Health inspection·June 20, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report the initial report of the physical abuse allegation was made within two (2) hours of the incident for one of five sampled residents (Resident 1). This deficient practice had the potential to result in delay of necessary actions to oversee the protection of the residents in the facility by the State Survey Agency (SSA). Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 2/8/2021 and re-admitted Resident 1 on 9/28/2023 with diagnoses that included left hand tenosynovitis (inflammation of the protective sleeve of tissue surrounding the tendons [tough cord of strong, flexible tissue that attaches muscle to the bone]), cardiomyopathy (disease of the heart muscle that makes it harder to pump blood to the rest of the body), and atrial fibrillation (irregular heartbeat). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 5/16/2024 indicated Resident 1 was able to be understood by others and was able to understand others. The MDS further indicated that Resident 1 had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). A review of Resident 1's Change in Condition (COC- when there is a sudden change in a resident's health) Evaluation Form dated 6/10/2024, timed at 11:32 a.m. indicated that on 6/8/2024 (unspecified time) Resident 1 reported to the Social Service Director (SSD) and Director of Nursing (DON) that Resident 2 run over her (Resident 2) wheelchair at him (Resident 1) twice. A review of Resident 1's care plan (untitled) dated 6/10/2024, indicated that Resident 1 was at risk for decline in psychosocial well-being related to being run over by a wheelchair of another Resident (Resident 2). The goal was for Resident 1 to not have indications of psychosocial wellbeing problem. A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 3/31/2023 with diagnoses that included dementia (impaired ability to remember, think, or make decisions that Page 1 of 2 555822 555822 06/20/2024 Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

F 0609 interferes with a resident's daily life and activities), and hypertension (high blood pressure). Level of Harm - Minimal harm or potential for actual harm A review of Resident 2's MDS dated [DATE] indicated Resident 2 had severely impaired cognition and required moderate assistance from staff with upper body dressing, and personal hygiene. The MDS indicated Resident 2 required maximum assistance from staff with toileting hygiene, shower, and lower body dressing. Residents Affected - Few A review of Resident 2's COC Evaluation Form dated 6/10/2024, timed at 11:44 a.m., indicated that Resident 1 accused Resident 2 of running her (Resident 2) wheelchair against him (Resident 1). A review of Resident 2's care plan (untitled) dated 6/10/2024, indicated that Resident 2 was at risk for decline in psychosocial well-being related to allegation of physical abuse. The goal was for Resident 2 to not have indications of psychosocial wellbeing problem. During an interview on 6/20/2024 at 11:00 a.m. with Resident 1, Resident 1 stated that on 6/8/2024 at around 7:03 p.m., Resident 1 was in the hallways when Resident 2 started to wheel towards him and run her (Resident 2) wheelchair against him (Resident 1). Resident 1 further stated he then moved away and reported the incident to Licensed Vocational Nurse 1 (LVN 1). During an interview on 6/20/2024 at 1:40 p.m. with LVN 1, LVN 1 stated that on 6/8/2024 (unable to recall specific time) Resident 1 informed her that Resident 2 attempted to run him over with her wheelchair. When asked if LVN 1 reported the incident to the Administrator (ADM) or DON, LVN 1 stated she did not. LVN 1 stated on 6/8/2024 (unable to recall specific time) LVN 1 was in the middle of the hallway. LVN 1 stated she did not witness any incident between Resident 1 and Resident 2. LVN 1 further stated Resident 1 stated it was an attempt only that is why she did not report to the ADM or DON immediately. During an interview on 6/20/2024 at 4:20 p.m. with the SSD, the SSD stated any abuse allegations should have been reported within two hours per the facility's abuse policy. The SSD further stated even if it was an attempt and not an actual abuse, LVN 1 should have reported immediately to ensure Resident 1's safety. During an interview on 6/20/2024 at 4:45 p.m. with the ADM, the ADM stated the allegation was not reported to the SSA until 6/10/2024. The ADM stated that the abuse allegation should have been reported within two hours, whether it was an attempt or actual incident of abuse to ensure resident's safety and protection. A review of the facility's policy and procedure (P&P) titled, Abuse (willful infliction of injury with resulting physical harm, pain or mental anguish), Neglect (failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress), Exploitation (the act of using someone or something unfairly for own advantage) or Misappropriation (wrongful use) - Reporting and Investigating last revised on 9/2022, last reviewed on 7/19/2023, indicated All reports of resident abuse (including injuries of unknown source) . are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by the facility management. Findings of all investigations are documented and reported. 555822 Page 2 of 2