Health inspection·November 3, 2023

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. On 9/18/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a Facility-Reported Incident (FRI) about resident abuse. The facility failed to protect Resident 1’s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) inflicted by Resident 2. On 9/5/2023, Resident 2 threw a plastic trash bin at Resident 1 causing skin discoloration (change in natural skin color) and a one centimeter (cm – unit of measurement) long skin tear (a wound that happens when the layers of skin separate) to Resident 1’s right upper eye that needed first aid (immediate care given to an injured or suddenly ill person) and daily wound treatments. As a result, Resident 1 was subjected to physical abuse by Resident 2 and had the potential to cause emotional harm which could result to a feeling of low self-esteem and self-worth. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances of alleged illegal activities) due to Resident 1’s moderately impaired cognition (ability to think and make decisions), an individual subjected to physical abuse has lifetime physical pain and psychological (mental or emotional) effects including feelings of embarrassment and humiliation. A review of Resident 1’s Admission Record indicated Resident 1 was admitted on 2/27/2023 with diagnoses that included dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life), schizophrenia (serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions, and relate to others) and hypertension (high blood pressure). A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 3/5/2023 indicated Resident 1 had moderately impaired cognition. A review of Resident 1’s Interdisciplinary Team (IDT - a group of members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Progress Note dated 9/7/2023 indicated on 9/5/2023, at around 7:35 a.m. Resident 1 was observed by Certified Nurse Assistant 1 (CNA 1) sitting on his bed with a skin tear on his right eye. Resident 1’s IDT Progress Note further indicated Resident 1 told Registered Nurse 1 (RN 1) that he was by his closet when he heard Resident 2 yell and as he turned to face him, he felt a trash can hit him. A review of Resident 1’s Situation-Background-Assessment-Recommendation (SBAR) Communication Form (a form used to facilitate prompt communication regarding a change in a resident’s health condition), dated 9/5/2023, indicated at around 7:35 a.m. CNA 1 observed Resident 1 sitting on his bed with a skin tear on his right upper eye socket (the two hollow parts on either side of your face, where your eyeballs are) with minimal bleeding. Resident 1 complained of pain and Acetaminophen (a medication used to relieve pain) was administered as ordered. A review of Resident 1’s Order Summary Report indicated a physician’s order dated 9/5/2023 for treatment for Resident 1’s Right Upper Socket Skin Tear: cleanse with Normal Saline (NS - sterile solution composed of salt and water), pat dry, cover with dry dressing (used to protect a wound from infection and absorb wound drainage), daily for 21 days. Further review of Resident 1’s SBAR Communication Form dated 9/7/2023 indicated Resident 1’s right periorbital (pertaining to or surrounding the orbit of the eyes) discoloration was bigger with an order from Resident 1’s physician to monitor the skin discoloration every shift for further skin breakdown. A review of Resident 2’s Admission Record indicated Resident 2 was admitted on 3/18/2023 with diagnoses that included cerebral infarction (stroke, occurs because of disrupted blood flow to brain) and hypertensive emergency (when a person’s blood pressure surges to an unusually high level). A review of Resident 2’s MDS dated 3/24/2023 indicated Resident 2 had fully intact cognition. A review of Resident 2’s SBAR Communication Form dated 9/5/2023 indicated Resident 2 displayed aggressive behavior towards another resident (Resident 1). Resident 2’s SBAR Communication Form further indicated Resident 2 told RN 1 that he lifted the trash can and threw it towards Resident 1. A review of Resident 2’s Individual Psychotherapy Progress Notes dated 9/6/2023 indicated Resident 2 presented with paranoid delusions (unfounded feelings that someone or some group is out to mistreat, harm and sabotage you or someone close to you), poor impulse control (ability to control oneself, especially one’s emotions and desires) and poor coping skills (activities used to reduce a stressful or emotional situation). Resident 2’s Individual Psychotherapy Progress Notes further indicated that Resident 2 admitted to acting on his impulses during the physical altercation