Health inspection·November 8, 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 interview and record review, the facility failed to protect other residents from potential abuse while the investigation was in progress, for two of seven residents reviewed (Resident 1 and Resident 2), when: Residents Affected - Few 1. The Certified Occupational Therapy Assistant (COTA); and 2. Certified Nurse Assistant (CNA) were allowed to continue to work pending the results of the alleged abuse. These failures had the potential to place the other residents in the facility at risk for abuse. Findings: 1. During a review of Resident 1's Progress Notes (PN), dated October 4, 2023 (late entry for October 3, 2023), the PN indicated Resident 1 stated the COTA was rough with him during a shower on September 27, 2023. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure) and generalized muscle weakness. During an interview on October 16, 2023, at 10:25 a.m., with the COTA, she stated the Physical Therapy Director (PTD) called her on October 3, 2023, at 5:36 p.m. The COTA stated the PTD told her Resident 1 claimed physical abuse against her. The COTA stated she was taken off Resident 1's schedule and was told to come to work. The COTA stated she was not placed on leave and worked on October 4, 2023. During an interview on October 16, 2023, at 11:18 a.m., with the Physical Therapy Assistant (PTA), she stated to her knowledge, the COTA was allowed to work while the investigation on the abuse allegation was on-going. The PTA stated she thought the COTA should have been taken off the schedule pending the investigation. The PTA stated she was not sure why the COTA was allowed to work while the investigation was still pending. The PTA stated the COTA was removed from Resident 1's scheduled therapies. During an interview on October 16, 2023, at 11:30 a.m., with Resident 1, in his room, Resident 1 stated the COTA was abusive to him. Resident 1 stated the COTA came to his room intentionally slamming things around. Resident 1 stated the COTA offered him to shower. Resident 1 stated the COTA was rough handling the shower chair and they had some verbal exchanges in the shower stall. Resident 1 Page 1 of 3 555775 555775 11/08/2023 Bayshire Rancho Mirage 72-201 Country Club Drive Rancho Mirage, CA 92270

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated when the COTA brought him back in his room and he went to bed, the COTA slammed the wheelchair to the wall. During an interview on October 16, 2023, at 11:49 a.m., with the Physical Therapy Director (PTD), she stated the COTA was not taken off the schedule and was allowed to work. The PTD stated she asked the administrator (ADM) about taking the COTA off the schedule and was told by the ADM not to remove the COTA from the schedule. The PTD stated the COTA was not assigned to Resident 1 after the allegation. During a review of the Labor Log (LL), dated November 3, 2023, the LL indicated, the COTA worked on the following days: - October 4, 2023; - October 5, 2023; and - October 6, 2023. 2. During an interview on October 16, 2023, at 4:11 p.m., with the CNA, the CNA stated she was told by the Social Service Assistant (SSA) and the ADM not to go to Resident 2's room. The CNA stated she was told Resident 2 accused her of verbal abuse. The CNA stated she was not taken off the schedule. The CNA stated she did not continue to care for Resident 2. During an interview on October 16, 2023, at 4:27 p.m., with the Social Service Director, she stated the CNA was immediately removed from the assignment and Resident 2's care was changed. The SSD stated the CNA stayed and was allowed to work. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included hypertension and atrial fibrillation (irregular, fast heart rate). Resident 2 was discharged to the hospital for an unrelated issue on October 4, 2023, and was not available for interview. During a review of the Labor Allocation (LA), for the pay period of October 1, 2023 to October 15, 2023, the LA indicated, the CNA worked on the following days: - October 4, 2023; - October 5, 2023; - October 6, 2023; - October 7, 2023; - October 8, 2023; and - October 9, 2023. 555775 Page 2 of 3 555775 11/08/2023 Bayshire Rancho Mirage 72-201 Country Club Drive Rancho Mirage, CA 92270

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on October 16, 2023, at 1:45 p.m., with the Assistant Director of Nursing (ADON) she stated from her understanding, if a staff was the alleged abuser, the staff should be removed from the work schedule pending the results of the investigation to protect the alleged victim and other residents from potential abuse. During an interview on October 16, 2023, at 5:07 p.m., with the ADM, she stated neither staff accused of allegedly abusing the resident were removed from the schedule. The ADM was asked how the facility protected the other residents from potential abuse if the staff was allowed to work while the investigation was pending. The ADM stated the facility policy and procedure for abuse did not indicate the staff should be suspended or relieved from work while the investigation was in progress. During a review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, revised January 2023, the P&P indicated, .Policy Interpretation and Implementation .The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented by removing the accused employee from any continued services/treatments . 555775 Page 3 of 3