Health inspection·August 27, 2024

F610 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. 72523 (a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 7/16/2024, the California Department of Public Health (CDPH) conducted a standard annual recertification survey and identified that the facility failed to: 1. Immediately investigate a resident-to-resident altercation between Residents 18 and 61. 2. Ensure staff followed the facility’s policy and procedure (P&P), titled, "Abuse, Neglect and Exploitation," that indicated “when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation was immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted.” As a result of these deficient practices, the facility was not able to identify other potential residents who may have had resident-to-resident altercations and had a potential for further resident-to-resident altercations to occur between Resident 18 and 61. a. A review of Resident 18's Admission Record indicated Resident 18, a 63 year-old male, was admitted to the facility on 10/13/2021with diagnoses including osteoarthritis (when the cartilage that cushions the ends of bones in the joints gradually deteriorates), acute kidney failure (the rapid loss of the kidney's ability to remove waste and help balance fluids in the body), and gastro-esophageal reflux disease ([GERD] stomach acid repeatedly flows back up into the tube connecting the mouth and stomach). A review of Resident 18's History and Physical (H&P) dated 2/10/2024, indicated Resident 18 could make his needs known but could not make medical decisions. A review of Resident 18's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 7/15/2024, indicated Resident 18 had severe cognitive (ability to make decisions of daily living) impairment and was sometimes understood and was able to sometimes understand others. The MDS indicated Resident 18 had no functional limitations in movement. b. A review of Resident 61's Admission Record indicated Resident 61, a 77 year-old male, was admitted to the facility on 3/22/2023 with diagnoses including gastro-esophageal reflux disease, hypertension (high blood pressure), and bipolar disorder (a serious mental illness which causes unusual shifts in mood, ranging from extreme highs to lows). A review of Resident 61's History and Physical (H&P) dated 11/4/2023, indicated Resident 61 had fluctuating capacity to understand and make medical decisions. A review of Resident 61's MDS dated 6/27/2024 indicated Resident 61's cognition was moderately impaired and had the ability to understand and be understood by others. The MDS indicated Resident 61 had functional impairment on one upper extremity and required setup or clean-up assistance from staff for eating. During an observation on 7/16/2024 at 10:18 a.m., in Resident 18’s and 61's room, Resident 61 was observed crawling on the floor towards Resident 18's bed. Resident 18 was observed sitting on his bed with his back towards Resident 61. During an observation on 7/16/2024 at 10:22 a.m., in Resident 18’s and 61's room, Resident 61 was observed grabbing the footrests of a wheelchair that was to the left of Resident 18's bed. Resident 18 was observed getting out of bed, walking over to Resident 61, grabbing the handles of the wheelchair, then shaking the wheelchair and yelling at Resident 61 stating "Get out of here, get your hands off the wheelchair, what are you doing!" Resident 18 was observed attempting to hit Resident 61 with the wheelchair. During a continued observation on 7/16/2024 at 10:23 a.m., in Resident 18’s and 61's room, Certified Nurse Assistant (CNA 3) was observed walking into Resident 18’s and 61's room and stopping the altercation between both residents. During an interview on 7/16/2024 at 1:18 p.m., CNA 3 stated she notified Licensed Vocational Nurse (LVN 3) of altercation between Resident 18 and 61. During an interview on 7/17/2024 at 9:47 a.m., the Administrator (ADM)stated he was not notified of the altercation between Resident 18 and 61 that occurred on 7/16/2024. During a follow-up interview on 7/19/2024 at 5:04 p.m., the ADM, stated LVN 1 said she did not consider what occurred between Resident 18 and 61 on 7/16/2024 as an altercation because Resident 18's method of communication was yelling. The ADM stated LVN 1 should have immediately reported what occurred between Resident 18 and Resident 61 to him so he could have started an investigation immediately. A review of the facility's undated policy and procedure (P&P) titled, "Abuse, Neglect and Exploitation," the P&P indicated when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. The facility failed to: 1. Immediately investigate the resident-to-resident altercation between Residents 18 and 61. 2. Ensure staff followed the facility’s policy and procedure (P&P), titled, "Abuse, Neglect and Exploitation," that indicated “when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted.” As a result of these deficient practices, the facility was not able to identify other potential residents who may have had resident-to-resident altercations and had a potential for further resident-to-resident altercations to occur between Resident 18 and 61. These violations had a direct or immediate relationship to the health, safety, or security of Resident 18 and 61.