Other·March 12, 2025

The following reflects the findings of the California Department of Public Health during the investigation of a facility reported incident number 926476. The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. A deficiency was written for FRI # 926476 at F-tag 600/G. §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. §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. California Code Regulations, Title 22, § 72315 (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, § 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. On 10/24/24, at 12:08 PM, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding staff to resident physical abuse. Based on observation, interview, and record review, the facility failed to protect one of three residents (Resident 1) right to be free from abuse when Resident 1 was physical abused by a facility staff (Certified Nursing Assistant-CNA 1). This failure resulted in Resident 1 sustaining discoloration (bruise) to the left inner corner eye, discoloration to the right eyebrow, discoloration to bilateral upper extremities (region of the body that includes arm, forearm, and hand), discoloration to the back of left thigh, a bald spot to the back of head, and hospitalization. Findings: Resident 1 is an 86-year-old female, admitted to the facility on 10/5/21. Resident 1's diagnoses included Alzheimer's (a disease characterized by a progressive decline in mental abilities and Dementia (a progressive state of decline in mental abilities). Resident 1's annual Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 10/11/24, indicated Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident with a range of 0-15) score of 0 (score range from 0-7 means severe impairment). During a review of Resident 1's "Progress Notes (PN)," dated 10/21/24 at 9:21 p.m., the PN indicated, "At Approx. (approximately) 1930 (7:30 p.m.) Resident (Resident 1) was sent to ER (Emergency Room) for further eval (evaluation) per MD (Medical Doctor) orders. . .Heat [sic] to toe assessment performed. Discoloration noted to bilateral (right and left side) forearms. Discoloration to left eye. Redness noted to upper right eyebrow. Approx. Nickel size abrasion to left shin. . ." During a review of the facility's "Investigation Report (IR), dated 10/28/24, the IR indicated, "This nurse immediately assessed (Resident 1) for reported skin changes at approximately 1730 (5:30 p.m.) and noted skin intact, with discoloration to left inner corner eye, discoloration to right eyebrow, discoloration to bilateral upper extremities, and to left posterior (back) thigh. (Resident 1) is unable to verbalize events surrounding discoloration due to cognition (process of knowing) impairment. . .During initial investigation (Resident 1) is noted to share roommate (Resident 2) with a BIMS of 14 (score range from 13-15 intact cognition), who (Resident 2) verbalizes that "this morning (Resident 1) was being combative with the CNA (CNA 1) and was kicking and hitting the CNA, but the CNA was also hitting her back and had her against a corner holding her down. . ." During an interview on 10/24/24 at 12:11 p.m. with Administrator in Training (AIT), AIT stated a facility investigation was completed regarding the allegation of staff to resident abuse reported on 10/21/24 at 5:30 p.m. AIT stated Resident 2 had witnessed CNA 1 "cornering her (Resident 1), holding her down, pulling her hair." AIT stated Resident 1 sustained injuries which included, discoloration to left and right eye, discoloration to bilateral upper extremities, discoloration to the back of left thigh, a bald spot to the back of head. AIT stated based on Resident 2's witnessed statement and Resident 1 ' s injuries, "lead us to believe it could be caused from (CNA 1) doing that." During a concurrent observation and interview on 10/24/24 at 12:20 p.m. with Resident 1, Resident 1 was in her room, sitting in a chair eating lunch. Resident 1's left outer eye was noted with red/purple/black discoloration measuring approximately 2.5 centimeters (cm) and left inner eye with red discoloration measuring approximately 1 cm. Resident 1 only smiled when spoken to. During an interview on 10/24/24 at 12:52 p.m. with Director of Nurses (DON), DON stated on 10/21/24 at approximately 5 p.m. Licensed Vocational Nurse (LVN 1) reported Resident 1 having a new discoloration to left and right eye. DON stated upon further assessment, Resident 1 also had discoloration to bilateral upper extremities and discoloration to the back