Health inspection·March 5, 2025

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. 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: (10) To be free from mental and physical abuse. 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. On 1/21/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a Facility-Reported Incident (FRI) regarding resident abuse. The facility failed to protect the resident’s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) when on 1/8/2025, Resident 2 punched Resident 1 in the face several times with a fist (a person’s hand when the fingers are bent in toward the palm and held there tightly). As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 sustained a left periorbital (around the eye) discoloration (change in the color, texture or pigmentation of the skin), abrasion (when the surface layers of the skin have been broken) on the left eyebrow, skin tear (a wound that happens when the layers of skin separate or peel back) on the left forearm (part of the arm between the elbow and the wrist) and skin tear on left dorsal (back portion) hand that needed first aid (initial assistance and care given to a resident who has been injured) and daily wound treatments. A review of Resident 1’s Admission Record indicated the facility admitted the resident on 12/5/2024, with diagnoses that included cauda equina syndrome (a rare but serious condition that occurs when the bundle of nerves at the end of the spinal cord becomes damaged), osteomyelitis (bone infection) of the left ankle and foot, cellulitis (a deep infection of the skin caused by bacteria) of the left lower limb (leg). A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool) dated 12/11/2024 indicated Resident 1 had intact cognition (ability to think and make decisions). A review of Resident 1’s Initial Psychiatric (relating to the medical specialty of psychiatry [branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders]) Evaluation dated 1/8/2025 indicated Resident 1 stated that on the morning of 1/8/2025 at around 9:00 a.m. to 9:30 a.m., he (Resident 1) was trying to sleep when his roommate (Resident 2) hit him (Resident 1) in the face with a fist. A review of Resident 1’s Situation-Background-Assessment-Recommendation (SBAR- a form that provides a framework for communication between members of the health care team about a resident’s condition) Communication Form dated 1/8/2025 indicated on 1/8/2025, Resident 1 was involved in a physical altercation (a confrontation that involves physical force or contact between two or more people) with another resident (Resident 2). The SBAR Communication Form further indicated that as a result of the physical altercation, Resident 1 sustained left periorbital discoloration, left eyebrow abrasion, left forearm skin tear, and left dorsal hand skin tear. A review of Resident 1’s document titled, “Nursing Notes for additional information on the Change of Condition (COC- when there is a sudden change in a resident’s condition),” dated 1/8/2025 indicated that on 1/8/2025, Resident 1 told staff that while he (Resident 1) was trying to sleep, his roommate (Resident 2) struck (hit forcibly) him (Resident 1) out of nowhere and he (Resident 1) used his left arm to block the next strikes. The Nursing Notes further indicated a complete body assessment was done and observed Resident 1 with left eyebrow abrasion 0.8 centimeter (cm- unit of measurement) in length by 0.7 cm in width and 0.1 cm in depth (0.8 cm x 0.7 cm x 0.1 cm), left forearm skin tear 0.8 cm in length by 0.5 cm in width (0.8 cm x 0.5 cm), left dorsal hand skin tear 0.5 cm in length by 0.2 cm in width and 0.1 cm in depth (0.5 cm x 0.2 cm x 0.1 cm), and periorbital discoloration. The Nursing Notes also indicated initial treatment (first aid) was rendered by the nurse (Director of Nursing [DON]) on Resident 1’s left eyebrow abrasion and left forearm and dorsal hand skin tears and an ice pack was applied to Resident 1’s left eyebrow. A review of Resident 1’s Skin & Body Assessment dated 1/8/2025 indicated on 1/8/2025, the assessment was done due to a physical altercation with another resident (Resident 2) and the following injuries were noted: 1. Left eyebrow skin abrasion measuring 0.8 cm x 0.7 cm x 0.1 cm 2. Left forearm skin tear measuring 0.8 cm x 0.5 cm 3. Left dorsal hand skin tear measuring 0.5 cm x 0.2 cm x 0.1 cm A review of Resident 1’s Order Summary Report indicated there were physician’s orders dated 1/8/2025 for the treatment of Resident 1’s left eyebrow skin abrasion as follows: 1. Cleanse with normal saline (NS – a liquid solution used to cleanse wounds), pat dry, then, apply steri-strips (thin, sticky bandages applied to the skin to help small cuts or wounds stay closed as they heal) daily, every day shift for seven (7) days. 2. Cleanse with NS, pat dry, then apply xeroform gauze (a medical dressing made of gauze [thin, woven cloth] and petrolatum [skin protectant and moisturizing agent commonly known as petroleum jelly] that is used to treat wounds) and cover with dry dressing (a wound dressing that absorbs moisture from a wound, leaving the area dry) daily, every day shift for seven (7) days. A review of Resident 1’s Order Summary Report indicated there were physician’s orders dated 1/8/2025 for the treatment of Resident 1’s left forearm skin tear as follows: 1. Cleanse with NS, pat dry, then apply steri-strips daily, every day shift for seven (7) days. 2. Cleanse with NS, pat dry, then apply xeroform gauze and cover with dry dressing daily, every day shift for seven (7) days. A review of Resident 1’s Order Summary Report indicated there were physician’s orders dated 1/8/2025 for the treatment of Resident 1’s left dorsal hand skin tear as follows: 1. Cleanse with NS, pat dry, then apply steri-strips daily, every day shift for seven (7) days. 2. Cleanse with NS, pat dry, then apply xeroform gauze and cover with dry dressing daily, every day shift for seven (7) days. A review of Resident 2’s Admission Record indicated the facility admitted the resident on 12/12/2024, with diagnoses that included chronic obstructive pulmonary disease (COPD – a lung disease that causes blocked airflow from the lungs, making it hard to breathe), unspecified dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life), opioid (a class