Health inspection·March 12, 2025

F600, Title 42, Section 483.12, Freedom 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. Section 483.12(a) The facility must- Section 483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. California Code of Regulations, Title 22, Section 72311, Nursing Service--General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 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. California Code of Regulations, Title 22, Section 72523, Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 1/23/25 at 9:25 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident regarding when Resident 1 threw a plate on Resident 2's face during an altercation. As a result of the investigation, the Department determined that the facility failed to protect Resident 2 from physical abuse by Resident 1 when Resident 2 sustained a laceration on the right eyebrow. A review of Resident 1's admission record indicated, Resident 1 was admitted in October 2024 with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), anxiety disorder (significant and uncontrollable feelings of anxiety and fear), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a progressive state of decline in mental abilities), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). Resident 1's Minimum Data Set (MDS), a federally mandated resident assessment tool) indicated Resident 1 had moderate cognitive impairment and did not exhibit physical or verbal behaviors toward self or others. A review of Resident 1's "Change in Condition" (COC) notes, dated 1/19/25 at 6:37 a.m., indicated, "[Resident 1] elicits an altered mental status. [Resident 1] exhibits physical and verbal aggression towards staff. Knocking over items on purpose. [Resident 1] has not slept in a single minute all night long. [Resident 1] has been naked the entire time. Urinating and bowel movements in the hallway. Not able to follow commands...Recommendations: Send out for further evaluation and treatment..." A review of Resident 1's COC notes, dated 1/19/25 at 12:27 p.m., indicated, "...observed [Resident 1] standing over another resident [Resident 2] and throwing items at him [Resident 2]. [Resident 1] also threw items at staff members, spit on staff, and uncontrolled aggressive behavior...Recommendations: Sent to ER [Emergency Room]." A review of Resident 1's "Nurses Progress Notes," dated 1/19/25, indicated, "...observed [Resident 1] standing over another resident [Resident 2] and throwing items at him [Resident 2]. [Resident 1] also threw items at staff members, spit on staff, and uncontrolled aggressive behavior. Attempted to redirect [Resident 1] by multiple staff members. Other residents advised to go in their rooms, doors closed..." A review of Resident 1's "Social Services Progress Notes," dated 1/22/25, indicated, "...[Resident 1] had witnessed altercation [with Resident 2]...Per order, [Resident 1] has capacity to make own decisions..." A review of Resident 2's admission record indicated Resident 2 was admitted in October 2024 with diagnoses that included low vision on right eye, blindness on left eye, muscle weakness, and dementia. Resident 2's MDS indicated Resident 2 had intact cognition and did not exhibit physical or verbal behaviors toward self or others. A review of Resident 2's COC notes, dated 1/19/25 at 12:26 p.m., indicated, "...heard [Resident 2] crying and screaming from room, observed another [Resident 1] standing over [Resident 2] and throwing items at him. [Resident 2] bleeding from cheek...nurse did skin assessment, noted right Eyebrow Skin tear..." A review of Resident 2's "Skin/Wound Note," dated 1/19/25, indicated, "Noted laceration to top right forehead measuring approximated 2x2cm [centimeters, a unit of measurement] with no skin flap..." During an interview on 1/23/25 at 10:19 a.m., Licensed Nurse (LN) 1 stated that on 1/19/25, staff saw Resident 1 throwing stuff and were telling him to calm down. LN 1 stated staff were outside and they heard a lot of crying from Resident 2's room. LN 1 further stated Resident 1 was seen standing in front of Resident 2 who was bleeding. LN 1 stated, "[Resident 1] used to be very calm...he started getting more agitated...