Health inspection·March 14, 2025

Freedom from Abuse, Neglect, and Exploitation 42 CFR §483.12(a) The facility must: (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 1/23/2025, the California Department of Public Health (CDPH) received a facility-reported incident (FRI) with two allegations of physical abuse from Resident 1 on 1/21/2025 and 1/23/2025 to Resident 2 and Resident 3. On 2/5/2025, an unannounced visit was conducted at the facility. The facility failed to: 1.Implement its Policy and Procedure (P&P), titled, "Abuse Prevention and Prohibition, which indicated the facility will promote an environment free from abuse and mistreatment. As a result, on 1/21/2025 Resident 1 pushed Resident 3 down in the hallway, and on 1/23/2025 hit Resident 2 on the head multiple times. A.) A review of Resident 1's Admission Record indicated Resident 1 was a 55-year-old male, admitted to the facility on 11/13/2024. Resident 1's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), Human Immunodeficiency Virus disease (HIV - a virus that attacks the body's immune system), and anxiety disorder (feelings of uneasiness). A review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 11/26/2024, indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making was severely impaired. The MDS indicated Resident 1 required substantial or maximal assistance (helper provides more than half of the effort) for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene. A review of Resident 1's SBAR ([SBAR] situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 1/21/2025 indicated Resident 1 shoved Resident 3 in the hallway. A review of Resident 1's SBAR dated 1/23/2025, indicated Resident 1struck Resident 2 in the head multiple times. The SBAR indicated Resident 2 sustained a scratch on the left arm and thumb. During an interview on 2/5/2025 at 1:30 p.m. with Registered Nurse (RN) 1, RN 1 stated the licensed nurses should have notified the physician on 12/4/2024 and 12/5/2024 when Resident 1 displayed episodes of aggression to prevent any abuse and minimize the chance of another altercation. During a concurrent interview and record review on 2/5/2025 at 4:45 p.m. with the Director of Nursing (DON), Resident 1's Nursing Progress Note, dated 12/3/2024 and 12/5/2024, were reviewed. The DON stated Resident 1 should have been sent out to the General Acute Care Hospital (GACH) on 12/4/2024 or 12/5/2024 to prevent further instances of physical aggression, physical altercations, or physical abuse. B. A review of Resident 2's Admission Record indicated Resident 2 was a 66-year-old male, admitted to the facility on 11/23/2024. Resident 2's diagnoses included dementia (a progressive state of decline in mental abilities) with other behavioral disturbances, lack of coordination, difficulty in walking. A review of Resident 2's MDS dated 11/27/2024, indicated Resident 2's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 2 required substantial or maximal assistance for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene, and was entirely dependent (helper does all the effort) on staff when walking ten feet (ft- a unit of measurement). A review of Resident 2's Progress note dated 1/23/2025, indicated Resident 2 was struck in the head multiple times by Resident 1. C. A review of Resident 3's Admission Record indicated Resident 3 was a 67-year-old male, admitted to the facility on 1/3/2025. Resident 3's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and difficulty in walking. A review of Resident 3's MDS, dated 1/9/2025, the MDS indicated Resident 3's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 3 required partial or moderate assistance (helper provides less than half of the effort) for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene. During an interview on 2/5/2025 at 4:45 p.m. with the DON, the DON stated the licensed nurses should have sent Resident 1 out to the GACH for a psychiatric evaluation on 12/4/2024 because it resulted in repeated episodes of abuse towards residents. The DON stated this could have led to physical abuse incidents on 1/21/2025 and 1/23/2025 to Resident 2 and Resident 3 by Resident 1. A review of the facility's P&P, titled, "Abuse Prevention and Prohibition," revised 11/2018, indicated the facility will promote an environment free from abuse and mistreatment. The P&P indicated the facility was to understand "behavioral symptoms" of residents that would increase the risk of abuse. The P&P indicated "aggressive and, or catastrophic reactions of residents and wandering behaviors" were symptoms that would increase the risk of abuse. The facility failed to: 1. Implement its P&P, titled, "Abuse Prevention and Prohibition, which indicated the facility will promote an environment free from abuse and mistreatment. As a result, on 1/21/2025 Resident 1 pushed Resident 3 down in the hallway, and on 1/23/2025 hit Resident 2 on the head multiple times. This violation had a direct or immediate relationship to the health, safety, or security of all residents.