Health inspection·February 12, 2025

F600 §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. §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. § 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. § 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. 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 1/21/2025 the California Department of Public Health (CDPH) received a facility reported incident (FRI) alleging Resident 2 punched and slapped Resident 1 in the face multiple times on 1/17/2025. On 1/22/2025, CDPH conducted an unannounced visit to the facility to investigate the FRI allegation. Upon investigation, CDPH determined the facility failed to protect Resident 1's right to be free from physical abuse when Resident 2 punched and slapped Resident 1 in the face multiple times. Resident 1 developed scattered facial redness and pain. The facility failed to: 1. Ensure Resident 2 has been transferred to a higher level of care for evaluation and treatment of aggressive behavior to prevent physical abuse toward Resident 1 and other residents and staff. 2. Ensure there was a plan of care in place for Resident 2's dislike to have roommates and noise, and preference to be alone in his room with interventions to safeguard Resident 1 and other Resident 2's roommates from actual and potential physical abuse. 3. Ensure staff monitored Resident 2's closely for aggressive behavior towards staff and residents as indicated in Resident 2's care plan titled, "Alteration in mood and behavior related to bipolar disorder, Alzheimer's Disease, and psychosis" revised on 8/26/2024. 4. Ensure staff followed the facility's policy and procedures titled, "Identifying Types of Abuse," revised 9/2022, which indicated, "Abuse of any kind against residents is strictly prohibited." As a result, Resident 2 slapped and punched Resident 1 in the face repeatedly on 1/17/2025. Resident 1 sustained scattered facial redness on bilateral (both) cheeks, forehead, and nose and complained of pain level three out of 10 on a pain rating scale from zero to ten (a numeric pain scale with zero represents no pain and 10 represents the worst pain imaginable) and verbalized loss of appetite after the incident. Findings: A review of Resident 1's Admission Record indicated Resident 1, an 82-year-old male, was admitted to the facility on 10/26/2022 with diagnoses including muscle weakness, fracture (broken bone) right femur (thigh bone) and cellulitis (a skin infection that causes redness and swelling). A review of Resident 1's Minimum Data Set ([MDS]- resident assessment tool) dated 11/3/2024, indicated Resident 1 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 1 required supervision with hygiene, bathing, and dressing. A review of Resident 1's Change of Condition (COC) dated 1/17/2025 timed at 8:30 p.m., indicated Resident 1 had emotional distress and psychological (relating to the mind, thoughts, feelings, and emotions) distress secondary to a physical altercation (an argument between people). The COC indicated Resident 1 was hit in the face by his roommate, developed scattered facial redness on bilateral (both) cheeks, forehead, and nose complained of pain, which was relieved by applying a cold compress, administration of Tylenol (pain medication), and numbing (loss of feeling) cream (unknown). A review of Resident 2's Admission Record indicated Resident 2, a 75-year-old male, was admitted to the facility 8/15/2022 with diagnoses including bipolar disorder (mood swings that range from lows of depression to elevated periods of emotional highs), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality). A review of Resident 2's MDS dated 11/21/2024, indicated Resident 2 had severe cognitive impairment. The MDS indicated Resident 2 required set-up assistance with eating, oral hygiene, and dressing. A review of Resident 2's COC dated 4/11/2024 timed at 5:24 p.m., indicated Resident 2 opened the bathroom door while roommate (unknown) was inside. The COC indicated roommate closed the bathroom door, Resident 2 got upset opened the bathroom door purposely causing to hit the roommate. A review of Resident 2's COC dated 1/17/2025 timed at 8:35 p.m., indicated Resident 2 admitted to hitting Resident 1 in the face because Resident 1 talks too much. A review of Resident 2's Physician Order Summary Report dated 12/27/2024 indicated an order for Seroquel ( medication that treats mental health condition) for bipolar ( mood swings that range from the lows of depression to elevated periods of emotional highs) disorder manifested by fluctuation (a constant back and forth change in something) of mood from being pleasant to having a loud sudden spontaneous angry outburst toward staff and others. A review of Resident 2's Physician Order Summary Report, dated 12/27/2024 indicated an order to monitor Resident 2's episodes of bipolar affective manifested by fluctuation of mood from being pleasant to having a loud sudden spontaneous angry outburst toward staff and others which impedes Resident 2's health condition. A review of Resident 2's Care Plan titled "Alteration in mood and behavior related to bipolar disorder, Alzheimer's Disease, and psychosis" revised on 8/26/2024, indicated the goal for the resident was not to have behavioral episodes. The Care Plan interventions included monitoring the resident's interactions with other residents to prevent offensive behaviors. The Care Plan interventions included to always approach resident