6/7/24 allegation from ADON 2. LVN 1 stated he could had done more, he could had charted the incident and informed the abuse coordinator who is the Administrator (ADM) on 6/7/24. LVN 1 stated the delay in investigating and reporting could cause emotional distress for Resident 1. During review of CNA 1's facility statement, dated 6/7/24, the statement indicated I asked if he (Resident 1) brief was wet and felt his brief he then got mad and said I'm supposed to ask I then said I was just checking because you are leaving for an appointment and I need to make sure he was upset and I did apologize but he was still really mad. During an interview on 6/21/24 at 4:45 p.m. with Assistant Director of Nursing (ADON) 1, ADON 1 stated she was first made aware of the incident with Resident 1 and CNA 1 on 6/7/24. ADON 1 stated CNA 1 came into the office and let her know Resident 1 was mad because she had checked his brief, and he did not want her to. ADON 1 stated she told CNA 1 to write a statement of events on 6/7/24. ADON 1 stated she took the statement on 6/7/24 and put it away and did not read the written statement after CNA 1 wrote it. ADON 1 stated she did not discuss CNA 1's statement with Resident 1 or LVN 1 on 6/7/24. ADON 1 stated after reading the statement, it was a clear violation what CNA 1 did to Resident 1. ADON 1 stated, she did not follow the facility's policy for reporting abuse. ADON 1 stated Resident 1 could have psychosocial harm, since Resident 1 had been thinking about this incident for a week and asked about it. ADON 1 stated Resident 1 could have been in distress. During a concurrent interview and record review on 6/21/24 at 5:03 p.m. with the Director of Staff Development (DSD), the facility In-Service Sign-In sheet (ISSIS) titled Your Legal Duty Reporting Elder and Dependent Adult Abuse , dated 1/11/24 was reviewed. The ISSIS indicated, .all healthcare practitioners and all employees in a long-term care health care facility are mandated reporters .[LVN 1 Name] .print title .LVN .(Signature) . The DSD validated LVN 1 received training for reporting elder abuse. The DSD stated the expectation was to ask and investigate if any resident reports any incident to staff. During an interview on 6/21/24 at 5:24 p.m. with the Director of Nursing (DON), and the Administrator (ADM) the DON stated the expectation of LVN 1 should have been to investigate and report the incident to the DON or the ADM. The DON stated, LVN 1 and ADON 1 did not follow policy for reporting. 555652 Page 2 of 7 555652 06/21/2024 Willow Creek Healthcare Center 650 W. Alluvial Clovis, CA 93611

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Both the DON and the ADM verified the written statement from CNA 1 to ADON 1, and stated the statement should have been read and reported right away. The ADM stated, LVN 1 did not follow policy for reporting. The ADM stated ADON 1 did not follow policy for reporting. During a review of CNA 1's Residents' Rights Contract (RRC) , Signed and dated 2/4/2024 by CNA 1, the RRC indicated, .Every resident has the right to every consideration of his/her privacy and individuality .I [CNA 1] .have been provided a copy of our residents' rights and have been given the opportunity to discuss them and ask questions . During a review of CNA 1's Acknowledgement (A) , signed and dated 2/4/2024 by CNA 1, the A indicated, .I have received a copy of the abuse policy .I have read and understand my responsibility to report abuse .I have seen the video regarding elder abuse. I have read and understand my responsibility as a mandated reporter . During a review of CNA 1's Training and Acknowledgement Safe Patient Handling (TASPH) , signed and dated 2/4/2024 by CNA 1, the TASPH indicated, .I have received reading material and video training on Gentle & Safe Handling Resident. I have read and watched a video and understand my responsibility for Gentle & Safe Handling Residents. During a review of LVN's Job Description (JD) , signed and dated 6/9/2022 by LVN 1, the JD indicated, .The primary purpose of your job position is provide direct nursing care to the residents .and to supervise the day-to-day nursing actives performed by nursing assistants .Ensure that all nursing personnel assigned to you comply with written policies and procedures established by this facility .Complete accident/incident reports as necessary .Chart nurses' notes in an informative and descript manner that reflects the care provided to the resident as well as the resident's response to the care. Fill out and complete accident/incident reports. Submit to Director as required. Chart all reports of