of her left thigh. DON stated all injuries "looked really fresh." DON stated Resident 1 had diagnosis of Alzheimer disease and dementia and was not able to verbalize how she sustained her new injuries. DON stated Resident 2 witnessed CNA 1 putting Resident 1 "against the wall, holding her down, and pulled her hair." DON stated Resident 2 is alert and oriented, and cognitively (process of knowing) intact. During a concurrent observation and interview on 10/24/24 at 1:26 p.m. with Resident 2, Resident 2 was in her room, sitting in her bed. Resident 2 stated on 10/21/24 at approximately 6 a.m. CNA 1 entered the room to provide care for Resident 1. Resident 2 stated the privacy curtain between the beds was halfway open and saw Resident 1 with eyes closed, when CNA 1 pulled her clothes down and attempted to change Resident 1. Resident 2 stated Resident 1 allowed CNA 1 to remove and change her top shirt but became combative. Resident 1 was kicking CNA 1 and refusing to change her pants. Resident 2 stated CNA 1 held Resident 1 with one hand and managed to pull Resident 1's pants off. Resident 2 stated she saw CNA 1 holding Resident 1 on the bed, pulled her hands by the wrist, got her up, placed her in the corner of the room, and pulled Resident 1 by the hair. Resident 2 stated Resident 1 continued to fight to be released. During an interview on 10/24/24 at 4:01 p.m. with CNA 1, CNA 1 stated on 10/21/24 at 5:30 a.m., she entered Resident 1's room to provide care. CNA 1 stated Resident 1 let her change her top clothing but "freaked out" when attempted to change Resident 1's briefs. CNA 1 stated Resident 1 became aggressive. During an interview on 10/30/24 at 11:32 a.m. with CNA 2, CNA 2 stated on 10/21/24 at 6:30 in the morning, she saw Resident 1 walking in the hallway with discoloration to her left eye. CNA 2 stated while changing Resident 1 with CNA 3, they noticed discoloration to bilateral upper extremities extending "from wrist all the way up below the elbow." CNA 2 stated Resident 1's discoloration to left and right eye, discoloration to her bilateral upper extremities found on 10/21/24 were not there on 10/20/24. CNA 2 stated Resident 1's discoloration to her left eye "looked like someone punched her in the eye" and the discoloration on bilateral upper extremities could be caused from being held too tight or "pressing on her like in a forceful way." During an interview on 10/30/24 at 11:48 a.m. with LVN 1, LVN 1 stated on 10/21/24 a full body assessment on Resident 1 was completed. LVN 1 stated Resident 1 had left and right eye discoloration and discoloration to bilateral upper extremities. LVN 1 stated the discoloration on both upper extremities would not have been caused by bumping into something. LVN 1 stated Resident 1's left and right eye discoloration and discoloration to her bilateral upper extremities found on 10/21/24, were not there on 10/20/24. LVN 1 stated Resident 1 was transferred to the acute hospital for further evaluation. During an interview on 10/30/24 at 12:01 p.m. with CNA 3, CNA 3 stated on 10/21/24, during breakfast, he noticed Resident 1's left eye and right eyebrow with red discoloration. CNA 3 stated while changing Resident 1 with CNA 2, they noticed discoloration to bilateral upper extremities. CNA 3 stated, "Really bad discoloration, like purple from wrist to below elbow." CNA 3 stated while combing Resident 1's hair, he noticed "bald spot in the back of her (Resident 1) head that had not been there before." During a review of Resident 1's "Emergency Documentation (ED-acute hospital)," dated 10/21/24 at 9:12 p.m. the ED indicated Resident 1 had "left periorbital (tissues around the eye) ecchymosis (bruise, discoloration) and bilateral forearm bruising." During a review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," dated 4/2021, the P&P indicated, "Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not acquired to treat the resident's symptoms. The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff;" In violation of the above cited standards, the facility failed to protect Resident 1 from physical abuse. This failure resulted in Resident 1 sustaining discoloration (bruise) to the left inner corner eye, discoloration to the right eyebrow, discoloration to bilateral upper extremities (region of the body that includes arm, forearm, and hand), discoloration to the back of left thigh, a bald spot to the back of head, and hospitalization. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and represents a Class "A" citation.