Health inspection·September 24, 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 8/12/2024, 8/19/2024 and 8/21/2024, the California Department of Public Health (CDPH) received three facility reported incidents (FRI) for allegations of physical and verbal abuse at the facility. On 8/22/2024, the CDPH conducted an unannounced FRI investigation on all three allegations of abuse at the facility. The facility failed to: 1. Ensure Resident 1 was free from Resident 2’s physical abuse. 2. Ensure Resident 5 was free from Resident 4’s physical abuse. 3. Ensure Resident 3 was free from Certified Nursing Assistant 1’s (CNA 1) verbal abuse. As a result, Resident’s 1 and 5 were physically abused by Resident’s 2 and 4, and Resident 3 was verbally abused by CNA 1. 1. Resident 1, was 75-year-old female, admitted to the facility on 7/5/2024 with diagnoses including hypertension (high blood pressure), anxiety (feeling of fear, dread, and uneasiness), Alzheimer’s disease (a brain disorder that slowly destroys memory and thinking skills), and schizophrenia (a serios mental illness that affects how a person thinks, feels, and behaves). A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 7/11/2024, indicated Resident 1’s cognitive skills (ability to think and process information) for daily decision-making were severely impaired (never/rarely made decisions). The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) from staff for toileting hygiene, shower, and personal hygiene. A review of Resident 1’s History and Physical (H&P), dated 7/6/2024, indicated Resident 1 had fluctuating (changing) capacity to understand and make decisions. A review of Resident 1’s Situation, Background, Appearance, Review (SBAR) Communication Form, dated 8/11/2024, indicated Resident 2 approached Resident 1 and punched Resident 1’s left shoulder. The SBAR indicated Resident 1 had left shoulder pain rated at six (6) out of 10 (6/10 [0 – no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain]) on a pain scale. During an interview on 8/22/2024 at 10:10 a.m., Resident 1stated on the morning of 8/11/2024 (Resident 1 did not remember the exact time), she (Resident 1) was standing by the nurses’ station when suddenly a male resident (Resident 2) approached her and punched her on the left shoulder and left arm. Resident 1 stated she felt scared, sad, upset, and disrespected. Resident 2, was a 60-year-old male, admitted to the facility on 2/1/2024 and readmitted on 6/7/2024 with diagnoses including chronic obstructive pulmonary disease ([COPD] a lung disease that makes hard to breathe), anxiety, schizoaffective disorder (mental illness that affects how person thinks, feels, and behaves), and major depression (a mental health condition that causes loss of interest, and ability to think). A review of Resident 2’s MDS, dated 8/8/2024, indicated Resident 2 could make his needs known, understand others and able to be understood. The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and /or touching/steadying assistance as resident completes activity) from staff for toileting hygiene, shower, and personal hygiene. A review of Resident 2’s H&P, dated 8/16/2024, indicated Resident 2 could make needs known but could not make medical decisions. A review of Resident 2’s Physical Aggression Report dated 8/11/2024, indicated Resident 2 approached the nurses’ station and reported Resident 1 was stealing his belongings. The report indicated Resident 2 hit Resident 1’s left shoulder. During an interview on 8/22/2024 at 10:20 a.m., Resident 2 stated on the morning of 8/11/2024 at the nurses’ station he (Resident 2) hit Resident 1 on her shoulder because he saw Resident 1 enter his room and steal his belongings. Resident 2 stated he was angry with Resident 1 for stealing his (Resident 2) belongings. During an interview on 8/22/2024 at 10:25 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated on 8/11/2024 around 9:30 a.m., she observed Resident 1 calm and quiet standing in front of the nurses’ station. CNA 2 stated she then observed Resident 2 walking fast and angrily toward the nurses’ station. CNA 2 stated Resident 2 was pointing his finger toward Resident 1 yelling, “She took my stuff, she took my stuff “. CNA 1 stated Resident 2 approached Resident 1 and hit her (Resident 1) left shoulder. CNA 1 stated she should have redirected Resident 2 right away when CNA 2 observed Resident 2 walking angrily and yelling. CNA 2 stated that could have prevented Resident 1’s physical abuse. 2. Resident 5, was a 60-year-old male, admitted to the facility on 7/18/2024 with diagnoses including hemiplegia (paralysis that affects only one side of your body) and hemiparesis (one-sided muscle weakness), epilepsy (a brain condition that causes unprovoked seizure), major depression, anxiety, and schizophrenia. A review of Resident 5’s MDS, dated 7/25/2024, indicated Resident 5 had moderately impaired (poor decisions, cues/supervision required) cognition. The MDS indicated Resident 5 required maximal assistance (helper does more than half the effort) from staff for toileting hygiene, shower, and personal hygiene. A review of Resident 5’s H&P, dated 7/19/2024, indicated Resident 5 had fluctuating capacity to understand and make decisions. A review of Resident 5’s SBAR, dated 8/21/2024, indicated Resident 5 was struck (hit forcibly) in the mouth by his roommate (Resident 4). During an interview