Health inspection·August 23, 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. §483.12(a) The facility must— §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; 42 CFR § 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: § 483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. § 483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Title 22 CCR § 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. 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. On 6/21/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident about resident abuse. The facility failed to implement its Abuse Prohibition Policy by: 1. Not protecting Residents 1, 3, 4, and 5 from Resident 2 who verbally abused them, threatened them with physical harm, and physically abused Resident 3 by shoving Resident 3’s wheelchair while the resident was sitting in the wheelchair. 2. Not reporting to CDPH local District Office (DO) an allegation of verbal abuse Resident 1 made on 6/17/2023 to Registered Nurse 1 (RN 1) when Resident 2 verbally abused and threatened Residents 1, 3, and 4 with physical harm. 3. Not reporting to CDPH local DO an allegation of verbal abuse Resident 1 made on 6/18/2023 to RN 3 and Certified Nursing Assistant 1 (CNA 1) when Resident 2 physically abused Resident 3 and verbally abused Resident 5. 4. Not reporting to CDPH local DO the results of the investigation of the alleged abuse occurred on 6/18/2023 within five working days. As a result, Residents 1, 3, 4, and 5 were placed at an increased risk of further verbal and physical abuse from Resident 2. A review of Resident 1’s Admission Record indicated the facility originally admitted the resident on 3/31/2022 with a readmission dated 3/5/2023. Resident 1’s diagnoses included major depressive disorder (a mental health disorder characterized by persistently depressed mood causing significant impairment in daily life) and anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one’s daily activities). A review of Resident 1’s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 4/6/2023, indicated the resident had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive one-person assistance with bed mobility, transfers, walking in the room and in the corridor, dressing, and personal hygiene. A review of Resident 2’s Admission Record indicated the facility originally admitted the resident on 6/17/2022 with a readmission dated 4/16/2023. Resident 2’s diagnoses included alcohol abuse (a pattern of drinking too much alcohol too often), major depressive disorder, and anxiety disorder. A review of Resident 2’s MDS, dated 3/20/2023, indicated the resident had intact cognition and required limited one-person assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 3’s Admission Record indicated the facility admitted the resident on 11/6/2020 with diagnoses including major depressive disorder and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory). A review of Resident 3’s MDS, dated 4/24/2023, indicated the resident had severely impaired cognition and required extensive one-person assistance with bed mobility, transfers, walking in the room and in the corridor, dressing, toilet use, and personal hygiene. A review of Resident 4’s Admission Record indicated the facility originally admitted the resident on 5/29/2019 and readmitted the resident on 10/12/2020 with diagnoses including cardiomyopathy (problems with the heart muscle that can make it hard for the heart to pump blood). A review of Resident 4’s MDS, dated 5/24/2023, indicated the resident had intact cognition and required supervision from staff for bed mobility, transfers, walking in the room and in the corridor, and toilet use. A review of Resident 5’s Admission Record indicated the facility originally admitted the resident on 11/18/2012 and readmitted the resident on 3/20/2015 with diagnoses including major depressive disorder. A review of Resident 5’s MDS, dated 5/12/2023, indicated the resident had intact cognition and required extensive one-person assistance with transfers, walking in the room and in the corridor, and dressing. 1. On 6/21/2023 at 10:58 a.m., during an interview, Resident 1 stated that on 6/17/2023, she (Resident 1), Residents 2, 3, and 4 were at the smoking patio when Resident 2 began to verbally harass Residents 3 and 4. Resident 2 threatened Residents 3 and 4 with physical violence and spoke racial obscenities to Resident 3. Resident 1 stated as she (Resident 1) was leaving to report the incident to RN 1, Resident 2 then began verbally harassing her, using racial obscenities. On 6/22/2023 at 3:17 p.m., during an interview, RN 1 stated she (RN 1) was working on 6/17/2023 when Resident 1 approached her to tell her that something happened with Resident 2 in the patio. RN 1 stated she could not understand what Resident 1 was trying to tell her and thought it was a smoking issue. RN 1 stated when she asked Resident 1 to write a statement about what happened, Resident 1 stated, “Never mind. I don’t want to report anything.” On 7/18/2023 at 3:51 p.m., during an interview, Resident 1 stated that on 6/17/2023, she went to nurses’ station 1 to report a verbal altercation to RN 1 happening in the outside smoking patio. Resident 1 stated that when she mentioned the smoking patio, RN 1 made a comment about telling the Administrator to close the smoking patio. Resident 1 stated that, at that point, she did not say anything further. On 7/18/2023 at 4:00 p.m., during an interview, RN 1 stated that Resident 1 approached her on 6/17/2023 and said something was going on at the smoking patio but did not give any further details. RN 1 stated that Resident 1 then turned around and left, so she assumed that was the end of their conversation. RN 1 stated she then went to the smoking patio to see what was going on, but there was no one there. RN 1 stated she left and did not follow up with Resident 1. RN 1 stated she did not document Resident 1’s allegation and if she had followed up with Resident 1 at that time, she would have known there was a resident-to-resident verbal altercation among the residents, and she would have reported it to the Director of Nursing (DON) and the Administrator (ADM). 