Health inspection·May 6, 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. §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property[.] 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. 22 CCR § 72527 Patient’s 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. (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. 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. On 3/25/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility-reported-incident (FRI) about a resident-to-resident physical altercation (refers to a confrontation or fight involving physical contact or force). The facility failed to protect Resident 1’s right to be free from physical abuse when on 3/12/2025, at around 5:45 p.m. while in the dining room, Resident 2 scratched Resident 1's right upper side of the nose during a physical altercation. As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 sustained a skin scratch with bleeding on the upper side of Resident 1's nose with moderate pain. A review of Resident 1's Admission Record indicated the facility originally admitted the 87-year old female resident on 2/10/2021 and readmitted on 2/18/2025, with diagnoses including chronic obstructive pulmonary disease (is a group of lung diseases characterized by long-term breathing difficulty and airflow obstruction), dementia (a broad term describing a decline in memory, thinking, and reasoning skills, impacting daily life, and often caused by damage to brain cells that affects their ability to communicate), and Alzheimer's disease (a type of dementia marked by a decline in mental abilities severe enough to interfere with daily activities). A review of the Physician’s Order for Resident 1, dated 2/18/2025, indicated to give the resident two tablets of acetaminophen (pain medication) 325 milligrams (mg) by mouth every four hours as needed for mild pain or general discomfort. A review of Resident 1's History & Physical (H&) examination, dated 2/20/2025, indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (a resident assessment tool), dated 2/25/2025, indicated Resident 1 had moderately impaired cognition (the mental processes we use to think, learn, and understand), used a wheelchair for mobility and needed moderate to total assistance with activities of daily living (ADLs, such us dressing, personal hygiene, and use of toilet). A review of Resident 1’s Progress Notes dated 3/12/2025, indicated that on 3/12/2025, at around 5:45 p.m., loud altercation and yelling was heard from Residents 1 and 2 who were in the dining room. Resident 1 was noted with a skin scratch on the right upper side of the nose with bleeding. The note indicated Resident 1's pain level was assessed at four of ten (4/10, using the pain scale from zero [0] to ten where ten is the worst possible pain), moderate pain and acetaminophen was given as ordered. A review of the Physician’s Order for Resident 1, dated 3/12/2025, indicated to cleanse the scratch on Resident 1's right upper side of the nose with normal saline solution (salt water, used for cleaning wounds), pat dry, apply antibiotic ointment, cover with dry dressing, and secure with tape twice a day for ten days. A review of Resident 1's Medication Administration Record (MAR), dated 3/12/2025, indicated two tablets of acetaminophen was given by mouth to Resident 1. A review of Resident 1's care plan titled, "Skin scratch: upper right side of nose," dated 3/12/2025, indicated interventions including to monitor Resident 1's affected area of the nose every shift for one month and to apply antibiotic ointment to the affected area of nose twice a day for two weeks as ordered. A review of Resident 1's care plan titled, "Resident has been substantially (to a great or significant) involved in a peer-to-peer (resident to resident) altercation on 3/12/2025," dated 3/13/2025, indicated goals for Resident 1 not to experience a repeat of the altercation. A review of Resident 1 Interdisciplinary Care Conference Review note, dated 3/13/2025, indicated Resident 1 was able to say what happened during the altercation with Resident 2. The care conference review indicated Resident 1 stated that while in the dining room the other resident (Resident 2), who was on a wheelchair, was hitting and bumping into her (Resident 1) wheelchair. The note indicated Resident 1 stated Resident 2 scratched her face. A review of Resident 2's Admission Record indicated the facility originally admitted the 96-year-old female resident on 3/21/2023 with a readmission dated 2/11/2025. Resident 2’s diagnoses included dementia and Alzheimer's disease. A review of Resident 2's H&P examination, dated 2/26/2025, indicated Resident 2 did not have the capacity to understand and make decisions. A review of Resident 2's MDS, dated 3/3/2025, indicated Resident 2's cognition was moderately impaired and was dependent on staff for all ADLs. On 3/25/2025 at 3:04 p.m., an interview with Resident 1 was conducted in the presence of the Activity Director assisting with translating in English Resident 1's responses to the interview. Resident 1 stated that Resident 2's wheelchair kept hitting her (Resident 1) wheelchair and Resident 1 told Resident 2 not to bother her or she would hit her (Resident 2). Resident 1 stated Resident 2 then hit her on the nose. During an interview on 3/25/2025 at 3:43 p.m., Certified Nursing Assistant 2 (CNA 2) stated hearing residents yelling in the dining room and went to check and noted that Resident 2 scratched Resident 1 on the face and Resident 1 had bleeding on the upper part of the nose. CNA 2 stated Resident broke a nail from scratching Resident 1's face. CNA 2 stated the incident between Residents 1 and 2 was considered a physical abuse because Resident 1 got a skin scratch with bleeding from Resident 2. During an interview on 3/26/2025 at 12:31 p.m., the Director of Nursing (DON) stated Resident 2 got a little agitated (angry) and scratched Resident 1's skin. The DON stated this incident was considered physical abuse. A review of the facility’s policy and procedure (P&P) titled, "Abuse Prevention and Prohibition Program," last reviewed date of 1/27/2025, indicated "Each resident has the right to be free from ... abuse .... The facility has zero-tolerance for abuse .... Staff must not permit anyone to engage in ... physical abuse .... The facility is committed to protecting residents from abuse by anyone, including but not limited to ... other residents ...." The facility failed to protect Resident 1’s right to be free from physical abuse when on 3/12/2025, at around 5:45 p.m. while in the dining room, Resident 2 scratched Resident 1's right upper side of the nose during a physical altercation. As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 sustained a skin scratch with bleeding on the upper side of Resident 1's nose with moderate pain. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.