Health inspection·June 20, 2025

§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. §483.25(d) Accidents The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 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 4/21/2025 the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) reporting a resident (Resident 1) struck another resident (Resident 3) multiple times with a stick. On 5/5/2025 CDPH conducted an unannounced visit to the facility to investigate the FRI. Upon investigation, CDPH determined Resident 1 acquired a stick ([dowel] a pole or rod used in rehabilitation to improve shoulder mobility and strength) from the facility's Rehabilitation (Rehab) room and used the dowel to strike Resident 3 on 4/19/2025, causing Resident 3 to fall on the floor. The investigation determined that Resident 1 was previously accused (2/24/2024) of striking another resident (Resident 2) with a cane/stick that resembled the dowel used to assault Resident 3 with on 4/19/2025. The facility failed to: 1 Ensure equipment located in the facility's Rehab room was secured and not readily accessible for unauthorized use by residents and/or visitors and used as a weapon. Resident 1 used the rehab's equipment, a dowel, to hit Resident 3 on 4/19/2025 and Resident 2 on 2/24/2025. 2. Ensure Resident 1 did not gain access to a dowel from the facility's Rehab room without staff knowledge or consent. 3. Ensure Resident 1 did not use a dowel to physically assault Resident 3 on 4/19/2024 and Resident 2 on 2/24/2025. 4. Ensure staff implemented the facility Policy and Procedure (P&P) titled, "Safety and Supervision of Residents" dated 7/2017, which indicated, "the facility has individualized resident centered approach to safety, addresses safety and accident hazards for individual residents. The interdisciplinary care team ([IDT] a group of health care professionals with various areas of expertise who work together toward the goals of the residents) shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment." These failures resulted in Resident 1 using a dowel to hit Resident 2 on her left arm on 2/24/2025, and Resident 3 on her right arm, right shoulder, and face then pushing Resident 3 to the floor on 4/19/2025. Resident 3 sustained a fracture (a break in a bone) to the mid sacrum (a triangular bone located at the base of the spine [back]) and was transferred to a General Acute Care Hospital (GACH) on 4/22/2025. These deficient practices placed residents' and/or visitors at risk for serious harm and death. A review of Resident 1's Face Sheet (the front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was originally admitted to the facility on 5/20/2024 and readmitted on 4/29/2025 with diagnoses including anxiety disorder (a mental health condition characterized by excessive worry and fear that significantly interferes with daily life) and unspecified signs and symptoms (s/s) involving cognitive function decline (changes in thinking, memory, or attention that are not clearly categorized as a specific type of cognitive deficit) following a cerebral infarction ([stroke] loss of blood flow to a part of the brain)). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 2/23/2025, indicated Resident 1's cognition was intact (able to make independent and reasonable decisions). A review of Resident 2's Admission Record, (Face Sheet), indicated Resident 2 was originally admitted to the facility on 4/15/2024 and readmitted 2/16/2025 with diagnoses including mild cognitive impairment (a brain condition that causes noticeable but mild memory and thinking problems) unspecified dementia (a progressive state of decline in mental abilities without behavioral disturbance, psychotic disturbance (a state where a person's thinking, perception, and behavior are significantly altered, leading to a loss in contact with reality), mood disturbance (a serious mental illness that causes persistent and intense changes in a person's mood, energy, and behavior), and anxiety. A review of Resident 2's MDS, dated 2/24/2025, indicated Resident 2's cognition was intact. A review of Resident 3's Admission record (Face sheet) indicated Resident 3 was admitted to the facility on 1/28/2025, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or inability to move on one side of the body) following a cerebral infarction affecting Resident 3's left non dominant side. A