Health inspection·February 19, 2025

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. 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 1/8/2025 and 1/21/2025, the California Department of Public Health (CDPH) received two facility reported incidents (FRIs) regarding resident-to-resident altercations. On 1/17/2025, the CDPH conducted an unannounced visit at the facility to investigate the FRIs. The facility failed to: 1. Ensure Resident 1 did not physically abuse Resident 7. 2. Ensure Resident 5 did not physically abuse Resident 6. As a result, Resident 7 sustained an acute (severe and sudden in onset) depressed nasal bone fracture (a break in the nasal [relating to or having to do with the nose] bone that pushed the bone inward toward the maxilla [the bones that formed the upper part of the jaw, the roof of the mouth, and parts of the eye socket and nose] usually caused by a direct blow to the nose), and Resident 6 was slapped in the face by Resident 5. 1. Resident 1 was a 64 year-old male, admitted to the facility on 8/19/2024 with diagnoses which included metabolic encephalopathy (a brain disorder that occurred when there's an imbalance of chemicals in the blood), dementia (a progressive state of decline in mental abilities), psychosis (a severe mental condition in which thought, and emotions were so affected that contact was lost with reality), and anxiety (a feeling of fear, dread, and uneasiness). A review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool), dated 11/22/2024, indicated Resident 1 had severely impaired cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 1 was independent (resident completed the activity by herself without assistance from a helper) with eating and personal hygiene, and required supervision with oral hygiene, toileting hygiene, and showering/bathing self. A review of Resident 1’s Order Summary Report, dated 10/18/2024, indicated to monitor Resident 1’s behavior of sudden shifts in mood from pleasant to extreme anger and striking out staff or peers every shift. A review of Resident 1’s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there was a change of condition among the residents), dated 1/7/2025 and untimed, indicated on 1/7/2025, Resident 1 slapped the hat off, of a resident (Resident 2). A review of Resident 1’s care plan titled “Altercation resident to resident verbal altercation resulting to physical assault to another resident,” initiated on 1/7/2025, indicated nursing staff were to distract and redirect Resident 1 by engaging the resident in alternative activities to divert attention away from triggers. A review of Resident 1’s Situation, Background, Assessment, and Recommendation (SBAR), dated 1/18/2025 and untimed, indicated on 1/18/2025 Resident 1 exhibited physical aggression towards another resident (Resident 7). Resident 7 was a 66 year-old male, admitted to the facility on 11/23/2024 with diagnoses which included difficulty in walking, metabolic encephalopathy, diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia. A review of Resident 7’s History and Physical (H&P), dated 11/24/2024, indicated Resident 7 did not have the capacity to understand and make decisions. A review of Resident 7’s MDS, dated 11/27/2024, indicated Resident 7 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 7 required partial assistance (helper did less than half the effort) with eating and substantial assistance (helper did more than half the effort) with oral hygiene, toileting hygiene, showering/ bathing self, and personal hygiene. The MDS indicated Resident 1 required supervision in walking and used a wheelchair for mobility. A review of Resident 7’s SBAR, dated 1/18/2025, indicated on 1/18/2025, Dietary Aid (DA 1) witnessed Resident 1 grab Resident 7 by the shoulder and with a closed fist and hit Resident 7 in the nose. The SBAR indicated on 1/18/2025, Resident 7 did not have pain nor changes in the skin observed. A review of Resident 7’s X-ray (a type of electromagnetic radiation that produced images of the inside of the body, used to diagnose and treat diseases and injuries) report, dated 1/19/2025, indicated Resident 7 had an acute depressed fracture involving the nasal bone. A review of Resident 7’s Interdisciplinary Team (IDT, a group of healthcare professionals who worked together to provide care for residents in a nursing home) Conference Record, dated 1/19/2025, indicated on 1/18/2025, DA 1 witnessed Resident 1 unprovokedly punched Resident 7 on the nose in the Station A hallway, and the facility abuse protocol was initiated. The IDT record indicated Resident 7 had no pain, no facial discoloration or swelling, nor had any chronic (a condition that lasted for a long time and requires ongoing medical care) or acute (something was severe and sudden, or immediate) changes noted. The IDT record indicated Resident 7 continued to enjoy his daily routines. During an interview on 1/22/2025 at 10:35 a.m., Licensed Vocational Nurse (LVN) 1 stated on the morning of 1/18/2025 (could not recall the time), she was informed by DA 1 that Resident 1 unprovokedly punched Resident 7 on the nose in the Station A hallway when they walked past each other. LVN 1 stated Resident 1 was calm and unable to indicate why he punched Resident 7 in the nose. During a telephone interview on 1/22/2025 at 11:23 a.m., DA 1 stated on the morning of 1/18/2025 (could not recall the time), DA 1 saw Resident 1 was using his left hand to hold Resident 7 by the shoulder and punched Resident 7 on the nose with his right fist in Station A’s hallway. DA 1 stated Resident 7 was trying to push Resident 1 away but was too weak to do so. DA 1 stated he tried to separate Resident 1 and Resident 7, but DA 1 did not get to the residents on time. DA 1 stated he called LVN 2 over to check on Resident 7. During a telephone interview on 1/22/2025 at 12:29 p.m., LVN 2 stated on the morning of 1/18/2025 (could not recall the time), she was informed by DA 1 that Resident 1 unprovokedly punched Resident 7 on the nose on. LVN 2 stated on 1/18/2025(could not recall the time), there was no visible injury to Resident 7’s face. LVN 2 stated Resident 7 was unable to provide information on what happened. 