Jerold Phelps Comm Hosp Snf

F-F607.

Findings:

1. A review of Resident 1's Minimum Dats Set (MDS- is a standardized assessment tool that measures health status in nursing home residents) dated 1/26/25, indicated Resident 1:

-had a Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 5 which indicated he had severe cognitive (the mental process involved in knowing, learning, and understanding things) impairment.

- was dependent on staff for toileting hygiene;

- has dementia (a progressive state of decline in mental abilities), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), anxiety (a group of mental health conditions characterized by excessive worry, fear, and avoidance behaviors that significantly interfere with daily life), and depression (a mood disorder characterized by persistent sadness and loss of interest or pleasure in daily activities).

A review of a document titled Report of Suspected Dependent Adult/Elder Abuse faxed to the CDPH on 4/7/25 at 2:03 p.m., from the facility indicated, Date Completed .4/5/2025 .Received report from nursing staff that another staff member unilaterally clipped a [Resident 1's] pubic hair without consulting others. The employee [CNA A] in question was placed on administrative leave pending completion of investigation and follow up action.

During an interview on 4/17/25 at 11:25 a.m., LN B stated she observed Resident 1's pubic area was shaved sloppily (in a careless, untidy, or messy way) on 4/3/25. The LN B confirmed she submitted an incident report regarding her observation of Resident 1's pubic area on 4/3/25 at approximately 6 p.m. to the facility's Human Resources (HR) department. LN B stated she also reported her observation to the Director of Nursing (DON) on 4/4/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 6 555516 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555516 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 During an interview on 4/19/25 at 2 p.m., CNA D stated on 3/29/25, she witnessed CNA A shave Resident 1's pubic hair using Resident 1's personal beard shaver. The CNA D stated she and CNA A both worked the Level of Harm - Minimal harm or 7 a.m. to 7:30 p.m. shift on 3/29/25. CNA D stated she was confused as to why CNA A shaved Resident 1's potential for actual harm pubic hair because Resident 1 had not asked for it and CNA A had not given a reason why she did it. CNA D stated Resident 1 looked agitated while CNA A shaved him but had not asked CNA A to stop. CNA D stated Residents Affected - Few on 4/3/25 at around 5 p.m., she received a phone call from CNA A asking her not to tell anybody she had shaved Resident 1's pubic area. CNA D stated she reported for work on 4/5/25 and informed LN C what CNA A did to Resident 1.

During an interview on 4/20/25 at 8:29 p.m., LN E stated CNA D reported to her CNA A shaved Resident 1's pubic hair on 3/29/25. LN E stated she did not know what to do so she reported this to the oncoming nurse, whose name she could not recall. LN E stated she had worked at other facilities and knew that things like shaving were care planned. LN E stated she had observed Resident 1's pubic area after the incident and noticed it was shaved at the center, but there was pubic hair on the sides, and it was not completely shaven. LN E stated the skin was a little red. LN E stated she asked CNA A why she shaved Resident 1's pubic hair and CNA A replied it was for hygiene, and did not elaborate or explain the reason further. LN E stated CNA A did not ask her if she could shave Resident 1's pubic hair.

On 4/28/25 a review of the facility ' s policy and procedure (P&P) titled Abuse and Neglect Investigation printed on 4/17/25 was conducted. Upon review, the P&P did not indicate the facility was to report allegations of resident abuse within 2 hours of the facility ' s awareness to CDPH.

On 4/28/25 at 10:13 a.m., the CDPH Surveyor requested a copy of the facility ' s P&Ps regarding reporting allegations of abuse to CDPH. The documents were received by CDPH on 4/28/25 at 3:39 p.m.

A review of the facility ' s undated P&P titled Abuse Reporting Requirements showed no documented evidence the facility was to report allegations of resident abuse within 2 hours of the facility ' s awareness to CDPH.

During an interview on 5/1/25, at 1:25 p.m., the DON stated facility staff were expected to report suspected abuse as required. The DON stated CNA D and LN E were mandated reporters of elder abuse and should have reported the allegation as soon as they were aware but no later than 2 hours of becoming aware of the suspicion of abuse on 3/29/25. The DON stated it was her understanding that the reporting requirements on

a suspected abuse allegation was to report it immediately or not later than 2 hours.

In an interview on 5/6/25 at 10:54 a.m., the DON acknowledged neither the P&Ps titled Abuse and Neglect Investigation and Abuse Reporting Requirements indicated the facility was to report allegations of resident abuse within 2 hours of the facility ' s awareness to CDPH. The DON stated she was notified of the 2-hour reporting timeframe by the facility ' s Chief Quality Officer.

2. During an interview on 4/21/25, at 1:07 p.m., the DON stated she did not provide a 5-day follow-up report to CDPH.

On 4/28/25 a review of the facility ' s policy and procedure (P&P) titled Abuse and Neglect Investigation printed on 4/17/25 was conducted. Upon review, the P&P did not indicate the facility was to submit a summary of the investigation to CDPH within 5 business days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 6 555516 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555516 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Jerold Phelps Comm Hosp Snf 733 Cedar Street Garberville, CA 95542

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 In an interview on 5/6/25 at 10:54 a.m., the DON acknowledged the P&Ps titled Abuse and Neglect Investigation and Abuse Reporting Requirements did not indicate the investigation summary was to be Level of Harm - Minimal harm or submitted to CDPH within 5 business days. The DON stated she was notified of the 5-day investigation potential for actual harm summary timeframe from the CDPH Surveyor.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 555516