of drugs that can be used to treat pain, but can also be addictive) dependence, and nicotine (an addictive, poisonous chemical found in tobacco) dependence. A review of Resident 2’s MDS dated 12/18/2024 indicated Resident 2 had severely impaired cognition. A review of Resident 2’s Initial Psychiatric Evaluation dated 1/8/2025 indicated Resident 2 stated that he (Resident 2) had been hearing voices and that on the morning on 1/8/2025, “the voice” told him (Resident 2) to punch his roommate (Resident 1). The Initial Psychiatric Evaluation further indicated that Resident 2 was agitated (a medical condition that causes a person to feel extremely tense and irritable) and restless (unable to remain still) at times during the evaluation, had impaired insight and judgment, and was having auditory hallucinations (hearing sounds or voices that do not exist in reality). A review of Resident 2’s SBAR Communication Form dated 1/8/2025 indicated Resident 2 was physically aggressive towards his roommate (Resident 1), hit his roommate (Resident 1) without apparent reason, and was a danger to himself or others. A review of the facility’s undated Final Investigative Report indicated that on 1/8/2025 Resident 1 was in bed when Resident 2 struck him (Resident 1). The Final Investigative Report further indicated that it was confirmed that Resident 2 physically hit Resident 1. During an interview on 1/21/2025 at 11:30 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated on 1/8/2025 he (CNA 1) went to answer the call light in Room A (Resident 1 and Resident 2’s room) and upon entering the room, he (CNA 1) found Resident 1 lying in bed and rubbing his (Resident 1) left eye. CNA 1 stated Resident 1 told him (CNA 1) that his roommate (Resident 2) hit him (Resident 1). During an interview on 1/21/2025 at 11:49 a.m., with the Case Manager (CM), the CM stated that on 1/8/2025, he (CM 1) was alerted by CNA 1 that assistance was needed in Room A because there was a resident-to-resident altercation. The CM stated he (CM) assisted in assessing Resident 1 who had told staff that Resident 2 had hit him (Resident 1) while he was sleeping in bed. The CM stated upon assessment of Resident 1, there were skin tears on the left dorsal hand and left forearm, discoloration around the left eye, and an abrasion to the left eyebrow. The CM stated the areas of open skin were not actively bleeding, but the treatment nurse (Licensed Vocational Nurse 1 [LVN 1]) did provide immediate treatment to Resident 1’s injuries. During an interview on 1/21/2025 at 12:30 p.m., with LVN 1, LVN 1 stated he (LVN 1) did not perform the actual treatment (cleanse left eyebrow abrasion and left forearm and left dorsal hand skin tears with NS and place steri-strips on left eyebrow, left forearm, and left dorsal hand) on Resident 1 as he only assisted the DON with measuring and providing treatment to Resident 1’s injuries caused by Resident 2. During an interview on 1/21/2025 at 12:37 p.m., with the DON, the DON stated that on the morning of 1/8/2025, CNA 1 answered Resident 1’s call light and after hearing about the altercation, CNA 1 immediately separated Resident 1 and Resident 2 and called the CM for assistance. The DON stated she (DON) was also made aware of the incident and immediately went to Resident 1 to assess him and provide treatment to his (Resident 1) injuries with the assistance of LVN 1. The DON stated that Resident 1 was interviewed and told staff that he (Resident 1) was in bed sleeping when Resident 2 hit him (Resident 1) in the face with his fist. The DON stated Resident 1 further explained to staff that he (Resident 1) used his left arm to cover his face from the other punches from Resident 2. The DON stated that as a result of the altercation, Resident 1 sustained an abrasion on his left eyebrow and skin tears on his left hand and forearm. The DON stated she (DON) measured and provided treatment to Resident 1’s abrasion and skin tears. The DON stated she (DON) cleaned Resident 1’s left eyebrow abrasion and left forearm and left dorsal hand skin tears with NS and placed steri-strips on Resident 1’s left eyebrow, left forearm, and left dorsal hand. During an interview on 1/21/2025 at 12:55 p.m., with the Social Services Director (SSD), the SSD stated on the morning of 1/8/2025, she (SSD) interviewed Resident 1 after the altercation and Resident 1 told her (SSD) that he was sleeping in bed when Resident 2 charged at him, hitting him in the left eye and left arm. The SSD stated on 1/8/2025, she (SSD) also interviewed Resident 2 after the altercation and Resident 2 admitted to hitting Resident 1, but when asked why he (Resident 2) did it, he did not respond. During an interview on 1/21/2025 at 3:10 p.m., with the Assistant Administrator (AADM), the AADM stated that he (AADM) was aware of the resident-to-resident altercation between Resident 1 and Resident 2. The AADM stated he (AADM) was involved in the investigation process. The AADM stated that Resident 2 punching Resident 1 in the face several times with a fist is physical abuse. During a review of the facility’s policy and procedure titled, “Abuse Reporting and Prevention,” last revised 4/2024, the policy indicated it is the policy of the facility to ensure that residents rights are protected by providing a method of investigation and reporting of alleged violations involving mistreatment, neglect (fail to care for properly), abuse including injuries of unknown sources, unusual occurrences … The policy and procedure further indicated that the facility is expected to take any necessary action to prevent resident to resident altercations to every extent possible and should be reviewed as a potential situation of abuse. If, during the investigation it is determined that the resident’s actions were “willful” and deliberate, then abuse has occurred. The facility failed to protect the resident’s right to be free from physical abuse when on 1/8/2025, Resident 2 punched Resident 1 in the face several times with a fist. As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 sustained a left periorbital discoloration, abrasion on the left eyebrow, skin tear on the left forearm and skin tear on left dorsal hand that needed first aid and daily wound treatments. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.