Health inspection·January 2, 2024

42 CFR §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. (a) The facility must— 1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 22 CCR §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. § 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. 22 CCR § 72527. Patient’s 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 11/21/23 the California Department of Public Health (CDPH) received a facility reported incident (FRI) indicating a License Vocational Nurse (LVN 1) aggressively threw Resident 1 in the bed. On 11/21/2023, the CDPH conducted an unannounced visit at the facility. The facility failed to: 1. Prevent the abuse of Resident 1 and Resident 2 when License Vocational Nurse (LVN 1) verbally and physically abused Resident 1 and verbally abused Resident 2. 2. Follow the facility’s policy and procedure (P&P), titled “Abuse and Mistreatment of Residents,” which indicated residents will be free from verbal, sexual, and mental abuse, corporal punishment, or involuntary seclusion when LVN 1 verbally and physically abused Resident 1, and verbally abused Resident 2. As a result, Resident 1 suffered abuse from LVN 1, LVN yelled at Resident 1 and pushed the resident on his bed causing the resident to cry, feel restless and fearful. The abuse from LVN 1 also resulted in Resident 2 feeling inhuman, withdrawn, and anxious (feeling uneasy). 1. A review of Resident 1’s admission record indicated Resident 1 was a 91-year-old man admitted to the facility on 6/15/2021 and re-admitted on 7/18/2023, with a diagnosis that included diabetes (abnormal blood sugar), dementia (impairment of memory and judgement) with behavioral disturbance, and encephalopathy (disturbance of the brain function). A review of Resident 1’s history and physical (H&P) dated 7/20/2023, indicated Resident 1 was able to make decisions for activities of daily living. A review of Resident 1’s minimum data set ([MDS] a standardized care assessment and care screening tool), dated 10/24/2023, indicated Resident 1’s cognitive skills (thought process) were moderately impaired, and he was sometimes understood by others. The MDS indicated Resident 1 required extensive assistance of one to two people assist with activities such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). The MDS indicated Resident 1 was always bowel and bladder incontinent (inability to control bladder and bowel function). A review of Resident 1’s care plan titled “Resident with episodes of uncontrollable mood swings, easily gets agitated and prefers to be alone,” dated 11/13/2023, indicated interventions including to approach resident in a calm and friendly manner, and if the resident became hostile during care, to stop and resume back when resident had calm down. A review of Resident 1’s change in condition (COC) form dated 11/20/2023 at 3:05 a.m., indicated Certified Nurse Assistant (CNA) reported that Resident 1 was standing at the door of his room and was unable to be re-directed to his bed. The COC indicated LVN 1, who was assigned to Resident 1, assisted the CNA’s in re-directing Resident 1 back to his bed. The COC indicated Resident 1 became aggressive and was swinging his arms uncontrollably. The COC indicated LVN 1 was unable to control Resident 1’s movements and LVN 1 became agitated and pushed Resident 1 onto his bed. A review of Resident 1’s Licensed Nurses Note dated 11/20/2023, at 2:10 p.m., indicated Resident 1 was alert and oriented to his name only, had impaired decision making and a long-term memory problem. The note indicated Resident 1 was being monitored after a staff (LVN 1) miss handled the resident. The note indicated Resident 1 was restless and showed signs of aggressive behavior towards staff when asked to sit in his chair. A review of Resident 1’s interdisciplinary team ([IDT]- team members from different disciplines working together to meet residents’ needs) dated 11/20/2023, indicated a meeting was held due to staff mishandling Resident 1. The IDT notes indicated Resident 1 became aggressive when staff asked him to return to his bed. The IDT notes indicated LVN 1 became agitated with Resident 1 and pushed the resident on to his bed. The note indicated Resident 1 was alert and oriented by name, but confused and unable to recall the pushing incident. During an interview on 12/11/2023 at 5:09 p.m., CNA 1 stated Resident 1 was standing outside of his room 11/20/2023 and even though he was not assigned to her (CNA 1), she was concerned that the resident would fall. CNA 1 stated she observed LVN 1 yelling and cursing at Resident 1 from the nursing station. CNA 1 stated LVN 1 walked over to Resident 1 and LVN 1 and CNA 1 grabbed Resident 1 by the arms and walked the resident back to his bed. CNA 1 stated LVN 1 was rushing Resident 1 back to his bed and Resident 1 became agitated and said, “slow down I cannot walk that fast, I feel like I am going to fall”. CNA 1 stated while at the edge of Resident 1’s bed, LVN 1 became agitated and pushed Resident 1 on the bed practically slamming the resident’s body. CNA 1 stated LVN 1 proceeded to yell and curse at Resident 1 stating “do not disrespect me. You will respect me and my nurses.” CNA stated she observed LVN 1 place his right fist on Resident 1’s chest and the left fist inside Resident 1’s mouth as he continued to curse and yell at Resident 1. CNA 1 stated Resident 1 looked frightened and started crying stating “please