Health inspection·May 22, 2024

Freedom from Abuse, Neglect, and Exploitation 42 CFR §483.12(a) The facility must: 42 CFR §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 22 CFR § 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 CFR § 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. 22 CFR § 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 4/12/2024, the CDPH conducted an unannounced complaint investigation at the facility for allegations of abuse from a Certified Nurse Assistant (CNA) to Resident 12 that occurred two to three weeks prior. The facility failed to: 1. Follow its policy and procedure (P&P), titled, "Abuse-Prevention, Screening, and Training Program," dated 7/2018, which indicated facility did not condone any form of resident abuse or neglect Resident 12. As a result, this violation placed Resident 12 and other residents in the facility at risk for abuse. A review of Resident 12 's Admission Record (face sheet) indicated the resident was a 61-year-old male, admitted to the facility on 5/23/2023 and readmitted on 3/19/2024. Resident 12 's diagnoses included metabolic encephalopathy (a chemical imbalance in the brain caused by an illness or organs), epilepsy (a brain disorder characterized by recurrent brief episodes of involuntary movement that may involve a part of or the entire body) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 's 12 's Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 1/29/2024, indicated Resident 12 was cognitively impaired with daily decision making. Resident 12 required supervision with toileting, bathing, and lower body dressing. A review of the facility 's 5-day conclusion letter dated 3/25/2024, indicated on 3/20/2024 at approximately 11:40 a.m., the Director of Staff Development (DSD) accompanied by CNA 9 and a housekeeping staff (HSK 1), went to the Administrator (ADM) office and The report indicated CNA 9 and HSK 1 stated two or three weeks ago, between 11 a.m., and 12 p.m., CNA 9 observed CNA 10 place his knee on Resident 12 's back and held the resident down. The report indicated CNA 9 rushed over and asked CNA 10 to get off Resident 12 and for him (CNA 9) to handle the situation because Resident 12 listened to him and would calm down. The report indicated CNA 9 also reported Licensed Vocational Nurse (LVN 1) observed the incident from around the corner and in addition, CNA 9 notified LVN1. The report also indicated HSK 1 agreed with what CNA 9 reported, adding that CNA 9 informed CNA 10, he (CNA 9) would "take care of it and report the incident." During an interview on 4/12/24 at 3:43 p.m. with the HSK 1, HSK 1 stated between 2/12- 2/28/24, Resident 12 was agitated and was going toward CNA 10. HSK 1 stated he observed CNA 10 push Resident 12 to the floor and put his knee on Resident 12 's back, around the waist area. HSK 1 stated he observed CNA 9 telling CNA 10 to stop placing his knee on Resident 12c. HSK 1 stated "I reported to the charge nurse what happened, and the charge nurse told me its ok, nothing happened." HSK 1 also stated he left an anonymous note under the ADM’s door a week later, on 3/3/24. HSK 1 stated the Assistant Administrator (AA) received the note, and placed it on his desk, but the ADM stated she never saw the note. During a telephone interview on 4/12/24 at 4:40 p.m., with CNA 9, CNA 9 stated the incident happened 2 or 3 weeks ago. CNA 9 stated Resident 12 walked towards CNA 10, in the hallway and CNA10 stood up from his chair and pushed Resident 12. CNA 9 stated CNA 10 then went behind Resident 12, pushed the resident to the floor, put his knee on the resident's back while holding the resident on the floor. CNA 9 stated LVN 1 was observed spying from a corner while CNA 10 abused Resident 12. CNA 9 stated he later asked LVN 1 "aren't you gonna do anything about what is happening?" CNA 9 stated LVN 1 responded "I’ll see." CNA 9 stated he would take a lie-detector test to prove his statement. A review of the facility 's P&P titled "Abuse Prevention, Screening and Training Program," dated 07/2018, indicated the facility did not condone any form of resident abuse, neglect and or mistreatment. The P&P defined abuse as the willful, deliberate infliction of injury, unreasonable confinement, physical or chemical restraint not required to treat symptoms and/or imposed for the purpose of discipline or convenience, intimidation, and mistreatment, with resulting harm, pain, or mental anguish. The P&P indicated the administrator or designated representative will provide for a safe environment for the resident as indicated by the situation and if the suspected perpetrator is an employee, remove the employee immediately from the care of the resident and immediately suspend the employee pending the outcome of the investigation in accordance with facility policies. The facility failed to: 1. Follow its P&P, titled, "Abuse-Prevention, Screening, and Training Program," dated 7/2018, which indicated the facility did not condone any form of resident abuse or neglect. As a result, this violation placed Resident 12 and other residents in the facility at risk for abuse. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.