Health inspection·September 6, 2024

F600: The following reflects the findings of the California Department of Public Health (CDPH) during an abbreviated standard survey. Facility Reported Incident Number: CA00912317. 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 Class B Citation was issued for the Facility Reported Incident: CA00912317. 42 CFR §483.12: Freedom from Abuse, Neglect, and Exploitation §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) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 42 CFR §483.12(b): Freedom from Abuse, Neglect, and Exploitation §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b)(4) Establish coordination with the QAPI program required under § 483.75 22 CCR §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 8/12/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident about abuse. The facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for Resident 1 who has severe cognitive impairment with no capacity to make decisions in accordance with facility's abuse policy and procedures. By failing to: 1. Implement the facility's policy and procedures (P&P) "Abuse Prevention and Prohibition Program" to protect and provide a safe and abuse free environment for two caregivers (CG1 and CG2). 2. Implement the facility's P&P "Caregiver Policy" to ensure the safety of residents in the facility. 3. Ensure the facility's Guest Liaison 1 (GL1- a person that ensures a seamless flow of communication and facilitates efficient utilization of resources) separated CG1 from Resident and did not leave Resident 1 alone in the facility's patio on 7/23/2024 at 1:09 PM with Care Giver 1 (CG1- another resident's caregiver) when CG1 and Resident 1 started to have a heated argument/conversation (a discussion or quarrel where the people involved are angry and exited). 4. Ensure Activities Director 1 (AD1) who entered the facility's patio on 7/23/2024 at 1:13 PM and having heard a verbal altercation (a heated or angry dispute: noisy argument) and witnessed CG1 argue with Resident 1, AD1 did not leave Resident 1 alone with CG1. AD1 did not separate CG1 from Resident 1. AD1 left the patio and allowed the altercation to continue between CG1 and Resident 1. On 7/23/2024 at 1:15 PM, CG1 slapped Resident 1 on the face twice. These deficient practices, resulted in CG1 physically abusing Resident 1 and placing Resident 1 at increased risk to suffer severe pain, and emotional distress (a highly unpleasant emotional reaction, severe body injury, serious impairment and/or death. During a review of Residents 1's Admission Record indicated Resident 1, an 83 years-old male, was initially admitted to the facility on 9/28/2023 and was readmitted on 1/5/2024 with diagnoses including diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), hypertension (HTN - elevated blood pressure), and generalized muscle weakness (lack of physical or muscle strength). During a review of Resident 1's Minimum Data Set (MDS - a standard assessment and care screening tool) dated 7/15/2023, indicated Resident 1 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. The MDS further indicated Resident 1uses a manual wheelchair for mobility and was dependent on staff to wheel and make turns. During a review of Resident 1's Change of Condition (COC -a sudden deviation from person/patient's baseline in physical, cognitive, behavioral or function) dated 7/23/2024 at 2:08 P.M., it indicated Licensed Vocational Nurse 1 (LVN 1) documented that the "administrative assistant saw ... the caregiver (CG1) allegedly got up and slapped [Resident 1] in the face." During a review of Resident 1's History and Physical (H&P- physician's examination of a resident, in which the physician obtains a thorough medical history from the resident or resident representative, performs a physical examination, and then documents the findings) dated 8/3/2024, it indicated Resident 1, "does not have capacity for medical decision making due to dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During an interview on 8/12/2024, at 7:30 A.M., the Infection Preventionist Nurse (IPN - a health professional who make sure healthcare workers and patients are doing all the things they should to prevent infection) stated that the facility had two caregivers who provided directed care to one resident (Resident 3). The IPN stated both caregivers were hired privately by the resident's family members. The IPN stated "I don't know the full name