State of California - Health and Human Services Agency SECTION 1424 NOTICE CITATION NUMBER: YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE Department of Public Health Page 1 of 3 23-2498?00?1 1221 -S Date: 03/19r2015 Time: 459: Type of Visit: Incident/Complaint No.(s) CA00397188, CA00396903 CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Gridley Healthcare Wellness Centre, LLC 246 Spruce Street 230000047 Gridley, CA 95948 Type of Ownership: Limited Liability Company Facility Name: Gridley Healthcare Wellness Centre, LLC Address: 246 Spruce St Gridley, CA 95948 Telephone: (530) 846-6266 Facility Type: Skilled Nursing Facility Capacity. 82 Facility ID: 230000041 SECTIONS CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT DEADLINE FOR $2,000.00 COMPLIANCE 3!31f15 8:00 am. 1418.91(a) CLASS CITATION -- PATIENT RIGHTS 1418.91 Health Safety Code: Fail to Report Alleged Abuse (a)A long?term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. The facility failed to operationalize their abuse prevention policies when incidents of abuse and mistreatment of residents were not investigated or reported to the department within 24 hours. This resulted in the offending CNAs continuing to work with residents which jeopardized resident safety and well?being. On 5/1114, the facility's undated policy to address abuse prevention, investigation, and reporting indicated that any allegations of abuse would be investigated immediately. The policy indicated that the purpose of the policy was to protect residents from abuse, neglect and mistreatment. The policy indicated gestured language that was derogatory or disparaging, was considered abuse, regardless of the resident?s age, ability to comprehend, or disability. The policy indicated "mental abuse", included humiliation and harassment of the resident. The policy indicated that facility staff who had witnessed or who believed that a resident had been a victim of mistreatment or abuse, Name of Evaluator: Nancy Elloway HFEN Without admitting guilt. I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name: Limo A magma Title: Ad r? I I Evaluator Signature Gg/ NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE State of California Heaith and Human Services Agency SECTION 1424 NOTICE CITATION NUMBER: Department of Public Health Page 2 of 3 1' 23-2498-0011221?8 Date: 0311912015 Time: ?we SECTIONS VIOLATED CLASS AND NATURE OF VIOLATIONS must immediately report, or cause a report to be made of the mistreatment. The policy indicated that the facility staff must not knowingly fail to report an incident of mistreatment or other offense. The policy indicated that the allegation of abuse would be reported to the department of public health within 24 hours. The facility's employee handbook, dated 4l2013, indicated that the use of personal communication devices, such as cellular (cell) phones, was prohibited during normal work hours and in all work areas. On 5l5l14 at 9:30 am during an interview, CNA eXplained that on 4/29/14, during the day shift, she made a report to the Administrator. CNA reported that CNA A had been using the snap chat application (app) (enables real time photographs and video to be displayed for a few seconds on another person's cellphone, but is not saved on either device) to send pictures of residents that were inappropriately exposed and/or appeared to be deceased. CNA added that she was absolutely disgusted by the lack of respect this showed for human life and for a person who had passed. CNA went on to explain that "our residents are mothers, fathers, sisters, brothers and are all humans that love and have feelings." CNA stated that it was amazing to her that a person could be so uncaring for a laugh. CNA stated that she had received abuse training in the facility. CNA stated that this constituted abuse to residents, which was why she had reported it to the Administrator. CNA stated that she was surprised to find out that CNA was still scheduled to work with residents after this had been reported. On 5fi4i14 at 1:30 pm, during an interview, CNA 0, confirmed that while working in the facility she had received video on her cell phone through the snap?chat app of CNA twerking (dancing to popular music in a sexually provocative manner involving thrusting hip movements and a low, squatting stance) over the head of a resident and of CNA A twerking over a recliner that was located in a resident room. CNA stated staff frequently used the snap-chat app to communicate by texting words to each other. CNA A explained that a photo of the background was always included with the text since the snap?chat app was designed for sending real time photos and videos. CNA stated that many times the background in the photos included partial pictures of residents. CNA 0 stated that the pictures and videos were sent on many occasions to multiple staff in the facility. CNA confirmed that these incidents had not been reported. When asked why she did not report the incidents. CNA stated that the resident in the video where CNA was twerking over his head was not identifiable from the picture and did not appear to be aware of what was happening. The resident appeared to be sleeping or unconscious. CNA explained that now after thinking it through, she realized it NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE State of California - Heaith and Human Services Agency SECTION 1424 NOTICE CITATION NUMBER: Department of Public Health Page 3 of 3 I Date: osr1sr2015 Time: 23?2498-0011221-8 SECTIONS VIOLATED CLASS AND NATURE OF VIOLATIONS should have been reported since the behavior in itselfwas undignified and humiliating towards the resident. On 5W14 at 5:15 pm during an interview, the Administrator confirmed that CNA had informed him on 4I29f14 that CNA A had sent inappropriate pictures of residents using the snap-chat app. The Administrator stated that he had not started an investigation process or reported the incident because there was no concrete evidence that it had occurred. The Administrator confirmed that he had not spoken with CNA A. The Administrator stated that CNA A was currently clocked in and working in the facility. The Administrator confirmed that the facility's abuse prevention policy had not been followed when CNA and other staff, did not report the alleged mistreatment of residents 4:15 pm during a telephone interview, the facility's New Administrator stated that the Department of Justice (DOJ) investigators had taken staff phones to retrieve deleted data, and were able to provide the facility with information that inciuded which residents and CNA's were involved. The New Administrator stated the facility had fired five CNAs who had been involved. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE