Health inspection·March 6, 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. 483.21(b) Comprehensive Care Plans 483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - 22 CCR § 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 CCR § 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. 22 CCR § 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. On 1/23/2025, California Department Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident (FRI). Upon investigation, CDPH determined the facility did not protect Resident 1 from Resident 2's physical abuse when Resident 2 punched Resident 1 in the head 10 times and Resident 1 later died from his injuries. The facility failed to: 1. Prevent Resident 1's physical abuse by ensuring Certified Nursing Assistant (CNA) 1 remained in resident's (Resident 1 and Resident 2) room on 1/20/2025 to address an escalating verbal conflict that directly led to Resident 2 punching Resident 1 in the head 10 times. 2. Prevent Resident 1's physical abuse and implement its own written abuse prevention policies when it did not investigate CNA 2's Grievance dated 12/11/2024 which indicated she had witnessed Resident 1 upset towards Resident 2 and a verbal altercation between them. 3. Develop a comprehensive care plan to evaluate and assess Resident 1 after he was injured that took into account his specific physical health such as not being able to walk and having a shunt in his brain. 4. Develop a comprehensive care plan for Resident 1's aggressive behavior (gets upset and jealous) and Resident 2's room dominating behavior (wants the room to himself and tries to impose his own rules) with intervention to prevent physical altercation between the residents. 5. Ensure Social Service staff and/or Social Service Director ([SSD]- promotes the welfare of others) conducted three days of follow up visits after Resident 2 was cohorted with Resident 1 in one room on 11/19/2024 to evaluate the residents compatibility as roommates. 6. Ensure staff followed the facility's policy and procedure titled "Abuse Prevention Program," revised 12/2016, which indicated staff had to protect residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, etc. 7. Ensure the facility's policy and procedure titled "Residents Rights" dated 12/2021, followed, which indicated the facility guaranteed residents basic rights to be free from abuse. As a result, Resident 1 was punched in the head 10 times by one of his roommates despite residents and staff noting verbal conflict between the two and there being multiple policies in place that, if properly implemented, would have prevented such an assault. The facility also failed to quickly and adequately respond to Resident 1's visible injury and reported symptoms for 10 days until finally Resident 1 went from being fully verbal and making decisions about their own health to being non-verbal and exhibiting seizure-like symptoms and was sent out to the hospital for evaluation. At the hospital, Resident 1 was diagnosed to have a brain bleed and also a herniation of the brain, which is a medical emergency where brain tissue protrudes outside of the skull. Resident 1 was diagnosed as clinically brain dead 2/2/2025, just 12 days after being punched in the head and two days after hospitalization. Resident 1 died two days later on 2/4/2024. A review of Resident 1' s Admission Record indicated Resident 1 to be a 58 year old male who was originally admitted to the facility on 2/8/2023 and readmitted on 11/06/24. Resident 1's diagnoses included seizures, presence of a ventriculoperitoneal (VP) shunt, a device that connects the brain's ventricles (fluid-filled spaces within the brain) to the peritoneal cavity (the space within the abdomen), allowing for the drainage of excess cerebrospinal fluid (CSF, the fluid surrounding the brain and spinal cord) history of other mental and behavioral disorders, peripheral neuropathy (disease causing numbness in the hands and feet), and essential hypertension (high blood pressure). A review of Resident 1's History and Physical (H&P), dated 3/16/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set ([MDS]- resident assessment tool) dated 12/12/2024, indicated Resident 1 was cognitively (ability to think, understand, learn, and remember) intact and needed substantial assistance (helper does more than half the work) with activities of daily living ([ADL's] - activities such as bathing, dressing, and toileting a person performs daily). The MDS also indicated Resident 1 was not able to walk. A review of Resident 1's Change of Condition (COC), dated 1/20/2025, and timed at 6:53 p.m., indicated Resident 1 was involved in a resident-to-resident altercation. The COC indicated Resident 1 reported being struck by Resident 2. The COC indicated Resident 1 was observed with a bump (an elevated area on the skin) on the left side of forehead measured 4.0 cm by 2.0 cm with blue and green discoloration. There was no documented evidence that the resident was sent to the GACH for an evaluation. A review of Resident 1's Psychosocial/Social Services Note dated 1/21/2025 and timed at 11:48 a.m. indicated Resident 1 stated that he and Resident 2 did not like each other. The Psychosocial/Social Services Note indicated Resident 1 could not remember the reason for his and Resident 2's argument, and Resident 1 moved to his bedside so quickly that by the time he realized Resident 2 was there and Resident 2 had already started hitting him (Resident 1) in the face 10 times. The Psychosocial/Social Services Note indicated Resident 1 used his hands to protect his face. A review of Resident 1's Psychosocial/Social Service Note dated 1/22/2025 and at 12:19 p.m., indicated Resident 1 complained of