review of Resident 3's MDS, dated 2/4/2025, indicated Resident 3 's cognition was intact. The MDS indicated Resident 3 used a walker (a device used to assist with walking) for mobility. A review of Resident 3's H&P dated 2/19/2025, indicated Resident 3 was alert and able to make decisions regarding routine medical decisions and her immediate needs. A review of Resident 1's Progress Note, dated 2/24/2025, indicated Resident 2 reported that Resident 1 hit her with a cane/stick on her left arm. A review of Resident 1's Change in Condition (COC) Evaluation, dated 2/24/2025, the COC indicated at 10:43 p.m., Resident 2 reported that Resident 1 struck her with a "stick." A review of the facility's Investigation of Resident 2's allegation dated 2/24/2025, indicated "the cane/stick" was not located and there were no witnesses who saw the cane/stick. A review of Resident 3's Nurses Progress Note, dated 4/20/2025, indicated Resident 3 reported that Resident 1 pushed her down and hit her with a "stick" multiple time on 4/19/2025. The Nurses Progress Note indicated three Certified Nursing Assistants (CNAs), CNA 2, CNA 3 and CNA 4, reported seeing Resident 1 walking away from Resident 3's bed with a "stick" wrapped in a white sheet. The Nurses Progress Note indicated Resident 1 reported that Resident 3 always disrespected her and would always close the sliding door in the room and the room was always hot. The Nurses Progress Note indicated Resident 1 reported today (4/19/2025) she (Resident 3) closed the sliding door, and she (Resident 1) opened it. A review of Resident 1's Nurses Progress Note, dated 4/21/2025 and timed at 10:06 a.m., indicated Resident 3 requested an X-ray of her right shoulder and back. A subsequent Nurses Progress Note dated 4/21/2025 timed at 12 p.m., indicated the Nurse Practitioner (NP) ordered a STAT (immediately) X-ray for Resident 3. A review of Resident 3's X-ray results dated 4/21/2025, indicated Resident 3 had an acute fracture of the mid sacrum. A review of Resident 3's Physician's Order, dated 4/22/2025, indicated to transfer Resident 3 to the GACH for an X-ray of her lumbar spine (lower portion of the back) and sacrum. A review of Resident 3's Nurses Progress Note, dated 4/22/2025 and timed at 2:40 p.m., indicated Resident 3 was transported to a GACH for evaluation due to an X-ray result that indicated a fracture of the mid sacrum. A review of the GACH's Face Sheet, indicated Resident 3 was admitted to the GACH on 4/22/2025. A review of GACH's Radiology Results, dated 4/22/2025, indicated Resident 3 sustained a non-displaced fracture (a broken bone where he bone fragments remain in their correct alignment after the break) of the mid sacrum. A review of the GACH's Assessment and Plan, dated 4/22/2025, indicated Resident 3 was given Percocet (no dosage indicated) and a Lidocaine patch (no dosage indicated) for pain management. A review of Resident 1's IDT Conference Record, dated 4/23/2025, indicated Resident 1 had poor impulse control and was easily angered. The IDT Conference Record indicated there was no reference to the dowel Resident 1 used to strike Resident 3 or interventions to prevent access to the dowel. During an interview on 5/5/2025, at 3:40 p.m., Resident 3 stated, approximately two Saturdays ago (unsure of the date), Resident 1 was upset because the patio door, that was located near her (Resident 3) bed, was closed and locked. Resident 3 stated Licensed Vocational Nurse (LVN) 1 explained to Resident 1 that the door had to remain closed at 7 a.m., because it was cold. Resident 3 stated Resident 1 argued with LVN 1 about the door being closed but thought she finally accepted what LVN 1 said. Resident 3 stated she was lying in bed watching television (4/19/2025) when Resident 1 called her names using expletives (a swear word). Resident 3 stated, Resident 1 had a "pole" in her hand and walked over to her (Resident 3) bed and hit her (Resident 3) on her right arm, right shoulder, and the "pole" grazed the right side of her face. Resident 3 stated she stood up because she was afraid of what Resident 1 would do next. Resident 3 stated she screamed for help and that was when Resident 1 turned and pushed her and she (Resident 3) fell backwards, hitting a wheelchair and bedside table on her way to the floor. Resident 3 stated Resident 1 tried to hide the "pole" in a sheet, but a CNA (unknown) saw