Health inspection·March 27, 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 interviews and record review, the facility failed to report an incident of alleged abuse involving one of one sampled resident (Resident 1) to the Department in accordance with State law within five working days of the incident. Resident 1 made sexual allegations against one CNA 1 who worked at the facility. This deficient practice had the potential for the underreporting of abuse incidents and a delay in an investigation of abuse allegations, placing the affected Resident 1 and/or other residents at risk for potential further abuse. Findings: During a concurrent interview and record review on 3/27/2024 at 10:08 a.m. with Director of Nursing Services (DON), Resident 1's initial psychiatric evaluation, dated 2/23/2024, was reviewed. The initial psychiatric evaluation indicated that Resident 1 was admitted on [DATE], to the Skilled Nursing Facility section. with a diagnosis including mild cognitive impairment (a mental condition related to a disconnection with reality) amongst other past medical history. During a review of Resident 1's Initial Psychiatric Evaluation (a commonly use assessment used to diagnose mental disorders), dated 2/23/2024, the initial psychiatric evaluation indicated Resident 1's diagnosis of unspecified psychosis (a mental condition related to a disconnection with reality) rule out major neurocognitive disorder (a decreased in mental function and loss of ability to do daily task) with psychosis. During an interview on 3/27/2024 at 10:15 a.m. with Social Worker (SW), SW stated that the staff initially reported the incident on 2/16/2024, and SW went to meet and interview Resident 1. SW stated that Resident 1 changed the story three days (2/19/2024) later, SW stated that Resident 1 reported that CNA 1 did something sexual to his wife. During an interview on 3/27/2024, at 10:34 a.m., with CNA 1, CNA 1 stated that he (CNA 1) had been working at the facility for two years. CNA 1 stated that he (CNA 1) got the assignment, he (CNA 1) opened the door to Resident 1's room and saw her (Resident 1's wife) coming out of the bathroom around 7 a.m. on 2/16/24. CNA 1 stated that he (CNA 1) offered to pick up her (Resident 1's wife) clothes and she (Resident 1's wife) went back to the bed. Resident 1 approached CNA 1 and told CNA 1 to get out of the room. CNA 1 reported what happened to the charge nurse (CN). CN informed CNA 1 to exchange resident with another CNA. CNA 1 stated that he (CNA 1) never went back to the room of Resident 1. Since then, CNA 1 stated that he (CNA 1) had never been to the room, CNA 1 said that he (CNA 1) had been assigned to a different area and different floor and continued to work for the remainder of Page 1 of 4 555846 555846 03/27/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0609 his (CNA 1) shift. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/27/2024, at 10:50 a.m., with the Charge Nurse (CN), CN stated that the assignment was done on 2/16/2024. CN stated that CNA 1 came to CN and told CN Resident 1 does not want me in the room. CN stated that she removed CNA 1 from the scene but CNA 1 continued to take care of other residents for the remainder of the shift. CN stated that she (CN) did not have a conversation with Resident 1. Residents Affected - Few During an interview on 3/27/2024, at 11:02 a.m., with Social Worker (SW) and DON, SW stated not reported because they did their own investigation, the abuse allegation was not reported to CDPH. SW stated we knew he was delusional; however, it was not reported to any licensing agency. SW stated that the importance is to have a third-party review to make sure nothing occurred. So that the third-party gives a chance to investigate. Both the SW and the DON stated that this allegation of abuse should have been reported to the agency (CDPH) and the individual (CNA 1) should have been suspended pending the outcome of the investigation. Both DON and SW verbalized understanding of this process. During a review of the facility's policy and procedure (P&P) titled Abuse and Crime Prevention and Reporting, dated 10/2023, the P&P indicated, when an allegation or reasonable suspicion occurs see Table A for agency reporting process and timeline, as per Title 42. CDPH District Office. Occurrence Alleged or Known incident involves abuse or serious bodily injury. Written or Electronic Report cover letter and SOC 341 or 342 within 2 hours. 555846 Page 2 of 4 555846 03/27/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

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 prevent further potential abuse when CNA 1 was allowed to finish his (CNA 1) shift after an allegation of abuse was made by one of one sampled resident (Resident 1) in accordance with the facility's policy and procedure regarding abuse investigation. Residents Affected - Few This deficient practice had the potential for exposing Resident 1 and other residents to potential abuse by the alleged perpetrator by not removing him (CNA 1) from the facility pending investigation of the abuse allegation and allowing him (CNA 1) to work for the remainder of his (CNA 1) shift. Findings: During a concurrent interview and record review on 3/27/2024 at 10:08 a.m. with the Director of Nursing Services (DON), Resident 1's initial psychiatric evaluation, dated 2/23/2024, was reviewed. The initial psychiatric evaluation indicated that Resident 1 was admitted on [DATE] to the Skilled Nursing Facility section with a diagnosis including mild cognitive impairment (a mental condition related to a disconnection with reality) amongst other past medical history. During a review of Resident 1's Initial Psychiatric Evaluation (a commonly use assessment used to diagnose mental disorders), dated 2/23/2024, the initial psychiatric evaluation indicated Resident 1's diagnosis of unspecified psychosis (a mental condition related to a disconnection with reality) rule out major neurocognitive disorder (a decreased in mental function and loss of ability to do daily task) with psychosis. During an interview on 3/27/2024 at 10:15 a.m. with Social Worker (SW), SW stated that the staff initially reported the incident on 2/16/2024, and SW went to meet and interview Resident 1. During the initial interview on 2/16/24, Resident 1 did not mention any sexual allegation. SW stated that Resident 1 changed the story three days (2/19/2024) later, SW said that Resident 1 reported that CNA 1 did something sexual to his (Resident 1)wife. During an interview on 3/27/2024, at 10:34 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated that he (CNA 1) had been working at the facility for two years. CNA 1 said that he (CNA 1) got the assignment, he (CNA 1) opened the door to Resident 1's room and saw Resident 1's wife coming out the bathroom around 7 a.m. CNA 1 stated that he (CNA 1) offered to pick up her (Resident 1's wife) clothes and she (Resident 1's wife) went back to the bed. Resident 1 approached CNA 1 and told CNA 1 to get out from the room. CNA 1 reported what happened to the charge nurse (CN). CN informed CNA 1 to exchange resident with another CNA. CNA 1 said that he (CNA 1) never went back to the room. Since then, CNA 1 stated that he had never been to the room, CNA 1 said that he had been assigned to a different area and different floor instead of being sent home. During an interview on 3/27/2024, at 10:50 a.m., with the Charge Nurse (CN), CN stated that the assignment was done on 2/16/2024. CN stated that CNA 1 came to CN and told CN Resident 1 does not want me in the room. CN stated that she removed CNA 1 from the scene, but CNA 1 continued to take care of other patients during the remainder of the shift. CN said that she (CN) did not have a conversation with Resident 1. During a review of the facility's policy and procedure (P&P) titled, Abuse and Crime Prevention and Reporting, dated 10/2023, the P&P indicated, if the suspected perpetrator is an identifiable 555846 Page 3 of 4 555846 03/27/2024 Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335

F 0610 Level of Harm - Minimal harm or potential for actual harm employee, remove the employee from providing care. The abuse prevention coordinator or designee will consider suspension of the employees in collaboration with HR. In this case CNA 1 continued working for the remainder of his shift on 2/16/2024 and returned to the care of the same resident on 2/18/2024 as per CNA Assignment Worksheet 7-3 shift as verified by the DON. Residents Affected - Few 555846 Page 4 of 4