in a calm and unhurried manner, provide reassurance and maintain trust and rapport with the resident, and reduce environmental stimuli (changes in the environment that cause a reaction from a person). During an interview on 1/22/2025 at 10:41 a.m., Resident 1 stated that Resident 2 repeatedly slapped and punched him when he was talking to him while lying defenseless in bed. Resident 1 stated this incident made him feel terrible. Resident 1 stated his face was reddened from the slaps and punches he "took from Resident 2." Resident 1 stated he was given Tylenol as his face was hurting. During an interview on 1/22/2025 at 2:21 p.m., the Licensed Vocational Nurse (LVN) 1 stated Resident 2 did not like having roommates, did not like noise, and preferred to be alone in his room. LVN 1 stated Resident 2 would be calm one minute and then suddenly snap. LVN 1 stated that Resident 2 has been known to be aggressive with other residents if they were talking a lot or were loud. During a concurrent interview and record review on 1/22/2025 at 2:44 p.m., with Registered Nurse Supervisor (RNS), Resident 2's care plan titled "Resident 2 had a history of aggressive behavior towards others..." was reviewed. RNS stated the incident could have been prevented if Resident 2 was given a private room or transferred to a higher level of care like general acute care hospital (GACH) for evaluation of Resident 2's aggressive behavior. RNS stated Resident 2 will benefit from being in a private room because of his unpredictable behavior toward other residents and staff. RNS 2 stated Resident 2's desire not to have roommates was not care-planned but should have been. RNS stated Resident 1 had loss of appetite after the incident on 1/17/2025 with Resident 2. During an interview on 1/22/2025 at 3:14 p.m., with the Director of Nursing (DON), the DON stated Resident 2 was easily getting angry and irritated. The DON stated the incident could have been prevented if Resident 2 was transferred out of the facility for evaluation of his aggressive behavior in the past with other residents. The DON stated Resident 2 was a higher risk for hurting another resident. The DON stated Resident 1 developed redness in his face from being slapped and punched in the face. The DON stated Resident 1 complained of pain and a loss of appetite after the incident on 1/17/2025. During an interview on 1/23/2025 at 3:38 p.m., LVN 2 stated Resident 2 told her he hit Resident 1 because he (Resident 1) talks too much. LVN 2 stated Resident 1 developed redness to his face from the incident and was provided with cold compress to the face. LVN 2 stated that this was the second time Resident 2 has had an altercation with a resident. LVN 2 stated Resident 2 resided in the room alone without the roommate. LVN 2 stated Resident 1 was transferred to Resident 2's room (cannot remember when) because the facility felt it was safe because Resident 1 was quiet and was not talking much. LVN 2 stated Resident 2 did not like to have roommates, and it could have been prevented if Resident 1 was not cohorted with Resident 2 in one room, and Resident 2 was monitored closely for aggressive behavior towards staff and residents. LVN 2 stated Resident 2 should have been transferred to a higher level of care because of his history of aggressive behavior and sudden outbursts of anger which was "scary to other residents." A review of the facility's policy and procedure (P&P) titled, "Identifying Types of Abuse," revised 9/2022, indicated, "Abuse of any kind against residents is strictly prohibited. It is understood by the leadership in this facility that preventing abuse requires staff education, training, and support, and a facility-wide culture of compassion and caring." A review of the facility's P&P titled, "Resident-to-Resident Altercations," revised 9/2022, indicated, "Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family, members, visitors, or to the staff ...Behaviors that may provoke a reaction of others include verbally aggressive behavior...physically aggressive behavior such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects." The facility failed to: 1. Ensure Resident 2 has been transferred to a higher level of care for evaluation and treatment of aggressive behavior to prevent physical abuse toward Resident 1 and other residents and staff. 2. Ensure there was a plan of care in place for Resident 2's dislike to have roommates and noise, and preference to be alone in his room with interventions to safeguard Resident 1 and other Resident 2's roommates from actual and potential physical abuse. 3. Ensure staff monitored Resident 2's closely for aggressive behavior towards staff and residents as indicated in Resident 2's care plan titled, "Alteration in mood and behavior related to bipolar disorder, Alzheimer's Disease, and psychosis" revised on 8/26/2024. 4. Ensure staff followed the facility's policy and procedures titled, "Identifying Types of Abuse," revised 9/2022, which indicated, "Abuse of any kind against residents is strictly prohibited." As a result, Resident 2 slapped and punched Resident 1 in the face repeatedly on 1/17/2025. Resident 1 sustained scattered facial redness on bilateral cheeks, forehead, and nose and complained of pain level three out of 10 on a pain rating scale from zero to ten and verbalized loss of appetite after the incident. These violations had a direct or immediate relationship to the health, safety, or security of residents.