do not let that nurse hurt me.” During an interview on 12/11/2023 at 5:28 p.m., CNA 2 stated she was walking towards the elevator to get linens with CNA 1 and noticed Resident 1 standing outside his room. CNA 2 stated she observed LVN 1 yelling and cursing at Resident 1 from the nursing station. CNA 2 stated LVN 1 and CNA 1 proceeded to re-direct Resident 1 back to his bed. CNA 2 stated when she walked into the room, she observed LVN 1’s right fist on Resident 1’s chest and his left fist on the resident’s mouth yelling and cursing at Resident 1. CNA 2 stated LVN 1 was “muzzling” (preventing one from speaking freely) Resident 1 with his left fist. CNA 2 stated she pushed LVN 1 off, of Resident 1 and told LVN 1 that he was not allowed to treat the residents is such manner. CNA 2 stated she observed Resident 1 crying and saying, “please do not let that big black man come hurt me like that.” CNA 2 stated she and CNA 1 reported the incident to the RN Supervisor. 2. A review of Resident 2’s admission record indicated Resident 2 was a 36-old year male admitted to the facility on 7/29/2022 and re-admitted on 10/3/2023, with a diagnosis including muscular dystrophy (loss of muscle), quadriplegia (condition in which both arms and legs are paralyzed), and depression (a mental health disorder affecting how a person thinks, feels and behaves). A review of Resident 2’s H&P dated 10/3/2023, indicated Resident 2 had the capacity to understand and make medical decisions. A review of Resident 2’s MDS dated 9/15/2023, the MDS indicated Resident 2 was able to understand and be understood by other. The MDS indicated Resident 2 required max assistance of two person assist for activities such as dressing, toilet use, personal hygiene, transfer, and bed mobility. The MDS indicated Resident 2 was always incontinent of bowel and bladder. A review of Resident 2’s IDT meeting notes, dated 12/12/2023, indicated a meeting was held due to Resident 2’s allegations of verbal threats by LVN 1. The IDT notes indicated Resident 2 alleged LVN 1 threatened him by stating “don’t you ever disrespect me.” The IDT notes indicated Resident 2 felt frightened. A review of Resident 2’s psychiatric progress note dated 12/13/2023, indicated Resident 2 had anxiety and was withdrawn during the interview. The note indicated Resident 2 reported LVN 1 cursed at him, when he (Resident 2) asked for his medication. The note also indicated Resident 2 will continue with the current psychotropic medications (medication that affects behavior, mood, thoughts, or perception). During an interview on 12/11/2023 at 5:09 p.m., CNA 1 stated Resident 2 also had encountered harsh treatments from LVN 1. CNA 1 stated Resident 2 had reported to her that LVN 1 had yelled at him stating “you should be grateful that I am here. I could be at home with my family.” During an interview on 12/11/2023 at 5:28 p.m., CNA 2 stated at an unknown date and time, she observed Resident 2 crying after he was informed that LVN 1 was assigned to him. During an interview on 12/12/2023 at 1:45 p.m., Resident 2 stated he experienced mistreatment from LVN 1 before. Resident 2 stated whenever he asked LVN 1 for assistance he would ignore him and when he yelled louder for LVN 1 to assist him, LVN 1 would tell him “You should be grateful that I am helping you.” Resident 2 reported LVN 1 made degrading remarks to him and would curse and yell at him. Resident 2 stated LVN 1 never hit him, but he would get in front of his face multiple times to the point where he felt afraid that one day, he would be physically hit by LVN 1. Resident 2 stated LVN 1 made him feel inhuman and his anxiety would worsen whenever LVN 1 was assigned to him. Resident 2 stated he had expressed his concerns to various nurses at the facility including CNA 1 and CNA 2. During a concurrent interview with the Administrator (Admin), and Assistant Director of Nursing (ADON) on 12/12/2023 at 2:25 p.m., the Admin stated it was difficult to substantiate the allegations against LVN 1 because the interviews with the CNAs were incongruent. The Admin and the ADON stated they were not aware Resident 2 experienced harsh treatment from LVN 1. The Admin stated LVN 1 was dismissed from the facility. A review of the facility’s undated P&P titled “Abuse and Mistreatment of Residents”, indicated the facility will uphold the residents right to be free from verbal, sexual, and mental abuse, corporal punishment, and involuntary seclusion. The P&P indicated abuse was the willful infliction of injury, unreasonable conferment, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The facility failed to: 1. Prevent the abuse of Resident 1 and Resident 2 when LVN 1 verbally and physically abused Resident 1 and verbally abused Resident 2. 2. Follow the facility’s P&P, titled “Abuse and Mistreatment of Residents,” which indicated residents will be free from verbal, sexual, and mental abuse, corporal punishment, or involuntary seclusion when LVN 1 verbally and physically abused Resident 1, and verbally abused Resident 2. As a result, Resident 1 suffered abuse from LVN 1, LVN yelled at Resident 1 and pushed the resident on his bed causing the resident to cry, feel restless and fearful. The abuse from LVN 1 also resulted in Resident 2 feeling inhuman, withdrawn, and anxious. The above violations either jointly, separately, or in any combination presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result to Resident 1.