Health inspection·April 25, 2025

T22 § 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. § 72527(a)(24). 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. 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. On 3/11/2025, the California Department of Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding physical abuse. The facility failed to prevent abuse to Resident 1, who had severe neuritis (inflammation of a nerve or nerves that causes pain, abnormal sensations, and muscle weakness or paralysis [inability to move limbs]) and polyarthritis (arthritis [conditions that cause joint pain and inflammation] that affects five or more of your joints) and pain of the arms and legs by failing to: 1. Ensure Certified Nurse Assistant 1 (CNA) 1 did not subject Resident 1 to physical and mental abuse. 2. Implement its policy on abuse to ensure Resident 1 was free from physical abuse. As a result, CNA 1 wrenched Resident 1’s limbs so forcefully despite their severe contracture and arthritis that Resident 1 sustained bruising (discoloration of the skin caused by the leakage of blood from damaged blood vessels under the skin), an acute impacted fracture (sudden broken bone pushed together in broken pieces due to traumatic injury) of the left upper arm; the left upper arm was also displaced (bone was out of its normal position) causing the resident severe pain, discomfort and hospitalization. Resident 1 was subjected to physical abuse by CNA 1 while under the care of the facility. During a review of Resident 1's Admission Record (Face Sheet), the facility admitted Resident 1 on 5/2/2023 with diagnoses including hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated), weakness, polyarthritis, muscle wasting (a condition where muscles lose mass and strength), muscle atrophy (the loss of muscle tissue, leading to a decrease in muscle mass and strength) and neuritis. During a review of Resident 1's "History and Physical" (H&P), dated 5/2/2023 indicated, Resident 1 had the mental capacity to make medical decisions. A review of the OT (Occupational Therapy- a branch of health care that helps people with physical, sensory, or cognitive problems) Evaluation and Plan of Treatment, dated 1/16/2025, indicated Resident 1 was referred to OT due to decline in ADL (Activities in Daily Living) participation, functional mobility, range of motion (ROM), strength and impairment of the RUE (Right Upper Extremity), LUE (Left Upper Extremity), both shoulders, Elbows/ Forearms, wrists, hands were impaired. The OT evaluation indicated Resident 1’s pain interferes and limits functional activity. During a review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 2/5/2025, indicated the resident's cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired, and required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) on toileting, dressing and personal hygiene. The MDS indicated Resident 1 had functional limitations in the upper and lower extremities. During a review of Resident 1's care plan for arthritis, not dated, indicated to prevent Resident 1 from trauma to joint x 90 days, the interventions indicated the facility will provide careful handling during care, avoid overexertion to reduce discomfort, gently provide range of motion (ROM) exercises during care. During a review of Resident 1's Change in Condition (COC) Evaluation Form, dated 3/7/2025, timed at 11:36 AM, indicated Resident 1 was noted with discoloration and bruising on the upper part of the left arm but denied feeling any pain, to prevent further movement of the affected arm, staff placed a rolled-up blanket for support. An ice pack was offered to help with swelling, but the resident declined. The doctor and Director of Nursing (DON) were notified, and the doctor ordered an emergency (STAT) X-ray (electromagnetic radiation to create images of internal structures in the body) of the left shoulder and upper arm to check for any fractures or injuries. During a review of Resident 1's Progress' Note, dated 3/7/2025 at 9:38 AM, the Progress Note indicated Resident 1 has a new aching pain in the left upper arm, rated as moderate 5/10 (pain scale 0-no pain and 10-severe pain). The note indicated Resident 1's pain occurs occasionally, has rarely affected sleep, and has sometimes limited Resident 1's daily activities and the resident has voiced complaints of pain. During a review of the X-ray Result report dated 3/7/2025 timed at 2:59 PM, indicated Resident 1 had a fracture in his left upper arm bone near the shoulder that was described as acute impacted and displaced fracture. A review of the physician order dated 3/7/2025, not timed, indicated to transfer Resident 1 to the hospital due to left shoulder fracture. A review of the general acute care hospital (GACH) records dated 3/7/2025 