2. Resident 5 was a 59 year-old female, admitted to the facility on 12/20/2024 with diagnoses including Parkinson’s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), schizoaffective disorder (a mental illness that could affect thoughts, mood, and behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that ranged from the lows of depression to elevated periods of emotional highs), and restlessness (a state of unable to stay still or quiet, or feeling worried or bored) and agitation (a state of extreme arousal, restlessness, or tension that could make it hard to relax). A review of Resident 5’s H&P, dated 12/21/2024, indicated Resident 5 did not have the capacity to understand and make decisions. A review of Resident 5’s MDS, dated 12/30/2024, indicated Resident 5 had mildly impaired cognitive skills for daily decision making. The MDS indicated Resident 5 was independent with eating, oral hygiene, toileting hygiene, showering/ bathing self, and personal hygiene. The MDS indicated Resident 5 had hallucinations (a false perception of a sight, sound, smell, taste, or touch that seems real but was not). A review of Resident 5’s Order Summary Report, dated 12/20/2024, indicated to monitor Resident 5 for auditory (hearing) and visual hallucinations. A review of Resident 5’s Order Summary Report, dated 12/30/2024, indicated to monitor Resident 5 for behavior of sudden angry outburst. A review of Resident 5’s care plan titled “Resident has a behavioral pattern,” initiated on 1/6/2025, indicated interventions included one-to-one (1:1, a situation where a dedicated healthcare professional constantly observed and attended to a single resident, maintaining close proximity [the state of being close to something or someone in space] at all times to ensure their safety and intervene as needed) supervision. A review of Resident 5’s SBAR, dated 1/8/2025, indicated on 1/7/2025 around 11:05 p.m. Resident 5 slapped Resident 6 near the vending machines. The SBAR indicated Resident 5 stated she slapped Resident 6 because Resident 6 drank all her (Resident 5) soda and did not want to light her cigarette. Resident 6 was a 47 year-old male, admitted to the facility on 12/6/2024 which diagnoses which included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), hyperlipidemia (a medical condition where there were abnormally high levels of fats in the blood), schizoaffective disorder, and bipolar disorder. A review of Resident 6’s MDS, dated 12/11/2024, indicated Resident 6 had mildly impaired cognitive skills for daily decision making. The MDS indicated Resident 6 required supervision with eating and partial assistance with oral hygiene, toileting hygiene, shower/ bathe self, and personal hygiene. The MDS indicated Resident 5 used a wheelchair for mobility. A review of Resident 6’s incident report, dated 1/7/2025, indicated on 1/7/2025 around 11:05 p.m., Activities Aide (AA) 1 witnessed Resident 5 slap Resident 6 on the side of the head in the patio. The report indicated Resident 6 stated he was walking out and Resident 5 smacked him. A review of Resident 6’s IDT record, dated 1/8/2025, indicated during the “wee” hours (the early hours of the morning) of 1/8/2025, Resident 6 stated Resident 5 slapped him on the right side of face when Resident 5 asked for a lighter and Resident 6 stated he did not have one. The IDT record indicated the mandated abuse reporting guideline had been completed and Resident 6 pressed charges (to take legal action against someone) against Resident 5. During an interview on 1/22/2025 at 10:06 a.m., Resident 6 stated on the night of 1/7/2025, Resident 5 punched him with a closed fist and hit him (Resident 6) on the right side of the cheek near the vending machines, after he told Resident 5 to light her own cigarette. Resident 6 stated there was no staff present when it happened. Resident 6 stated being slapped by Resident 5 made him feel “weird” because he thought Resident 5 was his friend. During an interview on 1/22/2025 at 11:35 a.m., AA 1 stated on the night of 1/7/2025 at 11 p.m., she was supervising Resident 5 and walked with Resident 5 to the vending machine area. AA 1 stated she left Resident 5 alone for about five minutes with Resident 6 to inform the charge nurse that she needed to leave work and go home. AA 1 stated on 1/7/2025 at 11:05 p.m., she witnessed Resident 5 slap Resident 6 across the face when she returned to the vending machine area. A review of the facility’s Policy and Procedure (P&P) tilted “Abuse Prevention and Prohibition”, dated 11/2018, indicated the facility did not condone any form of resident abuse. The P&P indicated the facility promoted an environment free from abuse and mistreatment. The P&P also indicated physical abuse was defined as hitting, slapping, pinching, and or kicking. The facility failed to: 1. Ensure Resident 1 did not physically abuse Resident 7. 2. Ensure Resident 5 did not physically abuse Resident 6. As a result of these failures, Resident 7 sustained an acute depressed nasal bone fracture, and Resident 6 slapped in the face by Resident 5. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.