and phone number of the caregiver who was involved in the incident or the second caregiver coming in (facility) later that is now taking care of [Resident 3]." During an interview on 8/12/2024, at 8:50 A.M., using public health translation services with Resident 1, Resident 1 was unable to recall the alleged incident by Resident 3's caregiver. Resident 1 was unable to confirm or deny if she felt safe in the facility. During an interview on 8/12/2024, at 9:45 A.M., with GL1, GL1 stated Resident 1 "is mostly Farsi speaking. She used to speak "some" English when I first started working here." GL1 stated Resident 1, "likes to spend the day on the patio, will typically sit with [Resident 3] and his [Resident 3's] CG1 who are both Farsi speaking." GL1 stated she has been working at the facility for six months and that CG1 started working in the facility before GL1. GL1 stated that on 7/23/2024 at around 1 P.M., Resident 1 was seating on the patio with other residents and watching television. GL1 stated Resident 1 was sharing a table with Resident 3 and CG1. GL1 stated Resident 1, Resident 3, and CG1's table, "was in the back, so the other residents didn't see what was going on (CG1 had the altercation with Resident 1 and slapped Resident 1)." GL1 stated Resident 1 and CG1 started speaking to each other in Farsi, "I don't know what they were talking about, but I could tell the conversation was heated." GL1 stated AD1who had been in the activity room by the patio had heard the commotion between Resident 3 and CG1 and came outside and helped to calm the situation. GL1 stated, "[CG1] is gaslighting (a form of emotional abuse where one person manipulates another person into doubting their own perception, memories, and sanity) [Resident 1]." GL1 stated CG1 would normally help translate what Resident 1, "is saying, but because the conversation seemed heated, I went into the building to get another Farsi speaking person because I didn't trust that [CG1] would translate the right information in that moment." GL1 stated that when CG1 was inside the facility and on the way back to the patio, "I heard CG1 slap [Resident 1] and then saw [CG1] slap [Resident 1]." GL1 stated when she arrived at the patio, Resident 1 was no longer at the same table with Resident 3 and CG1. GL1 stated, "[CG1] had moved [Resident 1] to the back of the patio which is further behind the tables where the residents watch television, and then [CG1] slapped [Resident 1]." GL1 stated she separated CG1 and Resident 1. GL1 stated GL1 informed the Administrator (ADM) who instructed her to inform the social worker about the incident. GL1 stated the social worker called police officers who came to the facility about 10 minutes later. GL1 stated CG1 left the facility after CG1 spoke with the police officers. During an interview on 8/12/2024, at 12:50 P.M., , the Director of Nursing (DON) stated, "in order to ensure the safety of the residents, caregivers coming into the facility are provided with abuse training, and their background checks conducted." The DON stated the facility did not have documented evidence that the facility completed background search and abuse training for CG1 and Resident 3's caregiver 2 (CG 2). The DON stated, "It's my fault. I should have checked, I don't' have any background or orientation training on her (CG1) or the one (CG2) that is here now." The DON stated the facility did not have CG1 or CG2's last name or contact information. The DON stated, "We only have Resident 3's family phone number. We called them (Resident 3's family), and they said they do not have her (CG1's) phone number or last name. I will go right now and ask her (CG2) right for that information [phone number or last name] for you." The DON stated CG1 has been coming to the facility as Resident 3's caregiver for one year. During a concurrent record review and interview on 8/13/2024, at 2:45 P.M., with the ADM in the ADM's office, the facility's video surveillance (no sound) dated 7/23/2024, was reviewed. The video surveillance indicated the following: 1. On 7/23/2024 at 1:11 P.M., Resident 1 was seating at a table with Resident 3 and CG1, and GL1 was talking to Resident 1. 2. On 7/23/2024 at 1:12 P.M., LVN 1 was observed seated at the table with Resident 1, Resident 3, and CG 1, next to Resident 1. LVN 1 handed Resident 1 a small cup and placed a glass of water on the table in front of Resident 1. Resident 1 then tossed out into the air and onto the ground, white looking particles. GL1 then picked up the white looking particles from the ground. 