Health inspection·February 19, 2025

The following reflects the findings of the California department of Public Health during the investigation of complaint number 933361. The inspection was limited to the specific complaint investigated during an Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the Department: 50409, HFEN A deficiency was written for Complaint #933361 at F-tag/S/S F609/D. Health & Safety Code §1418.91 (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. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 12/11/24, an unannounced visit was conducted at the facility to investigate a complaint regarding an alleged verbal altercation between two residents (Resident 1 and Resident 2). Resident 1 is a 73-year-old female who was admitted to the facility on 7/4/24 with diagnoses of major depressive disorder (mental health condition that causes a persistent low mood and loss of interest in activities), cerebrovascular disease (conditions that affect the blood vessels and blood flow to the brain), muscle weakness, and difficulty walking. Resident 2 is a 69-year-old who was admitted to the facility on 4/13/23 with diagnoses of unspecified dementia (group of thinking and social symptoms that interferes with daily functioning) and schizoaffective disorder (mental illness that can affect thoughts, mood and behavior). Based on interview and record review, the facility failed to report an allegation of resident-to-resident altercation to CDPH (California Department of Public Health [state agency]) within 24 hours between two sampled residents (Resident 1 and Resident 2). This failure resulted in CDPH being unaware of the allegation and had the potential to result in continual physical and psychosocial harm for both Resident 1 and Resident 2. Findings: During a review of Resident 1's "MD/NP Progress Notes (MPN)," dated 11/26/24, the MPN indicated, "Writer was alerted to possible resident to resident altercation. Resident nurse stated that resident (Resident 1) had come to her and made an excited utterance stating that another resident had 'ran over' her foot and 'punched' her in the face twice. However, resident later denied that the other resident had made physical contact. . . Resident also indicated that they each started yelling at each other and commented that she had 4 brothers growing up so she 'knows how to swear like them.'" During a review of Resident 2's MPN, dated 11/26/24, the MPN indicated, "Resident does admit to a verbal 'loud' exchange where she stated that both residents were yelling at each other. . . While probable that resident (Resident 2) was involved in resident-to-resident altercation, Resident physical examination and interview indicates that it is unlikely that physical contact was made." During a review of Resident 1's "SBAR (Situation, Background, Assessment, Recommendation)," dated 11/26/24, the SBAR indicated, "Resident (1) came to nursing station 1 and reported to charge nurse that another resident (Resident 2) run over her right foot/toes and punched her twice on her left side of the face at the back gazebo smoking area. " During a review of Resident 1's "IDT (Interdisciplinary Team)," dated 11/27/24, the IDT indicated, "According to witness (Resident 3), (Resident 2) and (Resident 1) engaged in loud verbal cursing at each other. " During a review of Resident 1's "Psychosocial Note (PN)," dated 11/27/24, the PN indicated, "Resident (1) continues alert and able to make needs known. . . Resident (1) verbalized having a verbal altercation with another female resident (Resident 2) due to the other resident accidentally bump her foot with the WC (wheelchair) and that incident happened on 11/26/24. " During a review of Resident 1's "Brief Interview for Mental Status (BIMS) Evaluation," dated 7/8/24, the BIMS indicated Resident 1 had a score of 15 (score of 13-15 indicates intact cognitive response). During an interview on 12/11/24 at 2:55 p.m. with Resident 1, Resident 1 stated, "We (residents) were just smoking right there (at the back gazebo smoking area) . . . She was so close to my toes she ran over my toes. I said, 'Get off my foot.' Then she yelled at me, 'No the f*** I ain't. I'm not on your f****** feet you f****** b****!" She said something to the effect of, 'I'm gonna kick your f****** a**!' I was in shock I haven't been called that." Resident 1 stated she felt she was mistreated and harassed. During an interview on 12/11/24 at 3:34 p.m. with Resident 3, Resident 3 stated he witnessed the altercation between Resident 1 and Resident 2 at the back gazebo smoking area on 11/26/24. Resident 3 stated, "I saw (Resident 2) basically tried to punch (Resident 1). I know (Resident 2) made contact with (Resident 1). (Resident 2's) first punch did not land but she continued to strike on (Resident 1), like open hand slaps, some landed on (Resident 1's) face and her feet was also rammed over. (Resident 1) was trying to make her move out of the way and at the same time (Resident 2) was assaulting her, cursing, and yelling at her. " During a review of Resident 3's BIMS, dated 10/10/24, the BIMS indicated Resident 3 had a score of 15 (score of 13-15 indicates intact cognitive response). During an interview on 12/11/24 at 3:42 p.m. with Registered Nurse (RN) 1, RN 1 stated, "It (Resident 1 and Resident 2's altercation on 11/26/24) is considered abuse. We have to notify the state with SOC 341 because they were yelling, or they used language that were not appropriate. We need to report (all allegations of abuse and abuse incidents) so that you guys (CDPH) can investigate what happened. " During an interview on 12/11/24 at 4:05 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, "It (Resident 1 and Resident 2's altercation on 11/26/24) was a verbal altercation. It is considered verbal abuse." LVN 1 stated, "It should've been reported to CDPH. " During an interview on 12/11/24 at 4:20 p.m. with Social Services Director (SSD), SSD stated, "If someone is alleging an abuse. I thought we do report. I thought we do our investigation. " During a concurrent interview and record review on 12/11/24 at 5:01 p.m. with Director of Nursing (DON), SOC 341, dated 11/26/24 was reviewed. SOC 341 (Report of Suspected Dependent Adult/Elder Abuse) indicated, "Resident (1) has a verbal altercation with another resident (Resident 2)." SOC 341 indicated it was not faxed to CDPH. DON stated, "For me yes cursing is verbal abuse especially if they threaten each other." DON stated the facility should have reported Resident 1 and Resident 2's altercation to CDPH. DON stated the facility did not follow the facility's policy on abuse reporting. During an interview on 12/11/24 at 5:26 p.m. with Administrator, Administrator stated he was the facility's abuse coordinator. Administrator stated, "If there was any suspicion of abuse then we do everything (investigate and report)." Administrator stated Resident 1 and Resident 2's altercation on 11/26/24 was not reported. Administrator stated allegations of abuse were supposed to be reported to the Ombudsman, CDPH, and the police department. During a review of the facility's policy and procedure (P&P) titled, "Resident Abuse Policy, " dated 2017, the P&P indicated, "Each resident at the Facility a skilled nursing facility Height Street Skilled Care has the right to be free from mistreatment, neglect, exploitation of residents' property and misappropriation of property. . . Facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required. . . Under State law, Height Street Healthcare Center must report any incident of alleged or suspected "abuse" (as defined in the Act) of a resident to CDPH - Licensing and Certification Department immediately or within 24 hours." In violation of Health & Safety Code 1418.91 (a), the department determined that the facility failed to report an allegation of abuse to the CDPH. The above violations caused or occurred under circumstances likely to cause significant anxiety, or other emotional trauma to Resident 1 and constitutes to a B citation.