Health inspection·November 27, 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, Residents Affected - Few 1. The facility did not provide results of an abuse investigation within five days of the incident for Resident 4 and, 2. The alleged perpetrator was not placed on administrative leave until completion of the abuse investigation. This failure had the potential for Resident 4 and other residents to be vulnerable and exposed to the alleged perpetrator. In addition, this failure resulted in the delay of the facility's investigation of abuse allegation, and a delay in determining the occurrence of abuse. Findings: Resident 4 was re-admitted to the facility on [DATE] with diagnoses which included traumatic brain injury (a sudden and violent blow to the head causing damage to the brain) and bipolar disorder (a mental illness causing intense mood swings from one extreme to another) according to the facility's admission Record. An observation and interview were conducted on 11/9/23, at 12:05 P.M. with Resident 4. Resident 4 stated there was an incident involving Licensed Nurse (LN) 2 in August 2023. Resident 4 stated he was in the wheelchair when LN 2, slapped the gel on both of his shoulders, upper back, and the top of his head. Resident 4 further stated he did not say anything to LN 2 because he was shocked. During an interview with the Director of Nursing (DON) on 11/9/23, at 12:20 P.M., the DON stated she was not aware of Resident 4's complaint regarding LN 2. The DON stated the abuse allegation will be reported to California Department of Public Health (CDPH) and will start an investigation of the abuse allegation. Another interview was conducted with the DON on 11/13/23, at 10:15 A.M. The DON stated the facility Administrator conducted the abuse investigation and the investigation has not been completed. LN 2's work schedule titled; November 2023-Licensed Nurse Schedule was reviewed. The schedule indicated T3 (team 3) on 11/10/23, 11/13/23, 11/14/23, 11/15/23 and additional days for the rest of November, which indicated LN 2 have worked while the facility have not completed the abuse investigation. Page 1 of 2 555764 555764 11/27/2023 Palomar Heights Post Acute 1260 E Ohio Avenue Escondido, CA 92027

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with LN 2 on 11/13/23, at 4:54 P.M. LN 2 stated he was scheduled off work on 11/9/23 and returned to work on 11/10/23, 11/12/23 and 11/13/23. LN 2 stated he was not removed from the schedule during the abuse investigation. During a phone interview on 11/27/23, at 1:53 P.M. with the Director of Staff Development (DSD), the DSD stated the abuse investigation was important for verification of the incident and identify any adverse effect on the resident. In addition, the DSD stated employees were removed from their work schedules during an abuse investigation to ensure all other residents were safe. The facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, dated September 2022 was reviewed. The P&P indicated, .Follow-Up Report 1. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report. 2. The follow-up investigation will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. The facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, dated September 2022 was reviewed. The P&P indicated, .Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. 555764 Page 2 of 2