[Resident 1] Started to become agitated not too long ago, staff tried redirecting him...At that time, we couldn't get close to him...anybody who tried, he will try to hit.." During an interview on 1/23/25 at 11:04 a.m., Certified Nursing Assistant (CNA) 1 stated, "[Resident 1] was wandering a lot that day [1/19/25], throwing things, not listening or cooperating with us, just disrupted...He was throwing stuff in the hallway from the nurses cart, throwing pillows, anything he can see..." CNA 1 stated Resident 1 went back to his room and the staff heard crying from the room. CNA 1 stated, "[Resident 1] was by [Resident 2's] side of the bed...all the food was all over [Resident 2], there was a lot of blood..." During an interview on 1/23/25 at 11:16 a.m., LN 2 stated Resident 1 was sent out on 1/19/25 (at 6:30 a.m.) to the hospital during the night shift for his behavior and altered level of consciousness and stated, "[Resident 1] was acting a little different the day before [1/18/25]...it was very difficult to redirect him..." LN 2 stated Resident 1 came back from the hospital on the same day, 1/19/25 (at 10:20 a.m.), and still had the same behavior. LN 2 stated, "...I don't know what happened but he got very very angry and uncontrollable...he was breaking plates and trying to hurt us..." LN 2 stated Resident 1 took himself to his bed and LN 2 stated, "Then we heard wailing from the room, it was [Resident 2], [Resident 1] was throwing things to him from his food tray...we saw [Resident 1] threw [Resident 2's] plate into his face...I was very scared, [Resident 1] broke [Resident 2's] face open.." LN 2 further stated, "We saw [Resident 1] throwing items on [Resident 2's] face...[Resident 2] was bleeding...had a cut on his eyebrow...I saw [Resident 1] standing over [Resident 2] and throwing items...it was really traumatizing..." LN 2 further stated Resident 2 was in shock and was crying at that moment and was able to express anger after he was moved on the other end of the facility. LN 2 added that on the following day (1/20/25) after the incident, Resident 2 was still upset and told the CNA, "He [Resident 1] is not coming back, right?" LN 2 stated, "I would say that's a sign of fear." During an interview on 1/23/25 at 11:55 a.m., the Director of Nursing (DON) stated, "On 1/19/25, staff on the floor witnessed [Resident 1] was throwing items. When they went in the room, they saw [Resident 1] standing by [Resident 2's] bed...[Resident 2] was bleeding from right upper eyebrow..." The DON stated Resident 1 was sent out (to the hospital on 1/19/25 at 6:30 a.m.) for altered mental status and came back from the hospital on the same day (1/19/25 at 10:20 a.m.) without new orders. The DON further stated, "He was disoriented and started throwing things...It happened very quickly, he was stabilized in his bed and suddenly he got up...He woke up and he was agitated...it was witnessed that [Resident 1] was throwing stuff on [Resident 2]." During an interview on 1/23/25 at 12:53 p.m., the Administrator (ADM) stated, "...[Resident 2] had a little skin tear above his eye..." The ADM stated he spoke with LN 2 about what happened, and LN 2 told him that LN 2 saw Resident 1 holding the plate on 1/19/25. The ADM stated, "This was the first time, [Resident 1] had been confused before, and we redirect him...We had increased supervision making sure staff was with him [Resident 1] and it was in between the checks when it happened." The ADM further stated, "When [Resident 1] came back [from the hospital on 1/19/25 at 10:20 a.m.], he settled down, laying down on bed, it was sudden agitation. For precaution, they [staff] closed the doors for other residents." During a concurrent observation and interview on 1/23/25 at 2:16 p.m. with Resident 2 in his room, translated by Housekeeping Staff (HS), Resident 2 was observed alert and calm, sitting on a wheelchair on the side of his bed, bandage was observed on his right eyebrow. When asked about what caused the wound on his right eyebrow, Resident 2 stated that somebody threw a plate with food and hit him with the plate. Resident 2 stated he was not able to remember who it was because he was blind and that he felt very bad. Resident 2 further stated that at that time, he felt too much pain on his head and that he can still feel the pain. Resident 2 added that he was hoping Resident 1 does not come back. During a review of the facility's policy and procedure (P&P) titled "Resident-to-Resident Altercations Policy," dated 10/2023, the P&P indicated, "1. Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to the staff...2. Behaviors that may provoke a reaction by residents or others include:..b. physically aggressive behavior, such as hitting, kicking, grabbing...threatening gestures, throwing objects..." During a review of the facility's P&P titled "Abuse, Neglect and Exploitation Prevention," dated 6/2023, the P&P indicated, "It is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property...8. Prevention of Abuse, Neglect and Exploitation...B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur...D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect..." Therefore, the facility failed to protect Resident 2 from physical abuse when Resident 1 threw a plate on Resident 2's face and Resident 2 sustained a laceration on the right eyebrow. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 2.