Other·March 26, 2025

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident 942455. The inspection was limited to the specific facility reported incident investigated during an Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the Department: 38993, HFEN A deficiency was written for Facility Reported Incident #942455 at F-tag/S/S F600/D. Health & Safety Code 1424 (e) Unless otherwise determined by CDPH to be a class "A" violation, any violation of resident's rights that caused or is likely to cause significant humiliation, indignity, anxiety, or other emotional trauma On 2/3/25, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding an alleged abuse towards one long-term care resident. Resident 1 is a 55-year-old male who was admitted to the facility on 9/16/22 with diagnoses of quadriplegia c-1-c-4 complete (spinal cord injury resulting in total paralysis of both arms and legs), dysphasia (condition that affects the ability to understand, use, or produce language) following cerebral infarction (lack of oxygen causing an area of dead tissue in the brain). . ." Resident 2 is a 60-year-old male who was admitted to the facility on 9/16/22 with diagnoses of major depressive disorder, need for assistance with personal care, muscle weakness and persistent mood disorders. Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from verbal abuse inflicted by his roommate (Resident 2). This failure resulted in Resident 1 being agitated, noisy, restless and the inability to sleep with the potential for psychosocial harm. Findings: During a review of Resident 1's "Minimum Data Set" (MDS), dated 12/28/24, the MDS indicated, "Brief Interview for Mental Status (BIMS). . .05 (severe cognitive impairment)." During a review of Resident 2's MDS dated 12/27/24, the MDS indicated, BIMS. . .13 (cognition is intact)." During a review of Resident 1's "Admission Record" (AR), dated 3/3/25, the AR indicated, Resident 1 was admitted 9/16/22 and had the following diagnoses. . .quadriplegia c-1-c-4 complete (spinal cord injury resulting in total paralysis of both arms and legs), dysphasia (condition that affects the ability to understand, use, or produce language) following cerebral infarction (lack of oxygen causing an area of dead tissue in the brain). . ." During a review of the facility's "Report of Suspected Dependent Adult/Elder Abuse" (SOC341), dated 1/23/25, the SOC 341 indicated, "It was reported today to Abuse Coordinator/Administrator and designee (Social Services Director) that the alleged aggressor, (Resident 2), displayed angry outbursts toward his roommate, (Resident 1). During a review of Resident 1's and Resident 2's "Census List" (CL), dated 2/7/25, the CL indicated, Resident 1 and Resident 2 had been roommates since 6/7/23 (approximately one year and 7 months). During an interview on 2/3/25 at 12:30 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated when Resident 1 and Resident 2 shared a room, Resident 2 would call Resident 1 a pedophile (person sexually attracted to children) and cuss at him. CNA 1 stated Resident 1 was unable to talk but would make grunting noises. CNA 1 stated after Resident 1 and Resident 2 were separated (1/23/25), Resident 1 yelled out less, slept more and seemed more comfortable. During an interview on 2/3/25 at 12:46 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 2 would yell at Resident 1 when he was moaning and groaning. LVN 1 stated Resident 2 was verbally aggressive towards Resident 1. LVN 1 stated after Resident 1 was moved to a different room, Resident 1 was resting more. During an interview on 2/3/25 at 12:54 p.m. with Social Service Director (SSD), SSD stated Resident 2 would have angry outburst towards others no matter how much he was redirected. During an interview on 2/3/25 at 1:37 p.m. with Director of Staff Development (DSD), DSD stated on 1/23/24, Resident 2 was telling Resident 1 to "shut up you f****** baby." DSD stated it was unfair for Resident 1 to hear those words on a day-to-day basis. DSD stated Resident 2 would say "shut the f*** up" all the time to Resident 1. DSD stated Resident 2 has always said (bad) words to Resident 1. DSD stated she reported it on 1/23/24 because when she went to ask Resident 2 to stop, Resident 2 told her to get the f*** out and if he was verbally abusive to her, she could only imagine what he said to Resident 1. DSD stated after Resident 1 was moved to a different room, Resident 1 was happier, sleeping more and he could moan without being called names. DSD stated Resident 2's verbally abusive behaviors should have been reported to the Administrator when it was happening in the past to protect Resident 1. During an interview on 2/6/25 at 3:55 p.m. with CNA 1, CNA 1 stated Resident 1 could not talk but was able to moan and yell out. CNA 1 stated Resident 2 would get mad at Resident 1 and tell him to shut up. CNA 1 stated when Resident 1 and Resident 2 shared a room together it was stressful to go in the room to provide care to Resident 1 because Resident 2 would call Resident 1 a dirty Mexican, say racial slurs and tell Resident 1 he was gay. CNA 1 stated Resident 1 and Resident 2 had shared a room together for a year. CNA 1 stated when she would report the verbal altercations to the nurses, they would say they were going to make a note of the behavior and care plan it. CNA 1 stated several CNAs said Resident 2 was verbally abusive to Resident 1. During an interview on 2/20/25 at 3:49 p.m. with Administrator, Administrator stated staff had never reported Resident 1 being verbally abusive to Resident 2. Administrator stated the staff should have reported the verbal abuse to him or the Director of Nursing (DON). During a review of the lesson plan titled "Abuse: Reporting Requirement & Procedures. . .What constitutes Abuse?" (ARRPWCA), dated 11/19/24 at 2 p.m., the ARRPWCA indicated, "Abuse Reporting & Investigations. . .What are the 7 types of abuse. . .verbal abuse. . .five things to do if you witness an abuse: Protect the victim. . .call for help. . .report. . .Resident Rights. . .Be free from abuse and neglect. . ." During a review of the facility policy and procedure titled, "Behavioral Assessment, Intervention and Monitoring" dated 3/19, the P&P indicated, "The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. During a review of the facility policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating" dated 9/22, the P&P indicated "If resident abuse, neglect, exploitation, misappropriation of resident property or injury or unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. . .Immediately is defined as within two hours of an allegation involving abuse resulting in serious bodily injury. . .within 24 hours of an allegation that does not involve abuse or result in serious bodily injury." The above violations caused or occurred under circumstances likely to cause significant anxiety, or other emotional trauma to Resident 5 and constitutes to a B citation.