Health inspection·September 21, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility to ensure a resident (Resident 1) was free from physical abuse when an employee 1 continued to work after an alleged incident of abuse was reported as witness by another staff member. This failure had the potential to negatively affect the resident's psychosocial well-being and the potential to expose all residents in the facility to abuse, increasing risk for resident injury and harm. Findings: On 8/22/2023 the Department of Public Health received a facility reported incident for alleged physical abuse from an employee to Resident 1 on 8/17/23 around 4:15 P.M. The employee 1 continued to work in the facility on 8/17/23. Per the report .[LN] reports to the social work[sic] [name] that same day, However, DON wasn't made aware until the next day, 8/18/23 Friday . On 9/14/23 at 1:26 P.M., an interview was conducted with LN 1. LN 1 stated 8/17/23 we were short staff, Resident 1 was pretty difficult to care for due verbal and physical combativeness and instructed all CNAs to leave Resident 1 in bed for dinner due to verbal and physical combativeness. LN 1 stated the employee 1 approached him and informed him that she would get Resident 1 up. LN 1 stated she would do this if Resident 1 agreed to it. LN 1 stated the employee 1 approached him and told him Resident 1 was screaming and the employee 1 would like LN 1 to speak to Resident 1. LN 1 stated the employee 1 informed him Resident 1 kept hitting the employee and Resident 1's brief was soiled and needed to be changed. LN 1 stated he went to Resident 1 but Resident 1 would not calm down. LN 1 stated he asked another CNA 1 to change Resident 1's soiled brief. LN 1 stated the employee 1 did not listen to him and went on the other side of Resident 1's bed. When Resident 1 was turned facing the employee 1, Resident 1 hit the employee 1. LN 1 stated he saw the employee 1 strike or slap Resident 1's arm. LN 1 stated Resident 1 stated did you see that she pinched me, she pinched me. LN 1 witness did not know what to do during an allegation of abuse and needed to know. LN 1 stated he spoke to the Social Worker (SW). LN 1 stated the SW advised him to report the witnessed incident to the Administrator Assistant (ADMA). LN 1 stated the ADMA would contact human resources, but it was 5 P.M. LN 1 stated it was a joint decision with the ADMA to allow the employee to continue to work the shift because we were short staffed and the employee would work on the other end of the facility. On 9/14/23 at 2:34 P.M. an interview was conducted with the ADMA. The ADMA stated LN 1 wanted to talk to me. The ADMA stated per LN 1 Resident 1 did not want employee 1 to have contact with Resident 1 and employee 1 continued to have contact with Resident 1. The ADMA stated the employee 1 would not Page 1 of 2 555919 555919 09/21/2023 Imperial Manor 100 East 2nd Street Imperial, CA 92251

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few listen to the LN 1 and Resident 1 was throwing punches and one person was not enough to change Resident 1's soiled brief. The ADMA stated when Resident 1 was between a CNA 1 and the employee 1 , LN 1 stated the employee 1 slapped Resident 1's arm. The ADMA stated I honestly do not take care of reporting, the DON does it. The ADMA stated it was past 5 P.M., the LN 1 is a fairly new employee and he is counting on us counting on guidance. The ADMA stated the employee 1 had no reports of past resident abuse. The ADMA stated I did not feel I needed to ensure the residents were safe because it was a random incident. Per the facility policy, Reporting Abuse to Facility Management, revised date December 2006, the facility's policy provided, did not guide staff how to immediately protect Resident 1 and other residents during an allegation of abuse 555919 Page 2 of 2