with his roommate (Resident 1). During an interview with Resident 1 on 9/18/2023 at 9:43 a.m., Resident 1 was unable to recall the incident with Resident 2 on 9/5/2023. During an interview with CNA 1 on 9/18/2023 at 1:44 p.m., CNA 1 stated on 9/5/2023 she was about to start passing out breakfast trays at around 7:30 a.m. when she heard screaming coming from Resident 1 and Resident 2’s room. CNA 1 stated that when she ran into Resident 1 and Resident 2’s room, CNA 1 found Resident 2 standing at the foot of his bed yelling at Resident 1. CNA 1 stated that Resident 1 was sitting on his bed. CNA 1 stated that she immediately got in between both Resident 1 and Resident 2 as she called out for help. CNA 1 stated that she noticed that Resident 1 had blood around his right eye. CNA 1 stated that Licensed Vocational Nurse 1 (LVN 1) came in right away to assist and removed Resident 2 from the room. During an interview with LVN 1 on 9/18/2023 at 2:02 p.m., LVN 1 stated she was setting up her medicine cart at around 7:35 a.m. when she heard yelling coming from Resident 1 and Resident 2’s room. LVN 1 stated when she arrived in Resident 1 and Resident 2’s room, she found Resident 1 sitting on his bed with blood around his right eye. LVN 1 stated that Resident 2 was standing at the foot of his bed and yelling at Resident 1 to stay out of his closet. LVN 1 stated that CNA 1 was standing in between Resident 1 and Resident 2. LVN 1 stated she immediately removed Resident 2 from the room. LVN 1 stated Resident 2 explained to her that Resident 1 was standing by his closet, so he threw his trash bin towards Resident 1 to get him away from his closet. LVN 1 stated that Resident 2 told her that he never meant to hit Resident 1, he just wanted to stop him from going into his closet. LVN 1 stated that when she went to check on Resident 2 a few minutes later, Licensed Vocational Nurse 2 (LVN 2) was already tending to Resident 1’s right eye skin tear. During an interview with LVN 2 on 9/18/2023 at 2:33 p.m., LVN 2 stated on 9/5/2023 at around 7:30 a.m., LVN 2 was stocking his treatment cart when he heard yelling coming from Resident 1 and Resident 2’s room. LVN 2 stated when he arrived in Resident 1 and Resident 2’s room, he saw that Resident 1 was bleeding around his right eye. LVN 2 stated he had Resident 1 hold a tissue to his right eye skin tear and apply pressure while he gathered some wound care supplies. LVN 2 stated he provided first aid care to Resident 1’s right eye skin tear. LVN 2 stated that he cleaned off Resident 1’s right eye skin tear that had minimal bleeding and placed a clean, dry dressing on the skin tear. LVN 2 stated the skin tear was about one cm long. LVN 2 stated after a few days, on 9/7/2023, he noticed Resident 1 was starting to have right periorbital discoloration. LVN 2 stated the discoloration was purple in color and around the outer corner of Resident 1’s right eye. LVN 2 stated he informed Resident 1’s physician who ordered for the discoloration to be monitored. During an interview with the Administrator (ADM) on 9/21/2023 at 3:40 p.m., the ADM stated during her investigation of the altercation between Resident 1 and Resident 2, she found that Resident 2 admittedly threw his trash bin towards Resident 1. The ADM stated that Resident 2 expressed remorse after the incident. The ADM stated that Resident 2’s action of throwing his trash bin at Resident 1 was deliberate and therefore willful and the action of Resident 2 deliberately throwing the trash bin at Resident 1 fits the criteria of abuse. A review of the facility’s policy and procedure (P&P) titled, “Abuse Prevention Program,” last revised on 12/2016, indicated residents have the right to be free from abuse. The policy and procedure further indicated that the facility is to protect its residents from abuse by anyone. The facility failed to protect Resident 1’s right to be free from physical abuse inflicted by Resident 2. On 9/5/2023, Resident 2 threw a plastic trash bin at Resident 1 causing skin discoloration a one cm long skin tear to Resident 1’s right upper eye that needed first aids and daily wound treatments. As a result, Resident 1 was subjected to physical abuse by Resident 2 and had the potential to cause emotional harm which could result to a feeling of low self-esteem and self-worth. Based on the reasonable person concept due to Resident 1’s moderately impaired cognition, an individual subjected to physical abuse has lifetime physical pain and psychological effects including feelings of embarrassment and humiliation. The above violations had a direct relationship to the health, safety, or security of Resident 1.