accidents/incidents involving residents Follow established procedures .Make daily rounds of your unit/shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Report problem areas to the Nurse Supervisor .Ensure that department personnel, residents, and visitors follow the department's established policies and procedures at all times .Review complaints and grievances made or filled by your assigned personnel. Make appropriate reports to the Nurse Supervisor as required or as may be necessary. Follow facility's established procedures .Notify the resident's attending physician when the resident is involved in an accident or incident .Ensure that personnel providing direct care to residents are providing such care in accordance with the resident's care plan and wishes . During a review of ADON's Job Description (JD) , signed and dated 11/12/2023 by ADON 1, the JD indicated, .Oversees clinical operation, including making daily rounds and monitoring resident conditions. Responsible for ensuring resident safety, and ensuring residents are treated with the utmost respect .Provides reports and recommendations to the DON concerning the operation of nursing services .Assists with the overall supervision and management of the nursing staff . During a review of the facility Policy & Procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program , dated 4/2021, the P&P indicated, .Residents have the right to be free from abuse .this includes but is not limited to .Sexual or physical abuse .Protect residents from abuse .by anyone including, but necessarily limited to: facility staff .Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents .Identify and investigate all possible incidents of abuse . 555652 Page 3 of 7 555652 06/21/2024 Willow Creek Healthcare Center 650 W. Alluvial Clovis, CA 93611

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During review of the facility's Policy and Procedure (P&P) titled, Unusual Occurrence Reporting , dated 12/2007, the P&P indicated .As required by federal or state regulations, our facility reports unusual occurrences or other reportable events with affect the health, safety, or welfare of our residents, employees or visitors .Our facility will report the following events to appropriate agencies .Allegations of abuse, neglect .unusual occurrences shall be reported via telephone to appropriate agencies as required by current law/or regulations .or as required by federal and state regulations . During a review of the facility Policy & Procedure (P&P) titled Resident Rights , dated 12/2016, the P&P indicated, .Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .b. be treated with respect, kindness, and dignity. c. be free from abuse .e. self-determination .h. be supported by the facility in exercising his or her rights. i. exercise his or her rights without interference .u. voice grievances. v. have the facility respond to his or her grievances . During a review of the facility Policy & Procedure (P&P) titled Charting and Documentation , dated 12/2022, the P&P indicated, .Any notable changes in the residents' medical, physical, functional, or psychosocial condition observed by the safe, should be documented in the residents' medical record . 555652 Page 4 of 7 555652 06/21/2024 Willow Creek Healthcare Center 650 W. Alluvial Clovis, CA 93611

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. Based on observation, interview and record review, the facility failed to report an allegation of alleged abuse to the state agency, ombudsman and local law enforcement within the required 24-hour time frame for one of five sampled residents (Resident 1) when on 6/7/24, Resident 1 reported to Licensed Vocation Nurse (LVN) 1 that Certified Nursing Assistant (CNA) 1 violated him. This failure led to the allegation of abuse on 6/7/24 to go unnoticed and unreported by the facility until 6/17/24. Findings: During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment dated 6/15/24, it indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment, 99 severely impaired). The BIMS assessment indicated Resident 1 was cognitively intact. During an interview on 6/21/24 at 11:24 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 refused care throughout the night and in the morning on 6/7/24. CNA 1 stated around 6 a.m. on 6/7/24 she asked Resident 1 if she could check his brief (product used to absorb urine) and he told her no he just needed to get up. CNA 1 stated she tapped his brief with the back of her hand and Resident 1 told her don't do that . CNA 1 stated she told LVN 1 and the LVN 1 directed her to inform Assistant Director of Nursing (ADON) 1, CNA 1 stated ADON 1 instructed her to provide a written statement. CNA 1 stated she did not honor Resident 1's wishes when she checked Resident 1 brief after he had said no. During a concurrent observation and interview on 6/21/24 at 12:25 p.m. with Resident 1, in Resident 1's room, Resident 1 was lying in bed. Resident 1 stated on 6/7/24 CNA 1 asked if he was wet. Resident 1 stated he told CNA 1 he was not wet and did not need his brief changed. Resident 1 stated CNA 1 then grabbed the brief where his genitals were with the palm of her hand and shook his genitals. Resident 1 stated he pushed CNA 1's hand away and with his arm, and told her she could not do that to him. Resident 1 stated, CNA 1 told him she was trained to check his brief and grabbed and shook his genitals a second time. Resident 1 stated he again pushed CNA 1's arm away. Resident 1 then told CNA 1 to get out of the room. Resident 1 stated he told the Licensed Vocational Nurse (LVN) 1 that lady (CNA 1) violated me, and I don't appreciate it . Resident 1 stated LVN 1 said he would talk to CNA 1. Resident 1 stated he felt awful, mad, and violated . During an interview on 6/21/24 at 1:23 p.m. with LVN 1 , LVN 1 stated Resident 1 told him on 6/7/24 he did not want CNA 1 to provide him care because she was rough . LVN 1 stated he did not question what Resident 1 meant by rough and thought it was rough in general. LVN 1 stated he never discussed looking into why. LVN 1 stated he did not chart that CNA 1 was rough with Resident 1. LVN 1 stated on 6/7/24 he told CNA 1 he would be switching her assignments and CNA 1 was agreeable with the plan. LVN 1 stated he did not document he switched CNA 1 from caring for Resident 1 or why. LVN 1 stated about a week later Resident 1 wanted to know if CNA 1 was still working at the facility. LVN 1 stated when he told Resident 1 CNA 1 was still working at the facility Resident 1 asked to speak to Assistant Director of Nursing (ADON) 2 to discuss the incident on 6/7/24. LVN 1 stated he was made aware 555652 Page 5 of 7 555652 06/21/2024 Willow Creek Healthcare Center 650 W. Alluvial Clovis, CA 93611

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of Resident 1's 6/7/24 allegation from ADON 2. LVN 1 stated he could had done more, he could had charted the incident and informed the abuse coordinator who is the Administrator (ADM) on 6/7/24. LVN 1 stated the delay in investigating and reporting could cause emotional distress for Resident 1. During review of CNA 1's facility statement, dated 6/7/24, the statement indicated I asked if he (Resident 1) brief was wet and felt his brief he then got mad and said I'm supposed to ask I then said I was just checking because you are leaving for an appointment and I need to make sure he was upset and I did apologize but he was still really mad. During an interview on 6/21/24 at 4:45 p.m. with Assistant Director of Nursing (ADON) 1, ADON 1 stated she was first made aware of the incident with Resident 1 and CNA 1 on 6/7/24. ADON 1 stated CNA 1 came into the office and let her know Resident 1 was mad because she had checked his brief, and he did not want her to. ADON 1 stated she told CNA 1 to write a statement of events on 6/7/24. ADON 1 stated she took the statement on 6/7/24 and put it away and did not read the written statement after CNA 1 wrote it. ADON 1 stated she did not discuss CNA 1's statement with Resident 1 or LVN 1 on 6/7/24. ADON 1 stated after reading the statement, it was a clear violation what CNA 1 did to Resident 1. ADON 1 stated, she did not follow the facility's policy for reporting abuse. ADON 1 stated Resident 1 could have psychosocial harm, since Resident 1 had been thinking about this incident for a week and asked about it. ADON 1 stated Resident 1 could have been in distress. During a review of Progress Notes (PN) dated 6/15/2024, the PN indicated, Resident [1] requested to this writer if he could speak to y ADON about incident with CNA on a previous date, referred to ADON on duty this am shift .author [LVN], LVN . During a review of Progress Notes (PN) dated 6/15/2024, the PN indicated, Resident reported to ADON feeling violated by a CNA. Resident stated he cannot recall her name but knew she was agency staff. He believes the incident occurred approximately a week and a few days ago .Later in the day, resident informed LVN [LVN name] that he no didn't want to have the CNA involved in his care, he did not tell him why. LVN [LVN name] promptly arranged for different CNA to attend to the resident and no other issues were reported .author [name of ADON 2], ADON . During a concurrent interview and record review on 6/21/24 at 5:03 p.m. with the Director of Staff Development (DSD), the facility In-Service Sign-In sheet (ISSIS) titled Your Legal Duty Reporting Elder and Dependent Adult Abuse , dated 1/11/24 was reviewed. The ISSIS indicated, .all healthcare practitioners and all employees in a long-term care health care facility are mandated reporters .