Health inspection·April 22, 2021

F600 Free from Abuse and Neglect Section 483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The following reflects the findings of the California Department of Public Health during an investigation of facility reported incident # CA00683214. The inspection was limited to the specific facility reported incident, and does not represent the findings of a full inspection of the facility. The Department determined that the facility failed to ensure one resident (Resident 1) was free from physical abuse when Resident 1's roommate (Resident 2) walked over to Resident 1's bed and hit him in the face. This failure resulted in physical injury to Resident 1 whereby he developed a red, swollen mark on his left cheek, and increased the risk of Resident 1 experiencing a decline in his emotional wellbeing. Findings: Review of the Admission Record indicated Resident 1 was admitted to the facility in the spring of 2019 with diagnoses, which included a stroke resulting in paralysis (inability to move) of his left arm and left leg. A Minimum Data Set (MDS, an assessment tool) dated 3/9/20, indicated Resident 1 required extensive assistance to move in bed, and to transfer from his bed to his wheelchair. Review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility in the spring of 2020. A MDS dated 3/10/20, indicated Resident 2 required supervision, defined as "oversight, encouragement or cueing," when moving in and out of bed, and walking with a walker. Review of Resident 1's medical record revealed the following: A nursing progress note dated 3/28/20, at 10:50 p.m., indicated Resident 1 and Resident 2 had an altercation. The note indicated Resident 1 stated Resident 2 punched him in his left eye, and the nurse noted "slight puffiness" under Resident 1's left eye. A document titled "Event Report," dated 3/29/20, at 1:25 a.m., indicated Resident 1 was in an altercation with his roommate (Resident 2), and that he was injured during the altercation. The report indicated Resident 1's injury as a "red welt [a red, swollen mark left on flesh by a blow or pressure] left cheek." A nursing progress note dated 3/29/20, at 4:34 a.m., indicated, "[Resident 1] has slight swelling to right [sic] cheek below right [sic] orbit [eye socket] with ice applied as tolerated by resident." During a review of a facility provided document dated 3/29/20, the document included nursing documentation on observations, beliefs, and statements made by Resident 1 and Resident 2. The nurse's documentation indicated the nurse found Resident 1 and Resident 2 in their shared room. The document indicated that Resident 1 stated Resident 2 hit him on the left side of his face, and that Resident 2 initially denied hitting Resident 1 but then stated he did slap Resident 1. The nurse's documentation indicated the nurse noted a red welt on Resident 1's left cheek. During an interview with Resident 1, on 3/29/21, at 12:25 p.m., Resident 1 stated he had a stroke over a year ago and could not walk because he was unable to move his left arm and leg. Resident 1 stated he remembered the altercation he had with Resident 2 on 3/28/20. Resident 1 stated Resident 2 said things to him that day that he did not like, so he called him an expletive name. Resident 1 stated Resident 2 walked over to his bed and punched him on his left cheek. During an interview with Licensed Nurse (LN) 1 on 3/29/21, at 1:15 p.m., LN 1 stated she was the nurse on duty when Resident 1 and Resident 2 had their altercation. LN 1 stated the roommates were not physically attacking each other when she entered the room, however, she found the two residents appeared "amped up." LN 1 stated she observed a red mark on Resident 1's cheek. During a concurrent interview and document review with the facility administrator (ADM) on 4/6/21, at 3:10 p.m., the ADM reviewed the nursing documentation on the facility document dated 3/29/20. The ADM verified the document indicated the nurse noted a red welt on Resident 1's left cheek. The ADM stated he considered a red welt a physical injury. During an interview with CNA 1 on 4/7/21, at 11:30 a.m., CNA 1 confirmed she was the CNA who reported the altercation between Resident 1 and Resident 2 to the nurse supervisor on 3/28/20. CNA 1 stated Resident 1 was bed-bound and only had the use of one arm, and Resident 2 walked independently with the use of a cane. CNA 1 stated, prior to the altercation, she was in the room getting Resident 1 ready for bed. Resident 2 was on his own side frequently interrupting the conversation between CNA 1 and Resident 1. CNA 1 told Resident 2 to wait his turn, to which Resident 2 replied, Resident 1 never knew when to be quiet. CNA 1 left the room to gather additional supplies. When she returned, she found the door closed and the light inside the room was off. CNA 1 stated, when she turned the light on, she saw the room in disarray; Resident 1's rolling side table was half flipped over with his items all over the bed and floor. CNA 1 stated Resident 1 had coffee spill over his chest area. CNA 1 stated she saw Resident 2 pacing the room on his toes and was bouncing "like a boxer during a fight." CNA 1 stated Resident 1 looked "roughed up and was wide-eyed." CNA 1 stated she noted a red mark appearing on Resident 1's cheek. CNA 1 stated she left the room to get the nurse supervisor. CNA 1 stated, on their return, the nurse supervisor did her assessment and investigation. CNA 1 stated, Resident 2 admitted to her and the nurse supervisor that he hit Resident 1 on the left side of his face. Review of a facility policy and procedure titled, "Preventing Resident Abuse," dated 1/11, indicated, "Our facility will not condone any form of resident abuse...The facility's goal is to achieve and maintain abuse-free environment."