Health inspection·May 29, 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 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 4/15/2025, the California Department of Public Health (CDPH) made an unannounced visit to investigate a Facility-Reported Incident (FRI) regarding resident abuse. The facility failed to protect Resident 1 and Resident 2’s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) when on 4/12/2025, Resident 1 and Resident 2, while in their wheelchairs, in a hallway, Resident 2 grabbed Resident 1’s right arm while Resident 1 grabbed Resident 2’s arm. The residents (Residents 1 and 2) then pushed against each other’s hands and arms, and each resident (Resident 1 and Resident 2) sustained abrasions (when the surface layers of the skin were broken). As a result, Resident 1 and Resident 2 were subjected to physical abuse while under the care of the facility. Resident 1 sustained two abrasions: one on the right forearm (part of the arm between the elbow and the wrist) and one on the right hand that needed first aid (initial assistance and care given to a resident who has been injured) and daily wound treatments. Resident 2 sustained an abrasion on the right arm that needed first aid. A review of Resident 1’s Admission Record indicated the facility originally admitted the resident on 11/23/2024 and readmitted on 1/27/2025, with diagnoses including but not limited to, encephalopathy (damage or disease that affects the brain), heart disease, and vascular dementia (a progressive state of decline in mental abilities caused by decreased blood flow to the brain). A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 2/26/2025 indicated Resident 1 can make self-understood and understand others. The MDS indicated Resident 1 required moderate assistance with most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). A review of Resident 1’s Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 4/12/2025 indicated Resident 1 had a physical altercation (confrontation or fight that involves physical contact, pushing, shoving, or other forms of aggressive behavior) with Resident 2 on 4/12/2025 at 3:50 p.m. in front of the patio door and sustained right arm abrasions. The SBAR indicated Resident 1 stated that Resident 2 grabbed his wheelchair, pushed him aside to get through, and put his (Resident 2) hand on his right arm causing his right arm to bleed. A review of Resident 1’s Non-Pressure Sore Skin Problem Report (a report documenting skin injuries that are not caused by pressure, but rather other factors), dated 4/12/25 indicated Resident 1 had a skin abrasion on the right arm. A review of Resident 1’s Order Summary Report (physician orders) dated 4/12/2025 indicated an order to cleanse Resident 1’s right arm abrasion with normal saline (a saltwater solution), pat dry, and cover with dry dressing daily. A review of Resident 2’s Admission Record indicated the facility originally admitted the resident on 1/10/2019 and readmitted on 4/24/2024, with diagnoses including but not limited to, type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and reduced mobility (the ability to move freely). A review of Resident 2’s MDS dated 1/31/2025 indicated Resident 2 had severely impaired cognition (the ability to think and make decisions) and was completely dependent on staff or required substantial assistance for most activities of daily living. A review of Resident 2’s Interdisciplinary Team (IDT- a group of healthcare professionals working together to provide comprehensive care to patients) Notes dated 1/31/2025 indicated Resident 2 had a diagnosis of psychosis (a mental disorder characterized by a disconnection from reality) manifested by uncontrollable extreme mood swings (sudden or intense changes in a person’s emotional state) causing verbal (having to do with words) expression of anger. A review of Resident 2’s SBAR, dated 4/12/2025 indicated on 4/12/2025 at 3:50 p.m. Resident 2 stated that Resident 1 grabbed his wheelchair, pushed him aside, and scratched his right arm. At 4:30 p.m., 911 (emergency number to request emergency assistance) was called per facility protocol. At 6:41 p.m., Resident 2’s responsible party (RP) and physician were notified. At 5:39 p.m., the police came and was provided a report by the licensed nurse (name not indicated). At 8:33 p.m., Resident 2 was transferred to a General Acute Care Hospital (GACH) Emergency Department for a "psyche evaluation” (a comprehensive assessment conducted by mental health professionals to understand an individual's mental health status, identify potential issues, and develop appropriate treatment