Health inspection·October 31, 2023

On 9/11/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about employee on resident abuse. The facility failed to protect the resident's right to be free from failed to be free from physical abuse when CNA student 1 (CS 1) and CS 2 witnessed Certified Nurse Assistant (CNA 1) roughly handle and was verbally demanding towards Resident 1 during incontinent (having no or insufficient voluntary control over urination) care for Resident 1. This deficient practice resulted in Resident 1 crying and feeling upset. During an observation on 9/11/2023 at 12:53 pm, Resident 1 was observed sitting on a wheelchair using both feet to move around the hallway. Resident 1 touched the wall, handrail, own clothing, and wheelchair ' s arm rest repeatedly. Resident 1 was seen mumbling (talking) to self at times. Resident 1 looked around the surroundings several times but did not recognize the staff and residents nearby. During an interview on 9/11/2023 at 1:00 pm with Resident 2, the resident stated Resident 1 was combative during care, but would stop being combative when the staff left the resident alone. During an interview on 9/11/2023 at 2:48 pm with Certified Nurse Assistant (CNA 2), CNA 2 stated Resident 1 "sometimes yells at me" when Resident needed to be changed due to incontinence. During a telephone interview on 9/12/2023 at 3:57 pm, CNA student (CS 1) stated Resident 1 was sitting on wheelchair while, "urine was leaking on the floor". CS 1 stated CS2 helped take Resident 1 the resident ' s room and informed the resident they needed to change her clothes and brief but Resident 1 stated "no." CS 1 stated she informed CNA 1 that Resident 1 was wet but declined to be changed. CS 1 stated CNA 1 came into Resident 1 ' s room, picked the resident up "from behind under her armpits then abruptly tossed her on the bed". CS 1 added CNA 1 "just turned (Resident 1) over abruptly facing the wall, took (Resident 1 ' s) pants off and removed the resident ' s brief. CS1 stated CNA 1 "pulled [Resident 1 ' s] pants from the back" while Resident 1 was "screaming and keeping her legs closed tight." CS 1 further stated CS 2 was translating, what Resident 1 was saying in Spanish, "you ' re being too rough" but CNA 1 continued to remove the incontinence brief ". CS1 stated CNA 1 "just ripped it off." CS 1 stated Resident 1 continued to say in Spanish "you ' re being too rough" over and over but CNA 1 continued to change Resident 1. CS 1 stated CNA 1 was "just too rough, CNA 1 pushed Resident 1 to the side of the bed then ripped off the pants - kind of like someone trying to take advantage of somebody, so maybe Resident 1 was thinking what was CNA 1 was doing..." During a telephone interview on 9/12/23 at 7:52 pm, CNA student (CS 2) stated Resident 1 was sitting in wheelchair with soiled brief "so full it was wetting the floor." CS 2 stated both CS 1 and CS 2 took Resident 1 to the resident ' s room. CS 2 stated CNA 1 laid Resident 1 on the bed, while Resident 1 was crying, and was stating she did not want the pants removed. CS 2 stated CNA 1 pushed the resident slightly on the bed so that the resident will be lying flat on the bed. Resident 1 had closed legs and kept saying "no, no". CS 2 stated CNA 1 "started removing the resident ' s pants, while the resident clenched legs, then CNA 1 turned the resident to face the wall. CNA 1 snatched the brief off while Resident 1 was crying. CNA 1 said to Resident 1 "you stink we have to change you." CS 2 further stated Resident 1 said to CNA 1 in Spanish "you are being rough" and translated this in English for CNA 1 to understand. CS 2 stated CNA 1 acted "like ...he did not hear me". CS 2 added CNA 1 took off Resident 1 ' s two shirts because "it was wet at the bottom of the shirts" by grabbing Resident 1 ' s left arm "roughly and grabbing the resident ' s wrist tightly" and "pried open her fingers so he could get the shirts removed." CS 2 stated when their CNA Instructor (CI) walked into the room, CNA 1 ' s "demeanor changed, all of a sudden CNA 1 was showing empathy to Resident 1. CNA 1 "was no longer rough towards the resident and CNA 1 spoke to the resident in a low voice." During a telephone interview on 9/13/23 at 4:46 pm, with CNA Instructor (CI), the CI stated when she entered the room, she saw CNA 1 "pushing Resident 1 on the left side of the resident ' s arm to move the resident to the middle of the bed ...like trying to reposition the resident to the center of the bed." CI stated Resident 1 was "not crying ...CS 2 talked to Resident 1 in Spanish comforting her ...I did not see any combative behavior from the resident (while she was being comforted)." During a record review of Resident 1 ' s Admission Record (face sheet), the face sheet indicated Resident 1 was admitted on 6/8/2023 with diagnoses including dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and may cause changes in mood and personality), Alzheimer ' s disease (a common type of dementia that affects memory, thinking, and behavior), muscle weakness (when muscles are weak causing difficulty performing normal activities that require strength), and urinary tract infection ([UTI], infection in the bladder or urethra-a tube where urine passes). During a review of Resident 1 ' s History and Physical [H&P] (a physician ' s first complete patient examination) dated 6/16/2023, the H&P indicated Resident 1 was able to make needs known but cannot make medical decisions. During a review of the facility ' s undated Policy and Procedure [P&P] titled "Abuse Prevention and Prohibition Program," indicated "each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property." The record also indicated that the "facility is committed to protecting residents from abuse by ...staff from other agencies serving residents." The facility failed to protect the resident's right to be free from failed to be free from physical abuse when CS 1 and CS 2 witnessed CNA 1) roughly handle and was verbally demanding towards Resident 1 during incontinent care to Resident 1. This deficient practice resulted in Resident 1 crying and feeling upset. The above violations had a direct relationship to the health, safety, and security of all residents in the facility.