Health inspection·October 18, 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 complete and submit an investigation summary regarding an alleged abuse incident that occurred between two of three sampled residents (Residents 2 and 3). This failure had the potential to compromise the facility's ability to determine the circumstances surrounding the incident and could have compromised the residents' safety. Residents Affected - Few Findings: Review of Resident 2's medical record indicated she was admitted on [DATE] and had the diagnoses of Depression (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Type 2 diabetes (A chronic condition that affects the way the body processes blood sugar) and muscle weakness. Review of Resident 3's medical record indicated she was admitted on [DATE] and had the diagnoses of major depressive disorder, seizures (uncontrolled jerking movements of the arms and legs caused by abnormal brain activity), chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe) and muscle weakness. Review of Resident 2's Change in Condition Evaluation, dated 5/6/23, indicated an incident had occurred between her and Resident 3. The documentation indicated, [Resident 2] was calling a nurse then [Resident 3] came out of her room and told [Resident 2] to go to her room and also told her to ' shut the hell up. ' [Resident 3] was behind [Resident 2's] wheelchair and was shoving her back to her room. Then [Resident 2] started to cry. All these were witnessed by another resident's family. Review of Resident 2's Minimum Data Set, (MDS, an assessment tool), dated 2/24/23, indicated she had brief interview for mental status (BIMS, cognition level) score of three, which indicated severe cognitive impairment. Review of Resident 3's nurse ' s note, dated 5/6/23, indicated a certified nursing assistant (CNA) reported to the nurse that Resident 3 had an altercation with Resident 2 in the hallway, made Resident 2 cry, and called her a bitch. This incident was witnessed by another resident's family member. During an interview on 7/25/23 at 11:30 a.m., with the family member who witnessed the incident on 5/6/23, the family member stated that on 5/6/23 around seven to eight p.m., Resident 2 was calling the nurse continuously. Resident 3 came out of her room, shouted at Resident 2, told her to shut the hell up, called her a bitch, and said, Go to your room, no one wants to hear it. The family member stated Resident 2 was crying. Page 1 of 2 555792 555792 10/18/2023 Sunnyvale Post-Acute Center 1291 S Bernardo Avenue Sunnyvale, CA 94087

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 7/25/23 at 10:30 a.m., with the director of nursing (DON), he could not provide the 5-day investigation summary regarding the incident that occurred on 5/6/23. When asked why there was no investigation summary, the DON stated he would ask the previous administrator (ADM) because he could not provide the document. During an interview with the ADM on 8/9/23 at 10:08 a.m., he stated the above incident between Residents 2 and 3 was reported to the police, the Ombudsman (resident advocate), and the California Department of Public Health (CDPH, state survey agency). He confirmed that when an alleged abuse incident occurs, the facility must submit an investigation summary to the CDPH within five days. The ADM provide a 5-day investigation summary for the incident that occurred between Residents 2 and 3 on 5/6/23, along with a fax confirmation page. The fax confirmation page indicated the investigation summary was faxed on 5/10/23 at 12:23 p.m. However, the investigation summary was faxed to the CDPH telephone number, not the fax machine number. During an observation on 8/18/23 at 11:00 a.m., CDPH staff did a test fax to the number indicated on the above-mentioned fax confirmation page. The fax did not go through, and a report was printed out. The printed report indicated Result Busy, meaning the fax was not successful. Review of the facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigating, Policy and Procedure, revised 9/2022, indicated all reports of resident abuse and incidents of suspected or alleged abuse are reported to local, state and federal agencies and thoroughly investigated. The policy further indicated, Within 5 working days of the incident, the administrator will provide a follow up investigation report. The follow up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. The follow-up investigation will provide as much information as possible at the time of submission of the report. The resident and or representative are notified of the outcome immediately upon conclusion of the of the investigation. 555792 Page 2 of 2