on 8/22/2024 at 2 p.m., Resident 5 stated on the morning of 8/21/2024 (resident did not remember the exact time), his roommate (Resident 4) was jumping on his bed and making noises. Resident 5 stated he asked Resident 4 to stop jumping and stop making noises. Resident 5 stated Resident 4 got upset, angry, and suddenly ran toward him (Resident 5), jumped on the top of him in the bed, and hit him on his head, face, and mouth repeatedly. Resident 5 stated he felt scared and terrified for his life. Resident 4, was a 59-year-old male, admitted to the facility on 8/16/2024 with diagnoses including schizoaffective disorder, anxiety, COPD, and dysphagia (difficulty swallowing). A review of Resident 4’s MDS, dated 8/22/2024, indicated Resident 4 could make his needs known, understand others and able to be understood. The MDS indicated Resident 4 required moderate assistance from staff for toileting hygiene, oral hygiene, and personal hygiene. A review of Resident 4’s H&P, dated 8/17/2024, indicated Resident 4 had fluctuating capacity to understand and make decisions. During an interview on 8/22/2024 at 2:25 p.m., Resident 4 stated he (Resident 4) hit his roommate (Resident 5) on the head. Resident 4 stated he was upset and angry because Resident 5 was looking at him and telling him to shut up and stop making noises. During an interview on 8/22/2024 at 3:05 p.m., Registered Nurse (RN 1) stated on the morning of 8/21/2024 around 9:30 a.m., he heard Resident 5 yelling for help. RN 1 stated he immediately went into Resident 5’s room and observed Resident 4 standing over Resident 5. RN 1 stated Resident 4 was hitting Resident 5’s face and head. 3. Resident 3, was a 25-year-old male, admitted to the facility on 7/31/2024 with diagnoses including paraplegia (a chronic condition that causes the loss muscle function in the lower half of the body, including both legs), COPD, anxiety, and depression. A review of Resident 3’s MDS, dated 8/6/2024, indicated Resident 3 could make his needs known, understand others and able to be understood. The MDS indicated Resident 3 required maximal assistance from staff for toileting hygiene, showering, and personal hygiene. A review of Resident 3’s H&P, dated 8/1/2024, indicated Resident 3 had the capacity to make medical decisions. A review of the facility’s Interdisciplinary Team ([IDT] a group of healthcare professionals who work together to provide patients with the care they need) conference report, dated 8/19/2024, indicated on 8/18/2024 at 9:40 a.m., Resident 3 was involved in a verbal altercation with CNA 1. The IDT report indicated CNA 1 verbally threatened Resident 3. The IDT report indicated CNA1 stated, “Catch me outside. Let’s go outside right now.” The IDT report indicated Resident 3 was passing by CNA 1 in the hallway at the time of the incident. The IDT report indicated Resident 3 stated CNA 1 was yelling and verbally threatened Resident 3. During a telephone interview on 8/23/2024 at 10:20 a.m., CNA 1 stated in the morning of 8/18/2024 around 9:30 a.m., Resident 3 was blocking his (CNA 1) walkway with a wheelchair. CNA 1 stated he told Resident 3 to get out of the way and go back into his room. CNA 1 stated Resident 3 got angry and kept following CNA 1 throughout the facility and the resident kept saying dirty words and using profanity towards CNA 1. CNA 1 stated he had enough and "snapped ". CNA 1 stated he told Resident 3, “Let’s go outside on the patio. Meet me outside”. CNA 1 stated he should not have said what he said to Resident 3. CNA 1 stated a verbal altercation was considered verbal abuse. CNA 1 stated residents have the right to be free from verbal abuse. During an interview on 8/23/2024 at 12:10 p.m., the DON stated on the morning of 8/18/2024 at 9:40 a.m., she was made aware by LVN 3 that CNA 1 was involved in a verbal altercation with Resident 3. The DON stated CNAs responsibilities were to provide care for residents and assist with residents needs when needed. The DON stated CNA 1 should not have engaged in verbal altercation. The DON stated CNA 1's action toward Resident 3 was considered verbal abuse. The DON stated it was the facility’s policy that the residents shall be free from verbal, or physical abuse. During a review of the facility’s policy and procedure (P&P) titled “Resident Rights”, revised 8/2009, indicated the facility's employees shall treat all residents with kindness, respect, and dignity. During a review of the facility’s P&P tilted “Abuse Prevention/Prohibition”, dated 12/2018, indicated the facility did not condone any form of resident abuse, and mistreatment. The P&P indicated the facility was to promote an environment free from abuse and mistreatment. The P&P indicated “Verbal Abuse” was any use of oral language that willfully disparaging (express negative), and derogatory terms directed to residents, regardless of their age, ability to comprehend, or disability. The P&P indicated “Physical Abuse” was hitting, slapping, pinching, and kicking. The facility failed to: 1.Ensure Resident 1 was free from Resident 2’s physical abuse. 2. Ensure Resident 5 was free from Resident 4’s physical abuse. 3. Ensure Resident 3 was free from Certified Nursing Assistant 1’s (CNA 1) verbal abuse. As a result, Resident’s 1 and 5 were physically abused by Resident’s 2 and 4, and Resident 3 was verbally abused by CNA 1. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.