Health inspection·June 6, 2023

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to protect one of two sampled residents (Resident 1) from abuse when Certified Nurse's Assistant (CNA) 1 roughly threw Resident 1 into bed, put a pillow on her face, and hit her on her head. This incident was heard by Resident 2. This resulted in Resident 1 to have an injury to the head with bruising and pain; and Resident 1 and Resident 2 to experience emotional distress. Findings: Review of a policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised 4/4/21, indicated that the facility would protect residents from being abused by facility staff, ensure adequate oversight, and implement policies and procedures that would identify and prevent abuse. Additionally, the policy indicated that the facility would maintain a culture of compassion and caring for all residents, particularly those with cognition and mentation deficits (a decline in mental ability). A review of Resident 1's admission record indicated she was admitted to the facility on [DATE] with diagnosis of kidney infection, left hip pain and recent falling. Review of two documented Minimum Data Sets (MDS, a Resident assessment tool) dated 1/20/23 and 4/22/23, indicated that Resident 1 scored a nine on the Brief Interview for Mental Status (BIMS), which indicated she had moderately impaired mentation (a slight decline in mental ability), had no disordered thinking and was able to recall words. During an interview on 5/5/23 at 10 AM, Resident 1 stated, CNA 1 slapped me, roughly threw me into my bed, put a pillow over my face and hit me here on my head (Resident 1 was pointing to her right forehead). Resident 1 stated, I was afraid and crying. Resident 1 confirmed that her roommate (Resident 2) called for help and that she had reported what happened to a nurse. Resident 1 stated, I feel safe now because the Administrator told me CNA 1 will not be coming back. Review of a record title MDS dated [DATE], indicated that Resident 2 had a BIMS score of 15 and had no difficulty with mentation or word recall. During an interview on 5/5/23 at 11:15 AM, Resident 2 (Resident 1's roommate) stated, CNA 1 came into the room, she was being rough with my roommate, I heard CNA 1 slap her, I could hear everything. Resident 2 explained that she was in her bed and that Resident 1 was in her wheelchair on the other side of the curtain. Resident 2 explained she could hear thrashing and Resident 1 hollering for CNA Page 1 of 7 555776 555776 06/06/2023 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

F 0600 Level of Harm - Actual harm Residents Affected - Few 1 to stop hurting her. Resident 2 stated, I heard my roommate crying and calling for help, I heard a slap, and my roommate saying she could not breath. Resident 2 stated, I felt so disgusted that I could not help, and I was afraid. Resident 2 confirmed that she had called for another nurse to come into the room and that Resident 1 had told them what happened. Resident 2 stated, I was afraid for her, she was crying and so upset. Resident 2 stated, The Administrator told me that her (Resident 1's) bed controller had slipped from the CNA's hand accidentally and that is all that I heard; he said I should not talk about it but what she (CNA 1) did was not right. Review of a document titled Final Report: Allegations of Abuse written by the Administrator, dated 4/25/23, indicated that during an interview on 4/21/23, Resident 1 stated that CNA 1 had hit her in the face, and that during another interview on 4/24/23 Resident 1 had stated that CNA 1 had hit her on the face and tried to smother her with a pillow. The report also indicated that on 4/22/23 a mark was visible on Resident 1's right head at the hair line and that Resident 2 had stated during the investigation interview that CNA 1 was grumpy when she entered the room, cursed while providing care, that she had heard slapping and hitting sounds, and had that she heard Resident 1 yell out twice, once indicating that she could not breath. Lastly, the report indicated that CNA 1 was allowed to return to work. During an interview on 5/5/23 at 10:18 AM, Licensed Vocational Nurse (LVN 1) stated that Resident 1 was not one to complain about others, was usually calm, nice, cooperative, and was not easily influenced. LVN 1 stated, I am very familiar with Resident 1, her memory is good. LVN 1 stated, yes, I think you can believe a confused resident. During an interview on 5/5/23 at 11 AM, the Administrator confirmed that CNA 1 was new to the facility and that he had planned on terminating her after the abuse was reported to him but that after his investigation he did not. The Administrator stated during his investigation, CNA 1 had stated she did not hit Resident 1, that the bed controller had slipped from her hand and may have hit Resident 1. CNA 1 explained she had not seen or heard it hit, and that Resident 1 said to her You hit me but she saw the resident was fine, had apologized and then left the room. Administrator