[LVN 1 Name] .print title .LVN .(Signature) . The DSD validated LVN 1 received training for reporting elder abuse. The DSD stated the expectation was to ask and investigate if any resident reports any incident to staff. During an interview on 6/21/24 at 5:24 p.m. with the Director of Nursing (DON), and the Administrator (ADM) the DON stated the expectation of LVN 1 should have been to investigate and report the incident to the DON or the ADM. The DON stated, LVN 1 and ADON 1 did not follow policy for reporting. Both the DON and the ADM verified the written statement from CNA 1 to ADON 1, and stated the statement should have been read and reported right away. The ADM stated, LVN 1 did not follow policy for reporting. The ADM stated ADON 1 did not follow policy for reporting. During a review of ADON's Job Description (JD) , signed and dated 11/12/2023 by ADON 1, the JD indicated, .Oversees clinical operation, including making daily rounds and monitoring resident conditions. Responsible for ensuring resident safety, and ensuring residents are treated with the utmost 555652 Page 6 of 7 555652 06/21/2024 Willow Creek Healthcare Center 650 W. Alluvial Clovis, CA 93611

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few respect .Provides reports and recommendations to the DON concerning the operation of nursing services .Assists with the overall supervision and management of the nursing staff . During a review of LVN's Job Description (JD) , signed and dated 6/9/2022 by LVN 1, the JD indicated, .The primary purpose of your job position is provide direct nursing care to the residents .and to supervise the day-to-day nursing actives performed by nursing assistants .Ensure that all nursing personnel assigned to you comply with written policies and procedures established by this facility .Complete accident/incident reports as necessary .Chart nurses' notes in an informative and descript manner that reflects the care provided to the resident as well as the resident's response to the care. Fill out and complete accident/incident reports. Submit to Director as required. Chart all reports of accidents/incidents involving residents Follow established procedures .Make daily rounds of your unit/shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Report problem areas to the Nurse Supervisor .Ensure that department personnel, residents, and visitors follow the department's established policies and procedures at all times .Review complaints and grievances made or filled by your assigned personnel. Make appropriate reports to the Nurse Supervisor as required or as may be necessary. Follow facility's established procedures .Notify the resident's attending physician when the resident is involved in an accident or incident .Ensure that personnel providing direct care to residents are providing such care in accordance with the resident's care plan and wishes . During a review of the facility Policy & Procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program , dated 4/2021, the P&P indicated, .As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety or welfare of our residents .1g. Allegations of abuse .2.Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident . During review of the facility's Policy and Procedure (P&P) titled, Unusual Occurrence Reporting , dated 12/2007, the P&P indicated .As required by federal or state regulations, our facility reports unusual occurrences or other reportable events with affect the health, safety, or welfare of our residents, employees or visitors .Our facility will report the following events to appropriate agencies .Allegations of abuse, neglect .unusual occurrences shall be reported via telephone to appropriate agencies as required by current law/or regulations .or as required by federal and state regulations . During a review of the California Welfare and Institutions Code Section 15630, . (ii) If the suspected abuse does not result in serious bodily injury, a telephone report shall be made to the local law enforcement agency within 24 hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse, and a written report shall be made to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within 24 hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse . 555652 Page 7 of 7