the "pole" and took it away from Resident 1. Resident 3 stated she does not feel safe; she can't sleep and is afraid Resident 1 will find her and harm her. During an interview on 5/5/2025, at 3:55 p.m., Resident 1 refused to speak about the alleged incident. During an interview on 5/5/2025, at 4:10 p.m., CNA 2, stated on 4/19/2025 she heard yelling and screaming coming from a room (Resident 1 and Resident 3's shared room) and when she entered the room, she saw Resident 3 on the floor against the wall and Resident 1 was standing over Resident 3 holding a "pole" in her hand and calling Resident 3 expletives. Resident 3 stated the "pole" that Resident 1 used to hit Resident 3 with, was approximately two to three feet long, wrapped in a sheet. During an interview on 5/6/2025, at 2:32 p.m., CNA 3, stated, around 10 p.m., (4/19/2025) she heard loud yelling coming from Resident 1's room. CNA 3 stated she, CNA 2, and CNA 4, who also heard the yelling, ran to Resident 1's room. CNA 3 stated when she arrived at the room, she saw Resident 1 holding a "pole" that was approximately three feet long, wrapped in a sheet, Resident 1 was standing over Resident 3 who was lying on the floor between the bed and the patio door in a fetal position (lying on one's side with knees pulled up towards the chest). During an interview on 5/6/2025, at 3:37 p.m., Registered Nurse Supervisor (RNS) 1 stated, a few months ago Resident 2, Resident 1's former roommate, accused Resident 1 of hitting her (Resident 2) with a stick. RNS 1 stated she looked everywhere for the stick but couldn't find it. During an interview on 5/7/2025, at 11:15 a.m., the Director of Rehabilitation (DOR) stated, when staff from the Rehab Department were not in the Rehab room, they close the door, but they don't lock it. The DOR stated, when the Rehab staff leave the facility, between 5 p.m. and 7 p.m., they (Rehab staff) lock the door. The DOR stated there were a total of 10 weighted dowels hanging on the wall in the Rehab room, and one of them was used by Resident 1 to hit Resident 3. The DOR stated the dowel weighed two pounds. During an observation on 5/7/2025 (18 days after Resident 1 struck Resident 3 with the dowel that was identified coming from the Rehab room), at 2:20 p.m., with the Administrator (ADM) and the Director of Nursing (DON) present, in the rehabilitation room, dowels and free weights of different weight and sizes were observed hanging unsecured on a wall in the Rehab room. During a concurrent observation and interview on 5/7/2025, at 2:57 p.m., the DOR showed the dowel to Resident 2 and Resident 2 confirmed that the dowel looked like the object that Resident 1 hit her with on 2/24/2025. During a review of the facility's P&P, titled, "Safety and Supervision of Residents" dated 7/2017, the P&P indicated, our individualized resident centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment. The P&P indicated Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The facility failed to: 1. Ensure equipment located in the facility's Rehab room was secured and not readily accessible for unauthorized use by residents and/or visitors and used as a weapon. Resident 1 used the rehab's equipment, a dowel, to hit Resident 3 on 4/19/2025 and Resident 2 on 2/24/2025. 2. Ensure Resident 1 did not gain access to a dowel from the facility's Rehab room without staff knowledge or consent. 3. Ensure Resident 1 did not use a dowel to physically assault Resident 3 on 4/19/2024 and Resident 2 on 2/24/2025. 4. Ensure staff followed the facility P&P titled, "Safety and Supervision of Residents" dated 7/2017, which indicated, "the facility has individualized resident centered approach to safety, addresses safety and accident hazards for individual residents. The IDT shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment. These deficient practices resulted in Resident 1 obtaining a dowel from the facility's Rehab room without staff knowledge or consent and used the dowel to hit Resident 2 on her left arm on 2/24/2025 and Resident 3 on her right arm, right shoulder, and face then pushing Resident 3 to the floor on 4/19/2025. Resident 3 sustained a fracture to the mid sacrum and was transferred to a GACH on 4/22/2025. These deficient practices placed residents' and/or visitors at risk for serious harm and death. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 3.