Greenfield Care Center Of South Gate

F-F609.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 4 056458

F-F610.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 4 056458 Department of Health & Human Services Printed: 09/10/2025 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 056458 B. Wing 02/03/2025

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

Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

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 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47858 potential for actual harm Based on interview, and record review, the facility failed to follow their Policy and Procedure (P&P), titled, Residents Affected - Few Abuse and Neglect Prevention, when the following occurred for one out of three sampled residents (Resident 1) by failing to:

1.Ensure a prompt investigation was initiated when Certified Nursing Assistant (CNA) 2 had knowledge Resident 1 alleged that CNA 1 was rough during care.

2. Ensure the facility implemented prompt measures to protect Resident 1 when CNA 2 had knowledge that Resident 1 alleged that CNA 1 was rough during care.

These deficient practices resulted in the delay of a timely investigation and allowed for further potential abuse by CNA 1 to Resident 1 and other residents within the facility while CNA 1 continued to work the remainder of his scheduled shift.

Findings:

During a review of Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE REDACTED]. Resident 1 ' s diagnoses included muscle weakness, spinal stenosis (abnormal narrowing of the spinal canal), and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).

During a review of Resident 1 ' s Minimum Data Set ([MDS], a resident assessment tool), dated 1/17/2025,

the MDS indicated Resident 1 ' s cognitive skills (ability to think and reason) for daily decision making was severely impaired. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and, or touching as resident completes activity) for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene.

During a review of Resident 1 ' s Nursing Progress Notes, dated 1/19/2025, the progress note indicated Resident 1 ' s son made the facility aware that his mother told him a nurse was too rough on her (Resident 1) last night. The progress notes indicated Resident 1 stated a male CNA (CNA 1) was rough with her, hurt Resident 1 ' s arm, and cleaned Resident 1 with hot water last night.

During a review of the facility ' s Five-Day Investigation Report, dated 1/22/2025, the report indicated CNA 1 asked CNA 2 to translate (in Spanish) for Resident 1 when Resident 1 became agitated. The report indicated Resident 1 told CNA 2 that CNA 1 was rough (during care).

During an interview, on 2/3/2025, at 11:51 a.m., with CNA 2, CNA 2 stated, during the 11 p.m.- 7 a.m. shift,

on 1/19/2025, she helped translate for CNA 1 and Resident 1. CNA 2 stated Resident 1 told her CNA 1 was too rough and Resident 1 wanted a pain pill because her left arm was hurting after CNA 1 repositioned her. CNA 2 stated that she only told LVN 1 Resident 1 wanted her pain pill, but did not report Resident 1 ' s complaint about CNA 1. CNA 2 stated she should have told LVN 1 or notified the proper agencies (CPDH, law enforcement, and the ombudsman) about Resident 1 ' s concern because it was considered an abuse allegation. CNA 2 stated this delayed the facilities ' ability to investigate timely and prevent Resident 1 from possible further abuse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 4 056458 Department of Health & Human Services Printed: 09/10/2025 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 056458 B. Wing 02/03/2025

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

Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

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 0610 During an interview, on 2/3/2025, at12:46 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he was assigned to care for Resident 1 for the 11 p.m. to 7 a.m. shift on 1/18/2025 and was not made aware of Level of Harm - Minimal harm or any incident or allegation of abuse between Resident 1 and CNA 1. LVN 1 stated that he would have potential for actual harm immediately reported the incident to the abuse coordinator, the police, the ombudsman, CDPH, and would have ensured CNA 1 was sent home. LVN 1 recalled that CNA 1 stayed in the facility until the end of his shift Residents Affected - Few (7:30 a.m.). LVN 1 stated if he had known about the allegation, he would have started an investigation sooner.

During an interview, on 2/3/2025, at 1:12 p.m., with the Administrator (ADM), ADM stated that all facility staff members were mandated reporters and did not have to wait for him to notify law enforcement, CDPH, and to fill out the SOC 341 form (a form that documents the information given by the reporting party on the suspected incident of abuse or neglect of an elder or dependent adult). The ADM stated CNA 2 should have reported the incident right away. The ADM stated this led to a delay in an investigation, and the facility could have acted on the information to prevent further abuse.

During a review of the facility ' s Policy and Procedure (P&P), titled, Abuse and Neglect Prevention Policy, revised 12/2014, the policy indicated the following for the management of abuse allegations:

1. Remove or protect the resident from danger

2. Assess the resident for injuries

3. Investigate the alleged incident immediately

4. Suspend the employee who may have been alleged perpetrators

Cross reference