stated, While conducting my investigation, Resident 1 changed her story from being hit to being smothered with a pillow, I believe her roommate (Resident 2) influenced her recollection of the event. Administrator explained that Resident 1's roommate likes to get into everyone's business and is a Confabulator. The Administrator stated, my investigation determined that CNA 1 did not intentionally hit Resident 1 and she was allowed to return to work. When asked, the Administrator stated, You can believe a confused resident, but again explained that his investigation determined that Resident 1's recollection of how she got the bruise on her head was not accurate. During an interview on 5/9/23 at 11:08 AM Resident 1 was observed with a pale-yellow green bruise with a small thin white scab to the center just below and extending to the hairline on the right forehead that was approximately 2.5 x 3 centimeters in size. When asked how she got the bruise Resident 1 stated, A CNA hit me. When asked to provide more details Resident 1 explained that CNA 1 had thrown her into bed, then hit her and held a pillow over her face. When asked what hit her, Resident 1 stated She hit me with her hand, and the television controller. When asked if she had told anyone, Resident 1 stated that her roommate (Resident 2) was there and that she called for help and then two staff members came into the room. Resident 1 stated that she was unable to call for help during the attack and that she was upset, crying, and scared. Resident 1 indicated she was in her wheelchair on the left side of the bed (near Resident 2 ' s bed) just before it happened. Resident 1 stated that she did not know why CNA 1 did this, and that she had asked the CNA why she was so mean. Resident 1 indicated that CNA 1 had not been in her room since and stated, I am afraid of her. Resident 1's bed 555776 Page 2 of 7 555776 06/06/2023 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

F 0600 Level of Harm - Actual harm Residents Affected - Few control remote was observed hanging from the bed rail, when asked if the bed control had hit her, Resident 1 stated, No, the television (TV) control (Resident 1 held up the TV controller in her hand). Resident 1 was observed using the TV control without difficulty and identified the call assist button, demonstrating she knows the difference between the items. Resident 1 stated, I feel safe now, I know they will not let her come back. During an interview on 5/9/23 at 1:15 PM, LVN 2 stated, CNA 2 came and got me, she was saying that the Resident 1 was crying, and that a CNA had abused her; I went into the room and saw both residents upset. Resident 1 was crying when she stated, CNA 1 had hit her, put a pillow over her face and choked her. LVN 2 explained Resident 1 was very sweet and never had conflict with anyone. LVN 2 stated he informed the Administrator and CNA 1 was sent home. During an interview on 5/9/23 at 1:38 PM, CNA 2 stated, Resident 1 told me CNA 1 had hit her, and I saw there was a red bump forming on the right side of Resident 1's head. CNA 2 explained that Resident 1 was crying and so upset that she could hardly get her words out, and that Resident 2 had stated to her I heard Resident 1 getting hit and yelling, stop you ' re hurting me, and I can ' t breathe. CNA 2 explained that the next day Resident 1 had stated to her, my head really hurts and then again stated, CNA threw me on the bed, hit me and held a pillow over my face. CNA 2 stated, The small bump on her head had formed into a larger raised bruise. CNA 2 confirmed she was familiar with Resident 1, and stated, she never cries out like that, I had never seen her so upset. CNA 2 stated, I had only worked with CNA 1 a few times before, she was different that day, she was angry and confrontational when she arrived. During an interview on 5/9/23 at 1:50 PM, CNA 1 stated, I was helping The lady (Resident 1) back into bed, I got her laid back down, I lost my grip, the bed controller slipped out of my hand and struck the lady on the head, I changed her, She was ok. CNA 1 confirmed that she had not told anyone about what had happened and stated, She (Resident 1) had a tiny bruise forming, and I did not think it was a big deal, I had already said I was sorry, and the lady was fine when I left the room. CNA 1 denied being upset about anything prior to or during her shift, having any conflicts and stated, other than calling off for the morning my shift, I had started as usual that day. During an interview on 5/12/23 at 10:50 AM, CNA 3 stated, she was near the nurses station just before Resident 1 reported the abuse. CNA 3 explained that CNA 1 approached her looking for CNA 2. CNA 3 told her that CNA 2 was at lunch, then CNA 1 turned abruptly and walked off towards the break room with a fast pace like she was Angry. Review of Nursing Note written on 4/21/23 at 5:10 PM, Licensed Nurse (LN) 3 indicated that Resident 1 complained of a headache that required pain medication. LN 3 indicated that Resident 1 was crying, had bruising to her right head, and had reported that CNA 1 threw her on to the bed, slapped her on the head, and put a pillow over her face that smothered her. Review of a Medication Administration Record, indicated that LN 3 gave Resident 1 Acetaminophen (pain medication) on 4/21/23 at 7:18 PM. Review of a nursing note dated 4/23/23 at 5:45 AM, by Registered Nurse 1 indicated that Resident 1 had a bruise to the right side of her head. Review of an Interdisciplinary team (IDT) note dated 4/24/23 at 9:30 AM, Director of Nursing (DON) indicated that Resident 2 stated she heard a slapping sound, that Resident 1 stated a CNA 1 had 555776 Page 3 of 7 555776 06/06/2023 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

