Health inspection·March 28, 2025

§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 §72523(a) 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 2/10/2025, the California Department of Health (CDPH) received a Facility Reported Incident (FRI) that a resident (Resident 2) physically assaulted another resident (Resident 1). On 2/12/2025, CDPH conducted an unannounced visit to the facility to investigate the FRI regarding a resident to resident assault. Upon investigation, CPDH determined Resident 2 hit Resident 1 with a "Wet Floor" sign (a sign placed on a slippery/wet floor to alert people of a fall risk, typically measuring 25 inches tall by 11 inches wide) on his right hand/arm, right knee and left leg and was transferred to a General Acute Care Hospital (GACH) on 2/8/2025 for evaluation and treatment. The facility failed to: 1. Ensure Resident 1 was not physically assaulted by Resident 2. 2. Follow its Policy and Procedures (P/P) titled, "Abuse-Prevention, Screening, & Training Program" which indicated the facility does not condone any form of resident abuse. As a result of this deficient practice, Resident 1 sustained a laceration (a deep, jagged tear or cut in the skin, often caused by a sharp object or blunt trauma, resulting in an irregular wound that could bleed significantly) to his right hand between his right thumb and right pointer finger that required eight sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision) and abrasions (a minor injury to the skin that occurs when the skin is rubbed or scraped) to his right forearm, right knee and left knee. A review of Resident 1's Admission Record (Face sheet) indicated Resident 1, a 69-year-old male, was initially admitted to the facility on 10/11/2023 and readmitted on 8/27/2024 with diagnosis including metabolic encephalopathy (a brain disorder that occurs when there is a chemical imbalance in the blood caused by an illness), and gait and mobility abnormalities (changes in a person's walking patterns or balance that occur because of problems in the body). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 1/18/2025, indicated Resident 1 was able to make decisions that were consistent and reasonable, and he was independent in ambulating (the act of walking and moving about) and transferring from bed/chair to chair in the facility. A review of Resident 1's Change of Condition (COC) Evaluation dated 2/8/2025 and timed at 10:38 a.m., indicated Resident 1 was hit on his hand by Resident 2 with a "Wet Floor" sign and sustained a cut to his right hand between his thumb and second finger requiring sutures. The COC indicated Resident 1 complained of pain rated two out of 10 on a pain rating scale (an eleven-point scale where pain is rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain) to his right hand. A review of Resident 1's Transfer Form dated 2/18/2025 and timed at 10:54 a.m., indicated Resident 1 was transferred to a General Acute Care Hospital (GACH) because of a cut on his right hand between his thumb and second digit (finger). A review of Resident 2's Admission Record (Face sheet), indicated Resident 2, a 48-year-old female, was admitted to the facility on 12/17/2024 with diagnosis including paranoid schizophrenia (a type of mental disorder that involves extreme feelings of paranoia [suspicions], delusions [false beliefs], hallucinations [seeing or hearing things that are not there], disorganized speech and behavior, difficulty concentrating, feelings of being controlled by someone and suicidal thoughts and behaviors). A review of Resident 2's MDS dated 12/24/2024, indicated Resident 2 was able to make decisions that were consistent and reasonable and required partial to moderate assistance with walking in the facility. A review of Resident 2's COC dated 2/8/2025 and timed at 10:19 a.m., indicated Resident 2 had behavioral symptoms that included agitation (restless moving, shouting, twitching and jerking of the body) and psychosis (a condition when a person's thoughts and perceptions are disrupted, with difficulty recognizing what is real and what is not). The COC indicated Resident 2 was aggressive and went inside Resident 1's room, hit Resident 1 with a "Wet Floor" sign cutting Resident 1's right hand between his thumb and second finger. A review of the GACH's Patient Education and Visit Summary dated 2/8/2025 and timed at 11:26 a.m., indicated Resident 1 was brought to the GACH by paramedics for treatment because of a right-hand laceration after being assaulted by his roommate (Resident 2). The GACH Visit Summary indicated Resident 1's right hand laceration was sutured. During an interview on 2/12/2025 at 2:14 p.m., Resident 1 stated, on 2/8/2025 around 10:30 a.m., he was in his room taking a nap, when Resident 2 came into his room screaming and accusing him (Resident 1) of killing her family. Resident 1 stated he was shocked and scared when Resident 2 hit him with a "Wet Floor" sign on his right hand/arm, right knee and left leg. Resident 1 stated he had injuries to his right hand, right forearm, right knee and left knee. Resident 1 stated, multiple staff came to help him and to stop Resident 2 from hitting him, but it was too late because he was already hurt and bleeding badly from the cut on his right hand. Resident 1 stated his right hand was painful to touch and he was worried if his hand would function after this injury. During an interview on 2/13/2025 at 11:02 a.m., Certified Nursing Assistant 2 (CNA 2) stated on 2/8/2025 at around 10:30 a.m., she was in another resident's room washing her hands when she heard Resident 2 screaming angrily in a foreign language. CNA 2 stated she immediately when to check on Resident 2 and saw Resident 2 at the foot of Resident 1's bed and CNA 1 and a housekeeper (HK) trying to remove the 'Wet Floor' sign from Resident 2's hands. CNA 2 stated, Resident 1 was bleeding from his right hand. During an interview on 2/13/2025 at 11:32 a.m., the HK stated, during the morning shift (unsure of the time) on 2/8/2025 she was cleaning a resident's bathroom when she heard a resident (Resident 2) screaming loudly. The HK stated she walked to the hallway and saw Resident 2 screaming angrily in a foreign language in front of Resident 1's room. The HK stated she saw Resident 2 enter Resident 1's room, pick up a 'Wet Floor' sign and hit Resident 1 with the sign many times. The HK stated she asked for help and she and CNA 1 went inside Resident 1's room to stop Resident 2 from hitting Resident 1. During a telephone interview on 2/13/2025 at 12 p.m., Licensed Vocational Nurse (LVN) 2 stated she was at the nursing station when she heard screaming and yelling coming from a resident's room. LVN 2 stated she went into Resident 1's room and observed CNA 1 telling Resident 2 to stop hitting Resident 1 while directing Resident 2 to leave the room. During an observation on 2/13/2025 at 12:51 p.m. in Resident 1's room, with Treatment Nurse 1 (TXN 1), Resident 1's right hand was observed with eight sutures and there were multiple dark purple discolorations to the palm of Resident 1's right hand surrounding the laceration/sutures and on the back of his right hand. During a telephone interview on 2/13/2025 at 1:13 p.m., CNA 1 stated she was providing care to another resident when she heard someone say "shut up" in a loud voice and saw Resident 2 run across the hallway into Resident 1's room. CNA 1 stated she saw Resident 2 pick up a 'Wet Floor' sign and hit Resident 1 with it. During an interview on 2/13/2025 at 4:35 p.m., the Administrator (ADM) stated, it was everyone's responsibility to ensure residents were safe and free from any abuse. A review of the facility's P/P titled "Abuse-Prevention, Screening, & Training Program" revised 7/2018, indicated the facility does not condone any form of resident abuse. The facility failed to: 1. Ensure Resident 1 was not physically assaulted by Resident 2. 2. Follow its P/P titled, "Abuse-Prevention, Screening, & Training Program" which indicated the facility does not condone any form of resident abuse. As a result of this deficient practice, Resident 1 sustained a laceration to his right hand between his right thumb and right pointer finger that required eight sutures and abrasions to his right forearm, right knee and left knee. The above violations jointly, separately, or in combination, presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 1 2