2. On 6/21/2023 at 10:58 a.m., during an interview, Resident 1 stated that on 6/18/2023, she (Resident 1), Residents 2, 3, and 5 were at the smoking patio when Resident 2 shoved Resident 3’s wheelchair. Resident 2 started to yell obscenities to Resident 5 after Resident 5 defended Resident 3. Resident 1 stated she reported the incident to RN 3 and CNA 1. On 6/21/2023 at 11:53 a.m., during an interview, Resident 4 stated that on 6/17/2023 he had witnessed Resident 3 outside in the patio passing by behind Resident 2. Resident 4 stated Resident 2 appeared angry and started cursing at Resident 3. Resident 4 stated he thought Resident 2 was going to hit Resident 3. Resident 4 stated that when Resident 1 said she was going to go inside to report the incident, Resident 2 started yelling and cursing at Resident 1. On 6/22/2023 at 12:53 p.m., during an interview, RN 3 stated he was working on 6/18/2023 when Resident 1 reported to him about the incident that had occurred between Residents 1, 2, 3 and 5. RN 3 stated Resident 1 told him (RN 3) Resident 2 was being verbally abusive. RN 3 stated that he immediately reported the incident to the DON who instructed him to ask all involved residents to file a grievance. On 6/23/2023 at 3:16 p.m., during an interview, the DON stated that on 6/18/2023, RN 3 informed her about an incident of alleged abuse reported by Resident 1. The DON stated they did not report the incident of alleged abuse because Resident 1 only wanted to file a grievance. The DON stated that Resident 1 did not want the alleged abuse incident on 6/18/2023 to be reported to CDPH. The DON stated that on 6/20/2023, Resident 1 expressed continued concern regarding the incident that occurred on 6/18/2023 which prompted the facility to report the allegation of abuse to CDPH (two days later). On 6/23/2023 at 3:45 p.m., during an interview, the ADM stated he had investigated the alleged abuse incident that occurred on 6/18/2023 between Resident 1, Resident 2, Resident 3, and Resident 5. ADM stated that Resident 1 initially only wanted the facility to file a grievance, and that was why the facility did not report the incident to the SSA until 6/20/2023. ADM stated they decided to escalate the situation to SSA on 6/20/2023 when Resident 1 continued to express concern regarding the incident. On 7/18/2023 at 4:20 p.m., during an interview about the incident occurred on 6/17/2023, the DON stated that after checking out the smoking patio, RN 1 should have gone back to Resident 1 to obtain more information and document the reported incident. The DON stated that the incidents occurred on 6/17/2023 and 6/18/2023 constituted verbal abuse and Resident 2’s actions were deliberate. On 7/18/2023 at 4:40 p.m., during an interview, the ADM stated he did consider Resident 2’s words to be verbal abuse. The ADM stated that if Resident 1 had tried to report this to RN 1, then RN 1 should have investigated it further to find out if it was something that needed to be reported. The ADM stated it was important to follow up with residents when they tried reporting something because the facility wanted to provide a safe environment for the residents. A review of the facility’s policy and procedure titled, “Abuse Prohibition Policy and Procedure,” indicated that upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the abuse coordinator or designee will perform the following: - Report allegations involving abuse (physical, verbal, sexual, mental) not later than two (2) hours after the allegation is made. - Notify local law enforcement, Ombudsman, Licensing District Office, Licensing Boards, Registries, and other agencies as required. 3. On 7/5/2023 at 11:15 a.m., during an interview, the DON stated that on 6/29/2023, the ADM completed his investigation of the alleged abuse occurred on 6/18/2023 and faxed the results to CDPH District Office the same day. The DON stated the final report was made nine calendar days from the date of the incident instead of the required five working days. The DON stated she did not know why the results of the investigation were reported late. A review of the facility’s policy and procedure titled, “Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating,” indicated that, within five (5) business days of the incident, the administrator will provide a follow-up investigation report. The facility failed to implement its Abuse Prohibition Policy by: 1. Not protecting Residents 1, 3, 4, and 5 from Resident 2 who verbally abused them, threatened them with physical harm, and physically abused Resident 3 by shoving Resident 3’s wheelchair while the resident was sitting in the wheelchair. 2. Not reporting to CDPH local DO an allegation of verbal abuse Resident 1 made on 6/17/2023 to RN 1 when Resident 2 verbally abused and threatened Residents 1, 3, and 4 with physical harm. 3. Not reporting to CDPH local DO an allegation of verbal abuse Resident 1 made on 6/18/2023 to RN 3 and CNA 1 when Resident 2 physically abused Resident 3 and verbally abused Resident 5. 4. Not reporting to CDPH local DO the results of the investigation of the alleged abuse occurred on 6/18/2023 within five working days. As a result, Residents 1, 3, 4, and 5 were placed at an increased risk of further verbal and physical abuse from Resident 2. The above violations had a direct relationship to the health, safety, or security of Residents 1, 3, 4, and 5.