plans). A review of Resident 2’s Non-Pressure Sore Skin Problem Report, dated 4/12/25 indicated Resident 2 had a right arm skin abrasion. A review of Resident 2’s Order Summary Report dated 4/12/2025 indicated to cleanse Resident 2’s right arm with normal saline, pat dry, and cover with dry dressing daily. During a concurrent observation and interview on 4/15/2025 at 10:03 a.m., with Resident 1, in Resident 1’s room, observed Resident 1 had one bandage on his (Resident 1) right forearm and one bandage on his (Resident 1) right hand. Resident 1 stated he (Resident 1) was injured when he (Resident 1) and another resident (Resident 2) were moving towards each other while in their (Residents 1 and 2) wheelchairs in the hallway. Resident 1 stated the other resident (Resident 2) grabbed his (Resident 1) arm when (Resident 2) was passing and said, “That is what you get for going on my side.” Resident 1 stated he (Resident 1) usually has pain in his (Resident 1) right arm but the scratches on his (Resident 1) arm caused additional pain. Resident 1 stated he (Resident 1) also grabbed the other resident’s (Resident 2) arm between his (Resident 2) elbow and shoulder and injured him (Resident 2) as well. During an interview on 4/15/2025 at 4:05 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated that on 4/12/2025 he (CNA 1) was at the nursing station when he (CNA 1) heard somebody yelling. CNA 1 stated he then turned his (CNA 1) head and saw Resident 1 grabbing Resident 2’s arm with his (Resident 1) hand, and Resident 2 grabbing Resident 1’s arm with his (Resident 2) hand at the same time. CNA 1 stated both residents (Residents 1 and 2) were putting pressure on each other and moving their hands and arms back and forth. CNA 1 stated when the residents (Residents 1 and 2) released each other, Resident 1 had two bleeding areas on his (Resident 1) arm and Resident 2 had one bleeding area on his (Resident 2) arm. CNA 1 stated he (CNA 1) was not sure which resident (Resident 1 or Resident 2) grabbed the other first. CNA 1 stated they (Residents 1 and 2) were intentionally (doing something on purpose) grabbing each other. During an observation on 4/16/2025 at 10:15 a.m., with Treatment Nurse 1 (TN 1) in Resident 1’s room, TN 1 removed the bandages from Resident 1’s right arm to perform wound care. Resident 1 had two wounds: one on the right forearm and one on the right hand. Each wound had bloody drainage (leakage of blood from an open wound). TN 1 measured the wound on Resident 1’s right forearm as 2.0 centimeters (cm – unit of length) by 0.2 cm. TN 1 measured the wound on Resident 1’s right hand as 1.0 cm by 0.5 cm. During an interview on 4/16/2025 at 1:55 p.m. with the Administrator (Adm) and the Director of Nursing (DON), the Adm stated she (Adm) did not think there was abuse between Residents 1 and Resident 2. The Adm stated this was an accident between Residents 1 and Resident 2 when they were trying to get around each other in the hallway. The DON stated she (DON) did not think abuse occurred and that the residents (Residents 1 and 2) were only trying to protect themselves while moving around each other. A review of the current facility-provided policy and procedure titled, “Abuse, Neglect (is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress), Exploitation (taking advantage of a resident for personal gain through the use of manipulation , intimidation, threats, or coercion) and Misappropriation (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident’s belongings or money without the resident’s consent) Prevention Program,” revised April 2021, the policy and procedure indicated, “Residents have the right to be free from abuse….” The policy and procedure indicated the facility will “Protect residents from abuse ... by anyone including … other residents.” The facility failed to protect Resident 1 and Resident 2’s right to be free from physical abuse when on 4/12/2025, Resident 1 and Resident 2, while in their wheelchairs, in a hallway, Resident 2 grabbed Resident 1’s right arm while Resident 1 grabbed Resident 2’s arm. The residents (Residents 1 and 2) then pushed against each other’s hands and arms, and each resident (Resident 1 and Resident 2) sustained abrasions. As a result, Resident 1 and Resident 2 were subjected to physical abuse while under the care of the facility. Resident 1 sustained two abrasions: one on the right forearm and one on the right hand that needed first aid and daily wound treatments. Resident 2 sustained an abrasion on the right arm that needed first aid. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1 and Resident 2.