Health inspection·April 30, 2025

The following reflects the findings of the California Department of Public Health during the investigation of two Facility Reported Incidents: CA00937559 and CA0093703. Event ID: EF7U11 State Citation B was written Code of Federal Regulations, §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. Cal. Code Regs. Tit. 22, § 72527 - Patients' Rights (a)Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. Cal. Code Regs. Tit. 22, § 72315 - Nursing Service-Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. On 3/11/25, an unannounced visit was conducted at the facility to investigate two Facility Reported Incidents (FRIs) regarding abuse. The Department determined the facility failed to implement interventions to protect residents' right to be free from physical abuse by a resident when: 1. Resident 2 splashed water on Resident's 1 face; and 2. Resident 2 spit on Resident 5. This failure resulted in Resident 1 feeling uncomfortable and had the potential to affect Resident 1's and Resident 5's psychosocial well-being. Review of Resident 1's "ADMISSION RECORD," indicated Resident 1 was admitted to the facility with a diagnosis of post-traumatic stress disorder (PTSD, a mental health condition that can develop after experiencing or witnessing a traumatic event) and bipolar disorder (a mental health condition characterized by significant and persistent shifts in mood, energy, and activity levels, often involving periods of extreme highs (mania) and lows (depression)). Review of Resident 2's "ADMISSION RECORD," indicated Resident 2 was admitted to the facility with diagnosis of major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), insomnia (a sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early, despite having adequate opportunity to sleep), and schizophrenia (a mental health disorder that affects a person's ability to think, feel, and behave clearly). During an interview on 3/11/25, at 2:05 PM, Resident 1 stated Resident 2 came towards her yelling at her stating that Resident 1 was sitting outside of Resident 2's room door. Resident 1 stated, shortly after that statement Resident 2 splashed a cup of water on her. Resident 1 also stated Resident 2 came to her room on a nightly basis. Resident 1 stated she closed her bedroom door at night to ensure that Resident 2 would not enter her room while she was asleep. However, Resident 1 stated Resident 2 would still open her door quietly and stood at the foot of her bed and stared at her while she was asleep. Resident 1 stated she did not feel safe in her room due to how often Resident 2 returned to her room after each incident. Resident 1 explained about an incident when Resident 2 entered her room with a box under her shirt. Resident 1 stated she had no idea what was in that box, and it scared her. Resident 1 stated, Resident 2 came to her room last night as well. Resident 1 stated each time Resident 2 would come to her room she would yell, and the staff would come and get Resident 2. Resident 1 stated when Resident 2 would come to her room she would yell "GO!" and sometimes that would get Resident 2 to leave. Resident 1 stated, "Emotionally I feel uncomfortable." Resident 1 stated she did not feel safe in her room. During an interview with Licensed Nurse (LN) 1, on 3/11/25, at 2:19 PM, LN 1 stated Resident 2 had interactions with other residents where Resident 2 would become extremely agitated and aggressive. LN 1 stated Resident 2's behavior changed quickly and when angry, Resident 2 would throw cups of water on other residents and staff. During an observation on 3/11/25, at 2:26 PM, Resident 2 was noted to be walking unattended down the hallway away from her room towards Resident's 1 room. Resident 2 stopped, opened the shower room door, went in the shower room and closed the door behind her. After a few minutes Resident 2 exited the shower room with a sheet taken from the shower room and continued down the hallway unattended. During an interview on 3/11/25, at 9:37 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 2 had a known history of attacking other residents and staff. CNA 1 stated when a resident was continuously aggressive the facility would provide them a staff member who would sit with them throughout the day to prevent any altercations. CNA 1 stated that Resident 2 had never had a sitter but would benefit from one. During an interview on 3/13/25, at 10:16 AM, Resident 4 stated that Resident 2 used to be her roommate until Resident 2 poured water on her in the middle of the night while angry. Resident 4 stated, Resident 2 had an extensive history of verbal and physical altercations with the staff. Resident 4 stated, Resident 2's behavior exacerbated at night. Resident 4 stated she was informed that she needed to move rooms due to Resident 2's aggression and altercations between them. During an interview with Resident 1 on 3/13/25, at 11:06 AM, Resident 1 stated Resident 2 returned to her room last night in the middle of the night. Resident 1 stated when she told Resident 2 to get out of her room, Resident 2 responded by saying, "I don't care what you say I can do what I want." Resident 1 stated after she yelled, the staff removed Resident 2 from her room. Resident 1 stated Resident 2 kept returning to her room. Resident 1 stated that she informed staff that she did not feel safe in her room and staff informed her that they did not know what to do. During an interview with Resident 3 (who was Resident 1's roommate at the time of the interview) on 3/13/25, at 11:11 AM, Resident 3 stated Resident 2 would come inside Resident 1's room at night and yell at Resident 1. Resident 3 stated Resident 2 had returned to Resident 1's room five times thus far for the month of March. Resident 3 stated Resident 2 had a history of being aggressive with her and with staff including throwing coffee on them. Review of Resident 1's care plan (outlines specific care needs, goals, and interventions to meet the goals), initiated on 12/28/24, indicated, "...Focus Resident to resident altercation (victim). Resident (alleged abuser) [Resident 2] threw water at resident (victim) [Resident 1] on 12/28/24... Goal Ensure the emotional and physical well-being of the resident and prevent further incidents...Interventions... Ensure that the resident is in a safe and quiet environment... Evaluate resident's emotional state for signs of fear, anxiety or agitation..." 