F 0600 slapped her, and that the facility assured Resident 1 that CNA 1 would not be coming back. Level of Harm - Actual harm Residents Affected - Few 555776 Page 4 of 7 555776 06/06/2023 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

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 observation, interview, and record review the facility failed to complete and thorough investigation of an allegation of abuse after Resident 1 and Resident 2 reported that a Certified Nurse Assistant (CNA 1) had abused Resident 1 physically and verbally. This resulted in an injury to Resident 1 and placed all residents at risk for potential abuse due to CNA 1 being allowed to return to work. Residents Affected - Few Findings: Review a of policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised on 4/4/202, indicated that the facility would protect residents from being abused by facility staff, ensure adequate oversight, and implement policies and procedures that would identify and prevent abuse. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Investigate and report any allegations within timeframe's required by federal requirements. Resident 1 was admitted to the facility on [DATE] with diagnosis of kidney infection, left hip pain and recent falling. Review of two documented Minimum Data Sets (MDS, a Resident assessment tool) dated 1/20/2023 and 4/22/23 indicated that Resident 1 scored a 9 on the Brief Interview for Mental Status (BIMS), had moderately impaired mentation (a slight decline in mental ability), but had no disorder thinking and was able to recall words. During interview an on 5/5/2023 at 10:00 AM, Resident 1 stated, CNA 1 slapped me, roughly threw me into my bed, put a pillow over my face and hit me here on my head (Resident 1 was pointing to her right forehead). Resident 1 stated, I was afraid and crying. Resident 1 confirmed that her roommate (Resident 2) called for help and that she had reported what happened to a nurse. Resident 1 stated, I feel safe now because the Administrator told me CNA 1 will not be coming back. Review of Nursing Note written on 4/21/23 at 5:10 PM by Licensed Nurse (LN) 3 indicated that Resident 1 complained of a headache that required pain medication; that Resident 1 was crying, had bruising to her right head, and reported that CNA 1 threw her on to the bed, slapped her on the head, and put a pillow over her face that smothered her. During an interview on 5/5/2023 at 10:18 AM, Licensed Vocational Nurse (LVN 1) confirmed that Resident 1 was not one to complain about others, usually calm, nice, cooperative, and was not easily influenced. LVN 1 stated, I am very familiar with Resident 1, her memory is good. LVN 1 stated, yes, I think you can believe a confused resident. During an interview on 5/5/2023 at 11 AM, the Administrator confirmed that CNA 1 was new to the facility and that he had interviewed both Resident 1 and CNA 1 while investigating the reported abuse and that he had anticipated terminating CNA 1. The Administrator stated during his investigation CNA 1 had stated she did not hit Resident 1, that the bed controller had slipped from her hand and may have hit Resident 1. CNA 1 further explained that she had not seen or heard it hit her forehead. CNA explained to Adminstrator that Resident 1 said to her you hit me but she saw the resident was fine, apologized and then left the room. Administrator stated, while conducting my investigation Resident 1 changed her story from being hit to being smothered with a pillow, I believe her roommate 555776 Page 5 of 7 555776 06/06/2023 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

F 0610 Level of Harm - Minimal harm or potential for actual harm (Resident 2) influenced her recollection of the event. Administrator explained that Resident 1's roommate likes to get into everyone's business and is a confabulator. The Administrator stated, my investigation determined that CNA 1 did not intentionally hit Resident 1, she was allowed to return to work. When asked, the Administrator stated, you can believe a confused resident, but his investigation determined that Resident 1's recollection of how she got the bruise on her head was not accurate. Residents Affected - Few Review of a record title MDS dated [DATE] indicated that Resident 2 had a BIMS score of 15 and had no difficulty with mentation or word recall. During an interview on 5/5/2023 at 11:15 AM, Resident 2 (Resident 1's roommate) stated, CNA 1 came into the room, she was being rough with my roommate, I heard CNA 1 slap her, I could hear everything. Resident 2 explained that she was in her bed and that Resident 1 was in her wheelchair on the other side of the curtain. Resident 2 explained she could hear thrashing and Resident 1 hollering for CNA 1 to stop hurting her. Resident 2 stated, I heard my roommate crying and calling for help, I heard a slap, and my roommate saying she could not breath. Resident 2 stated, the Administrator told me that her (Resident 1's) bed controller had slipped from the CNAs hand accidentally and that is all I heard; he said I should not talk about it, but I know what she (CNA 1) did was not right. During an interview on 5/9/23 at 11:08 AM, Resident 1 was observed with a pale-yellow green bruise with a small thin white scab to the center at the hairline on the right forehead that would measure approximately 2.5 x 3 centimeters. When asked how she got the bruise Resident 1 stated, a CNA hit me. When asked to provide more details Resident 1 explained that CNA 1 had threw her into bed, hit her and held a pillow over her face. When asked how the bruise occurred, Resident 1 stated she hit me with her hand, and she threw the television controller at me, before she walked out. When asked if she had told anyone, Resident 1 stated that her roommate (Resident 2) was there and that she called for help and then two staff members came into the room. Resident 1 ' s bed control remote was observed hanging from the right-side bed rail, when asked if the bed control had hit her, Resident 1 stated, No, but she (CNA 1) threw the television (TV) controller at me (Resident 1 held up the TV controller in her hand). Resident 1 identified the call assist button when prompted demonstrating she knows the difference between the items. Resident 1 stated, I feel safe now, I know they will not let her come back. During an interview on 5/9/23 at 1:38 PM CNA 2 stated, Resident 1 told me CNA 1 had hit her, and I saw there was a red bump forming on the right side of Resident 1 ' s head. During an interview on 5/9/23 at 1:50 PM CNA 1 stated, I was helping the lady (Resident 1) back into bed, the bed controller slipped out of my hand and struck the lady on the head, she was ok. CNA 1 confirmed that she had not told anyone about what had happened and stated, she (Resident 1) had a tiny bruise, I did not think it was a big deal, I had already said I was sorry, and the lady was fine when I left the room. CNA 1 denied being upset about anything that prior to or during her shift, and stated, other than calling off for the morning my shift had started as usual. During an interview on 5/12/23 at 10:50 AM, CNA 3 stated, she was near the nurses station just before Resident 1 reported the abuse. CNA 3 explained that CNA 1 approached her looking for CNA 2. CNA 3 told her that CNA 2 was at lunch, then CNA 1 turned abruptly and walked off towards the break room with a fast pace like she was angry. Review of a document titled Final Report: Allegations of Abuse written by the Administrator, indicated Resident 1 was interviewed on 4/21/23, and stated that CNA 1 had hit her in the face, and on 555776 Page 6 of 7 555776 06/06/2023 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4/24/23 Resident 1 stated that CNA 1 had hit her on the face and tried to smother her with a pillow. The report indicated on 4/22/23, a mark was visible on Resident 1 ' s right forehead at the hair line and on 4/24/23, a small bruise was observed only to the left hairline. The report also indicated that Resident 2 had stated that CNA 1 seemed grumpy when she entered the room, had cursed while providing care, that she had heard slapping and hitting sounds. There were no interviews in the report documented that any of the direct care staff scheduled that day were interviewed to determine CNA 1's disposition (mood). Resident 2 explained that she had heard Resident 1 yell out twice, and once stating that she could not breath. In conclusion, the Administrator had determined that Resident 1's allegation that CNA 1 abused her was not substantiated due to Resident 1's story had changed, and that Resident 1's statement had been directly influenced by Resident 2. Administrator concluded that Resident 1 had only a small bruise that occurred accidentally to Resident 1's left head and that CNA 1 was allowed to return to work. During an interview on 5/9/23 at 11:35 AM the Administrator stated, the facility investigation concluded that the bruise to Resident 1's head resulted when the bed control recoiled out of CNA 1's hand striking Resident 1 on the head and that CNA 1 had been allowed to return to work. The Administrator stated, Resident 1 kept changing her story, CNA 1 said it was an accident, and I believe Resident 2 influenced Resident 1's statements. 555776 Page 7 of 7