timed at 8:19 PM indicated to refer Resident 1 to an orthopedic surgeon (doctors specialized in diagnoses, treatment, and performs surgery on conditions affecting the musculoskeletal system including bones, joints, ligaments, tendons, muscles, and nerves) as soon as possible, ideally one-week further evaluation on the proximal humerus fracture found on X-ray today which sustained last week. The GACH discharge record indicated to administer Tramadol 50 (a pain medication) milligrams tablet to be given by mouth every six hours as needed for three times daily. During a review of Resident 1's Progress' Note, dated 3/7/2025 at 9:29 PM the Progress Note indicated Resident 1 was being monitored after a left shoulder fracture. Resident 1 arrived in the facility stable, alert, and able to communicate. Resident 1 reported mild pain (3/10) and was prescribed Tramadol but chose not to take medication until bedtime. Resident 1 had bruising present on the left upper arm, unable to move the arm due to a prior contracture. Two staff members assisted Resident 1 with care for safety, and repositioning was done every two hours for comfort and skin protection. Resident 1's medication was tolerated. During a review of the investigation report dated 3/7/25, timed 12 midnight, indicated Resident 1 had pain level of 7/10 and skin discoloration. The report indicated Resident 1 reported that on last week before he was sent to the hospital a different “guy” came to change him who was very rough from the beginning. Resident 1 stated "I said please be gentle, I have body pain due to my arthritis and he said, ‘shut up. I will change you the way I change other people.’ He turned me to the side and that was when he really pulled me by my arm. It hurt so bad. I screamed. He said shut up. Then he pushed me hard. It was very painful. He told me to turn. I told him I cannot, and he purposely pulled my legs open. I cannot open my legs because of arthritis. I hurt so bad." The report indicated Resident 1 stated the staff said something in a foreign language and when asked the guy what he said, "He said I am finished with you and he walked away." During a concurrent observation and interview on 3/11/2025 at 9:50 AM, with Resident 1, in Resident 1's room, Resident 1 was observed lying on his bed with visible discomfort and extensive bruising and discoloration in various shades of deep purple, red, and yellow on his left elbow, arm and shoulder with contractures on all extremities. In an interview Resident 1 stated, he was feeling discomfort and pain on the left shoulder. Resident 1 stated he sustained an injury while receiving care from a CNA (CNA 1) who was unfamiliar to him. Resident 1 stated, "I have severe contractures, so I need a bit more help and time, but he didn't know that. I told him but he dismissed me." Resident 1 recalled telling the CNA 1 to be "gentler" but CNA 1 "dismissed me" and continued repositioning him forcefully. Resident 1 stated he has severe contractures and requires additional time and assistance with care, but CNA 1 did not appear to know about his condition and handled him roughly, causing pain. Resident 1 explained due to his pre-existing arthritis and chronic pain, he did not realize the severity of the injury until Friday 3/7/2025, when the pain became unbearable. Resident 1 stated he then informed the nurses who assessed him and facilitated his transfer to the hospital in which an X-rays confirmed fractures in his left shoulder. During an interview of Resident 1's roommate, Resident 2, on 3/11/25, at 10:15 AM, Resident 2 stated while he was in the room with Resident 1, he heard CNA 1 interacting with Resident 1 on multiple occasions and observed CNA 1 handling Resident 1 roughly. Resident 2 stated he could hear Resident 1 expressing discomfort during care by CNA 1 and CNA1 did not request assistance from other staff when attending to Resident 1. During an interview on 3/11/2025 at 11:25 AM, CNA 2 stated on 3/7/2025, Resident 1 was observed with bruising on the elbow that extended to the shoulder. CNA 2 stated Resident 1 informed him that Resident 1 had been rough while giving him care which he reported to the charge nurse on the same day. During an interview on 3/11/2025 at 2PM with the DON stated Resident 1 denied falling and only reported pain on the left shoulder on 3/7/25, the attending physician was notified, and the resident was transferred to the hospital for surgical evaluation. The DON stated Resident 1 returned to the facility on the same day and was ordered to be administered pain medication and referral to the orthopedic surgeon. The DON stated he initiated the investigation on 3/7/2025 but did not interview CNA1 who matched the description that the Resident 1 reported, and he did not suspend the CNA1 who returned to work