2. Review of Resident 5's care plan, last reviewed 4/23/25, in the section titled "Diagnosis," indicated Resident 5 had the following diagnosis, major depressive disorder and dementia. During an interview with LN 3 on 4/23/25 at 2:04 PM, LN 3 stated Resident 2 spat on Resident 5 inside of Resident 5's room. LN 3 stated Resident 2's bedroom was at the opposite end of the facility, however Resident 2 would wander and end up on the opposite side of the building. Review of Resident 5's clinical record titled, "Progress Notes," dated 12/24/24, indicated, "...Nursing observations, evaluation, and recommendations are: Reported from ADON [Assistant Director of Nursing], [Resident 2] witnessed by another staff on duty [Resident 2] (abuser) spitting on another [Resident 5] (victim)..." A record review of Resident 5's clinical record titled, "Social Services Progress Note," dated 12/25/24, indicated, "...Follow up on resident-to-resident altercation from yesterday incident. No changes in psychosocial wellbeing... [Resident 5] able to recall that she was spit by the said [Resident 2] ..." Review of Resident 5's care plan, initiated 11/14/24, indicated, "Focus...Resident to resident altercation- Focus on ensuring safety, providing emotional support, and promoting respectful communication and social interactions...Goal... Ensure the resident feels safe and secure in the environment..." Review of Resident 5's clinical record titled, "Social Services Progress Note," dated 12/29/24, indicated, "...Follow upon resident-to-resident altercation today and spoke to [Resident 5]. She reports that the [Resident 2] from South station...once again came to her room. [Resident 5] said that their room was closed, and she heard someone yanking at the doorknob and it eventually opened and saw the [Resident 2] from South station...at the door by her bed yelling at [Resident 5] and told her that [Resident 5] is on her bed. [Resident 5] said that she told the resident from South station to get the hell out of here and yelled for the nurse. [Resident 5] said that a nurse came and brought a wheelchair and took... [Resident 2] ... back to South station..." During an interview with the Assistant Director of Nursing (ADON), on 4/23/25 at 2:25 PM, the ADON was able to confirm the occurrence of the altercation between Resident 2 and Resident 5 after reviewing the documentation of the incident. The ADON stated the risk of the altercation to Resident 5 was physical and psychosocial affects. The ADON stated the risk could be that Resident 5 did not feel safe in her home, not feel heard, and could have a negative effect on her wellbeing. During an interview with the Director of Nursing (DON) on 3/13/25, at 11:57, the DON confirmed there were multiple altercations Resident 2 had with other residents. The DON stated given the history of Resident 2 the facility should have provided Resident 2 with a one-to-one support of a staff member to always be with Resident 2. The DON stated the facility should have implemented behavior monitoring to monitor the Resident 2's behavior. The DON stated monitoring Resident 2's behavior would have allowed the facility the opportunity to observe behavior patterns, develop a baseline of behaviors, and possibly prevent future occurrences of abuse from occurring. Review of the facilities five-day follow-up report, following the resident to resident incident, dated 12/29/24, indicated, "...Incident On 12/24/24, A staff member witness Resident [2] spitting on Resident [5]... Q30 [every] minutes visual safety check initiated on Resident [2]...12/25/24...SSD followed up with Resident [2] on resident-to resident altercation from yesterday when the resident [2] was reported spitting on another resident in North Station..." A review of a facility provided document titled, "Resident Rights" dated 12/21, indicated, "...Federal and State law guarantee certain basic rights to all residents of this facility. These rights include the resident right to...Be free from abuse, neglect..." A review of an undated facility provided document titled, "QAPI-Role of the Social Serviced Director," indicated, "...Developing and implementing policies and procedures for the identification of medically related social and emotional needs of the resident...Develop preliminary and comprehensive assessments of the social service needs of each resident..." A review of an undated facility provided document titled, "Abuse Prohibition Policy and Procedure," indicated, "...Purpose: to ensure that the Center staff are doing all that is within their control to prevent occurrences of abuse...Understanding the behavioral symptoms of patients that may increase the risk of abuse and neglect and how to respond...The Center is responsible for identifying residents who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation...Options for room changes will be provided based on the situation...The Center will protect the patients from further harm...Provide the patient with a safe environment by identifying the persons whom he/she would feel safe...Assign a representative from Social Services or a designee observe the patients feelings concerning the incident...Analyze occurrences to determine what changes are needed, if any, to prevent further occurrences..." Therefore, the Department determined the facility failed to implement interventions to protect residents' right to be free from physical abuse by a resident when: 1. Resident 2 splashed water on Resident's 1 face; and 2. Resident 2 spit on Resident 5. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Resident 1 and Resident 5.