Health inspection·March 19, 2025

California Code of Regulations, Title 22,  22 CCR § 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: (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. 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. 22 CCR § 72517. Staff Development. (a) Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not be limited to: (3) Interpersonal relationship and communication skills. (7) Preservation of patient dignity, including provision for privacy. Code of Federal Regulations, Title 42  F557 42 CFR §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: 42 CFR §483.10(a) Resident Rights. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident’s individuality. The facility must protect and promote the rights of the resident. An unannounced visit was conducted by California Department of Public Health (CDPH) on 2/7/2025 to investigate a complaint regarding an allegation of an abuse. The facility failed to ensure Resident 2 was treated with dignity and respect during a routine diaper change by failing to: 1. Ensure Resident 2 was treated with kindness, respect, and dignity as indicated in the Facility Policy titled "Dignity" dated February 2021. 2. Ensure the facility's staff spoke respectfully, without the use of demeaning practices and standards of care that compromised dignity as indicated in the Facility Policy titled "Dignity" dated February 2021. This resulted in having the potential to negatively impact the Resident 2, leading to decreased self-worth, fear, vulnerability and depression. A review of Resident 2's admission record indicated Resident 2, a 69-year-old-female, was admitted on 5/26/2022 with a diagnosis that included cerebral infarction (or stroke, occurs when blood flow to the brain is blocked, damaging brain cells) and hemiplegia (weakness of one side of body) and hemiparesis (inability to move on one side of the body) related to cerebral infarction (stroke). A review of Resident 2's Care plan dated 3/22/2023, titled "Urinary incontinence" indicated Resident 2 was to be kept clean, dry, and odor free. The listed interventions included to conduct a bladder assessment, check incontinence every two hours, encourage fluid intake and offer fluids, and provide Perineal care (cleaning and hygiene of washing the genital and anal area of the body) as needed. A review of Resident 2's Minimum Data Set (MDS), a comprehensive assessment used as a care- planning tool dated 12/13/2024, indicated Resident 2's cognition was intact (the ability for one to think, learn and understand with the ability to use sufficient judgment in planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment). The MDS Further indicated Resident 2 required moderate assistance (helper does more than half the effort, lifting or holding trunk or limbs) with toileting hygiene. During an interview with Certified Nursing Assistant 2 (CNA2) on 2/7/2025 at 12:42PM, CNA2 stated having knowledge of an abusive CNA who has been mistreating residents. CNA2 stated Resident 2, who has a boyfriend, told her CNA3 and CNA4 had been teasing her and making inappropriate comments such as whether she is too old to have a boyfriend and asking her if she plans to have sex with him. CNA2 further stated she had recommended that she report this to her Social Worker. CNA2 stated after speaking to Resident 2 she reported the incident to the Social Worker. During an interview with Resident 2 on 2/7/2025 at 1:10PM, Resident 2 stated there were CNAs, CNA3 and CNA4 who repeatedly teased her on 2/6/2025. Resident 2 further stated the CNAs would ask her if she would have sex with her boyfriend, stating they would laugh at her and thought it was amusing to ask her these things while they were changing her diaper. Resident 2 went on to say how vulnerable she felt and further stated feeling helpless to say anything, fearing it would only make the situation or her treatment worse. Resident 2 stated this type of behavior went on for a while until she reported the incident to her social worker (SW) and the Director of Staff Development (DSD). Resident 2 stated after she had reported the incidents the CNAs were not assigned to her again. During an interview with Director of Staff Development (DSD) on 2/7/2025 at 2:26 PM, the DSD stated Resident 2 had spoken with him on 2/6/2025, stating Resident 2 did not wish to be assigned to CNA3 or CNA4. The DSD stated at the time Resident 2 did not wish to specify why she no longer wished to be assigned to CNA3 and CNA4, only stating that she did not want anyone to get into trouble. The DSD stated he did not investigate further, nor did he provide documentation of the incident. The DSD further stated he had not spoken to either CNA3 or CNA4 regarding the incident only that they were not to be assigned to Resident 2 in the future. The DSD stated it was the responsibility of the Social Worker and the Director of Staff Development to further investigate ensuring the safety and wellbeing of the resident. During a concurrent interview and record review on 2/7/2025 at 2:07 PM with the Director of Staff Development (DSD), employee records for CNA3 and CNA4 were reviewed. The Employee records indicated there were no past corrections that had been issued for CNA3 or 4, nor have there been any in-services conducted related to conduct concerning the dignity of residents. During a concurrent interview and record review on 2/7/2025 at 2:30 PM with the Director of Staff Development (DSD) the 2023 and 2024 grievance logs were reviewed and indicated there were no grievance filed for this incident. A review of the facilities policy with a revised date of February 2021 titled "Dignity" indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well- being, level of satisfaction with life, feeling of self-worth and self- esteem. The policy indicated residents are to be treated with dignity and respect and spoken to with respect at all times. The policy further indicated the use of demeaning practices and standards of care are prohibited. The facility failed to ensure Resident 2 was treated with dignity and respect during a routine diaper change by failing to: 1. Ensure Resident 2 was treated with kindness, respect, and dignity as indicated in the Facility Policy titled "Dignity" dated February 2021. 2. Ensure the facility's staff spoke respectfully, without the use of demeaning practices and standards of care that compromised dignity as indicated in the Facility Policy titled "Dignity" dated February 2021. These violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Resident 2 and other residents residing in the facility.