3. On 7/23/2024 at 1:13 P.M., the AD1 showed up at the table where Resident 1, Resident 3, CG1, GL1 and LVN 1 were gathered. The AD 1 spoke to Resident 1 and CG1 for about two minutes. AD 1 then left the table and was out of frame of the video. 4. On 7/23/2024 at 1:13 P.M., LVN 1 left the table where Resident 1, Resident 3, CG 1, and GL 1 and were gathered and went inside the facility building. 5. On 7/23/2024 at 1:14 P.M., GL1 and the ADS both left the patio leaving Resident 1, Resident 3, and CG1 at the same table. 6. On 7/23/2024 at 1:14 P.M., Resident 1 stretched her right arm with closed fist toward CG1. 7. On 7/23/2024 at 1:15 P.M., Resident 1 was observed picking up a cup in front of her, on the table, and threw a clear liquid substance in the direction of CG1 and it landed on CG1. 8. On 7/23/2024 at 1:15 P.M., CG1 unlocked the brakes of Resident 1's wheelchair (WC), pulled and wheeled Resident 1 on the WC backwards. CG1 then turned Resident 1's WC to Resident 1's left side and around, and then pushed the WC forward toward the patio furniture. Resident 1, Resident 3, and CG1 were seating a few feet away directly opposite the table. CG1 then locked the left side of Resident 1's WC and slapped Resident 1 twice on the left cheek. During the concurrent record review and interview, the ADM stated the incident between CG1, and Resident 1 could have been avoided by separating CG1 and Resident 1 immediately. During a telephone interview on 8/12/2024, at 9:54 A.M., AD1 stated he was coming from the activities room and noticed that Resident 1 was "escalated, (when someone becomes more agitated, angry, or violent in a situation) was very, very upset, her body gestures were a little larger than they usually are, her voice was more elevated. She (Resident 1) was yelling which I did not understand what she (Resident 1) was yelling at but apparently it was directed at the caregiver [CG1] that was there for the other resident. I talked to her (Resident 1), she seemed to have come down a little bit, so I continued to assist the residents in the activity room." During a review of facility's undated policy and procedures (P&P) title "Caregiver Policy", indicated, "Purpose: To ensure staff and caregivers are aware of expectations of the facility and care of resident. * All Caregivers for resident will undergo an orientation ... which will include education on abuse, ..., and safety in the facility... * Caregivers on the facility will only be allowed to interact with the resident whom they have been hired for. During a review of facility's P&P dated 10/24/2022, title "Abuse Prevention and Prohibition Program", indicated, "Purpose: To ensure the facility establishes, operationalizes, and maintains an abuse prevention and prohibition program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. II. The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors..." The facility failed to protect the resident's right to be free from physical abuse for Resident 1 who has severe cognitive impairment with no capacity to make decisions in accordance with facility's abuse policy and procedures. By failing to: 1. Implement the facility's policy and procedures (P&P) "Abuse Prevention and Prohibition Program" to protect and provide a safe and abuse free environment for two of two caregivers (CG1 and CG2). 2. Implement the facility's P&P "Caregiver Policy" to ensure the safety of the residents in the facility. 3. Ensure the facility's GL1 separated CG1 from Resident and did not leave Resident 1 alone in the facility's patio on 7/23/2024 at 1:09 PM with CG1 (another resident's caregiver) when CG1 and Resident 1 started to have a heated argument/ conversation. 4. Ensure Activities Director 1 (AD1) who entered the facility's patio on 7/23/2024 at 1:13 PM and having heard a verbal altercation (a heated or angry dispute: noisy argument) and witnessed CG1 argue with Resident 1, AD1 did not leave Resident 1 alone with CG1. AD1 did not separate CG1 from Resident 1. AD1 left the patio and allowed the altercation to continue between CG1 and Resident 1. On 7/23/2024 at 1:15 PM, CG1 slapped Resident 1 on the face twice. These deficient practices resulted in CG1 physically abusing Resident 1 and placing Resident 1 at increased risk to suffer severe pain and emotional distress. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.