on 3/11/2025. During a concurrent interview and record review 3/11/2025 at 2:30 PM with the DON indicated the Facility Reported Incident (FRI) intake (a report provided by the facility to the Department of Public Health), dated 3/10/2025 timed at 1:37 PM, indicated the facility reported to CDPH the allegation of injury of unknown origin related to Resident 1 who reported on 3/7/2025 at 10 AM that Resident 1 had contractures, discoloration on the left upper arm and refused to be touched by the DON. The FRI report did not indicate Resident 1's report of allegation of abuse. During an interview on 3/11/2025 at 3:15 PM, with CNA 1, CNA 1 denied handling Resident 1 roughly and claimed he assisted Resident 1 multiple times. CNA 1 stated that he used a sheet to reposition the resident rather than pulling his arms and asking a staff to assist with repositioning Resident 1. CNA 1 stated he did not ask any staff to assist with repositioning Resident 1. CNA 1 stated repositioning Resident 1 with significant mobility limitations required maximum assistance. CNA 1 was unable to explain how the resident sustained visible injuries and denied hearing any complaints of pain at the time of care. During an interview on 3/11/2025 at 3:30 PM with the DON, the DON stated that CNA 1 should not have been rough with Resident 1. The DON stated that proper care protocols were not followed, which contributed to the resident's injury. A review of the investigation report dated 3/11/2025, not timed, indicated the DON went to Resident 1's room with CNA 1 without exchange of words. Then CNA 1 walked out. The DON came back and asked Resident 1 if that was the CNA. The report indicated Resident 1 confirmed that CNA1 was the staff that took care of him and was rough. DON reassured Resident of his safely. A review of facility's policy and procedure (P&P) titled "Abuse-Prevention, Screening, & Training Program" revised on July 2018, indicated the facility does not condone any form of resident abuse. The P&P indicated the facility conducts mandatory staff training programs during orientation, annually and as needed on recognizing abuse, to whom and when to report without fear of reprisal. The P&P indicated "The facility identifies, corrects, and intervenes in situations in which abuse, neglect, exploitation, misappropriation of resident property/and or mistreatment is more likely to occur. The P&P indicated "The facility provides, and staff sign an acknowledgement of their responsibility to report alleged or suspected abuse, neglect, exploitation, misappropriation of resident property/and/or mistreatment. A review of the PT (Physical Therapy- form of treatment that uses exercises, stretches, and other physical techniques to help people improve their physical function and reduce pain ) Evaluation and Plan of Treatment, dated 3/17/2025, indicated Resident 1 with diagnosis of unspecified fracture of upper end of left humerus, after fracture, was referred to PT due to exacerbation of decrease in functional mobility, reduced static balance, reduced dynamic balance, decreased in strength, decreased in range of motion (ROM), reduced ADL participation, falls/fall risk, decreased coordination and increased need for assistance from others. A review of facility's P&P titled "Abuse-Reporting & Investigations" revised on May 2018, indicated "To protect the health, safety, and welfare of Facility residents by ensuring that alt reports of resident abuse, mistreatment, neglect, exploitation or injuries of an unknown source and suspicion of crimes are promptly reported and thoroughly investigated." The P&P indicated "The administrator or designated representative conducting the investigation will interview individuals who may have information relevant to the allegation or suspected crime; Individuals who may have information relevant to the allegation or suspected crime are the resident, witnesses to the incident, other residents under the care of the staff member involved, roommates, family, visitors, etc. " The facility failed to prevent abuse to Resident 1, who had severe neuritis and polyarthritis that affects five or more of your joints) and pain of the arms and legs by failing to: 1. Ensure CNA 1 did not subject Resident 1 to physical and mental abuse. 2. Implement its policy on abuse to ensure Resident 1 was free from physical abuse. As a result, CNA 1 wrenched Resident 1’s limbs so forcefully despite their severe contracture and arthritis that Resident 1 sustained bruising an acute impacted fracture of the left upper arm; the left upper arm was also displaced causing the resident severe pain, discomfort and hospitalization. Resident 1 was subjected to physical abuse by CNA 1 while under the care of the facility. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Residents 1.