Health inspection·August 23, 2024

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 7/18/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a Facility-Reported Incident (FRI) and complaint regarding resident abuse. The facility failed to protect the Resident 2's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) when on 7/3/2024 Resident 1 hit Resident 2's face. As a result, Resident 2 was subjected to physical abuse by Resident 1 while under the care of the facility. Resident 2 sustained a cut (a break in skin due to injury) on the left eye area of Resident 2's face, redness (red discoloration [a change in natural skin tone] to the skin) on the left eye area of Resident 2's face and swelling (accumulation of fluid in the skin tissues due to injury) on the left eye area of Resident 2's face. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances of alleged illegal activities) due to Resident 2's severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), 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 the facility admitted Resident 1 on 5/6/2022 with diagnoses that included seizures (a sudden, uncontrolled burst of electrical activity in the brain that causes temporary abnormalities in muscle tone or movements) and schizophrenia (a serious mental health condition that affects how people think, feel, and behave). A review of Resident 1's Initial History and Physical, dated 5/14/2024, indicated Resident 1 did not have the ability to understand or make his (Resident 1) own decisions. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 4/30/2024 indicated Resident 1 had severely impaired cognition. A review of Resident 1's Change in Condition (COC- when there is a sudden change in a resident's health) Evaluation Form, dated 7/3/2024, timed at 1:30 p.m., indicated that Resident 1 had physical aggression (behavior causing or threatening physical harm towards others) with another resident (Resident 2). The COC form further indicated that Resident 1 hit Resident 2. A review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 1/26/2021 with diagnoses that included dementia (the loss of the ability to think, remember and reason to levels that affect daily life) and schizophrenia. A review of Resident 2's MDS dated 4/15/2024 indicated Resident 2 had severely impaired cognition. A review of Resident 2's COC Evaluation Form, dated 7/3/2024, timed at 1:30 p.m., indicated that Resident 2 was hit by Resident 1 and sustained a cut on the left eye area with minimal bleeding, skin discoloration, and swelling to the left periorbital (the area around the left eye). The COC form further indicated that Resident 2 required ice packs to the left eye to decrease the swelling. A review of Resident 2's Comprehensive Skin Assessment Report dated 7/23/2024, indicated Resident 2 sustained a cut on the left eye area with a width of 1.5 centimeters (cm- a unit of measurement) with bleeding noted on Resident 2's left eye area. A review of Resident 2's Physician Order dated 7/3/2024 indicated to cleanse the cut on the left eye area with Normal Saline Solution (NSS - a wound cleansing solution), pat dry, then apply antibiotic (a medication applied topically [to the skin surface] to prevent wound infection) and leave the area open to air daily for 14 days. During a concurrent observation and interview on 7/19/2024 at 12:35 p.m., with Director 1 (DIR 1), observed Resident 2 lying in his bed with visible purplish discoloration and swelling around Resident 2's left eye. DIR 1 stated that Resident 2's left eye had purplish discoloration and swelling. During an interview on 7/19/2024 at 1:50 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that on 7/3/2024 (unable to recall specific time) she (LVN 1) saw Resident 1 walk past Resident 2 while in front of the nursing station. LVN 1 stated that she (LVN 1) then turned away when LVN 1 suddenly heard a "disruption". LVN 1 stated that she (LVN 1) turned and saw Resident 1 and Resident 2 "struggling" and "grabbing each other's arms". LVN 1 stated that she (LVN 1) ran and separated Resident 1 and Resident 2. LVN 1 stated that upon separating Resident 1 and Resident 2, LVN 1 noticed discoloration to Resident 2's left eye. LVN 1 stated that Resident 1 likely hit Resident 2 during the altercation because Resident 2 did not have discoloration to the left eye prior to the incident. During a concurrent interview and record review on 7/19/2024 at 2:30 p.m. with the Director of Nursing (DON), the DON reviewed Resident 2's COC Evaluation Form dated 7/3/2024. The DON stated Resident 2's injury (cut and swelling with discoloration to the left periorbital area) that was sustained on 7/3/2024, after Resident 2's altercation with Resident 1, was consistent with someone being hit. The DON stated that Resident 1 hitting Resident 2 was physical abuse which should not have been allowed to happen. During an interview on 7/19/2024 at 2:55 p.m., with the Administrator in Training (AIT), the AIT stated that he (AIT) is the facility's abuse coordinator (the person that investigates allegations of abuse in the facility). The AIT stated that the altercation that occurred between Resident 1 and Resident 2 on 7/3/2024 was physical abuse. The AIT stated that Resident 2 sustained physical injuries (cut and swelling with discoloration to the left periorbital area) from the altercation. During a concurrent interview and record review on 7/19/2024 at 3:05 p.m., with the DON, the DON reviewed the facility's policy titled "Abuse Prevention Program", dated 12/2016. The DON stated that the facility failed to ensure that Resident 2 was free and protected from abuse when on 7/3/2024, Resident 1 hit Resident 2, causing Resident 2 to sustain a cut, discoloration and swelling to the left periorbital area. The DON stated that this failure indicated that the facility did not follow the facility's policy for the prevention of abuse. A review of the facility's policy titled, "Abuse Prevention Program", dated 12/2016, last reviewed on 1/16/2024 indicated that the facility's residents have the right to be free from abuse ... this includes physical abuse. The facility failed to protect the Resident 2's right to be free from physical abuse when on 7/3/2024 Resident 1 hit Resident 2's face. As a result, Resident 2 was subjected to physical abuse by Resident 1 while under the care of the facility. Resident 2 sustained a cut on the left eye area of Resident 2's face, redness on the left eye area of Resident 2's face and swelling on the left eye area of Resident 2's face. Based on the reasonable person concept due to Resident 2's severely impaired cognition, an individual subjected to physical abuse has lifetime physical pain and psychological (mental or emotional) effects including feelings of embarrassment and humiliation. The above violation had a direct relationship to the health, safety, or security of Resident 2.