a headache. A review of Resident 1's Nurses Progress Notes dated 1/22/2025 at 7:57 p.m., indicated Resident 1 had a purplish skin discoloration on the left side of forehead measured 3.0 cm by 2.0 cm with swelling. On 1/30/2025 timed at 3:01 p.m., Resident 1 was transferred to a GACH for evaluation due to COC of having seizure like activity. At the GACH Resident 1 was diagnosed to have a subdural hematoma (brain bleed) and herniation of the brain. A review of Resident 1's GACH Emergency Room Note dated 1/30/2025, indicated Resident 1 was brought by paramedics from facility for evaluation of seizure-like activity. Resident 1was reported to have rightward gaze, was flexing his right arm, and was currently nonverbal. A review of GACH's Computed Tomography Scan ([CT] scan- imaging test used to detect internal injuries) dated 1/30/25, indicated Resident 1 had a large right hemispheric (half of the brain) hyperacute (unusually severe) /acute (sudden) subdural hematoma with brain herniation. A review of GACH's Emergency Department (ED) Notes dated 1/30/2025 indicated Resident 1 visit diagnoses included subdural hematoma, assault, and herniation of the brain. A review of GACH's ED notes dated 2/1/2025 at 7:57 a.m., indicated plan recommendations included exam is consistent with clinical brain death. Brain death declaration per Intensive Care Unit (ICU) and neurology. Extubation as per ICU team. A review of Resident 2 ' s Admission Record, indicated Resident 2 to be a 50 year old male who was originally admitted to the facility on 6/6/2023 and readmitted on 1/04/2025 with diagnoses including chronic obstructive pulmonary disease ([COPD]-a chronic lung disease causing difficulty in breathing), type 2 diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), and heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). A review of Resident 2's H&P, dated 5/2/2024, the H&P indicated, Resident 2 had the capacity to understand and make decisions. A review of Resident 2's Psychosocial/Social Services Note dated 11/19/24, indicated that Resident 2 room was changed due to roommate (Resident 4) incompatibility. A review of Resident 2's MDS dated 12/14/2024, indicated Resident 2 had moderate cognitive impairment and needed set up or clean up assistance (helper sets up and cleans up) with ADL's. A review of Resident 2's COC form, dated 1/20/2025 and timed at 7:07 p.m., indicated Resident 2 was involved in a resident-to-resident altercation resulting in Resident 1 being struck by Resident 2. The COC indicated Resident 2's physician was informed with recommendations including to monitor Resident 2 for aggressive behavior, emotional distress and psychiatric (mental and behavior) evaluation. A review of CNA 1's Statement dated 1/20/2025, indicated CNA 1 was present in the room during the incident (verbal altercation) involving Resident 1 and Resident 2. CNA 1's Statement indicated Resident 2 verbalized "I am done Mama." Resident 1 began saying inappropriate words (unknown) and CNA 1 left the resident's room. A review of Resident 2's Psychosocial/Social Services Note dated 1/21/2025, indicated Resident 2 stated that Resident 1 was talking bad about him (Resident 2) and laughing. The Psychosocial/Social Services Note indicated Resident 2 did not remember what was said, he just "felt like he needed to do something to Resident 1," so he went to Resident 1's bed side and "thinks he hit Resident 1 on his face three times." The Psychosocial/Social Services Note indicated Resident 2 stated he does not get along with Resident 1. During an interview with Resident 1 on 1/22/2025 at 4:00 p.m., Resident 1 stated that he and Resident 2 have not been getting along well, and staff was aware of this situation. Resident 1 stated that Resident 2 insists he turns off his television and lights by 8 p.m. Resident 1 stated Resident 2 wanted the room to himself and tried to impose his own rules. Resident 1 stated, he refrained from speaking up his concerns (Resident 2's behavior towards Resident 1) to facility staff because he felt this was his room and space and did not want to move to another room. Resident 1 stated that he did not remember what triggered the argument between him and Resident 2 on 1/20/2025. Resident 1 stated he remembered when Resident 2 approached the side of his bed, and he (Resident 2) began hitting him on the head and face with his fist. During an interview on 1/23/2025 at 12:20 p.m., with Resident 3 (roommate of Resident's 1 and Resident 2), Resident 3 stated he witnessed the altercation between Resident 1 and Resident 2. Resident 3 stated Resident 2 called CNA 1 "mama, mama, mama" then Resident 1 said she (CNA 1) was not your "mama." Resident 3 stated, when CNA 1 left the room, Resident 2 got out of bed went over to Resident 1's bed and started hitting him on the head multiple times. Resident 3 stated, Resident 1 did not like when Resident 2 called CNAs "mama." During an interview on 1/23/2025 at 12:49 p.m. CNA 2 stated she had taken care of Resident 1 and Resident 2 multiple times. CNA 2 stated Residents 1 and 2 argued a lot. CNA 2 stated Resident 1 was the aggressor as he gets upset and jealous if she (CNA 2) spends more time with Resident 2. CNA 2 stated in December 2024 Resident 1 got into an argument with Resident 2 when CNA 2 gave Resident 2 two cups of coffee. CNA 2 stated Resident 1 does not like when Resident 2 calls CNA 1 "mama." Resident 1 thinks it was unprofessional for Resident 2 to call CNAs "mama." CNA 2 stated she told the Registered Nurse Supervisor (RNS) about the argument on 12/11/2024 and was advised to complete a Grievance report and give it to SSD. CNA 2 stated she filled out the Grievance and gave it to the Registered Nurse Supervisor (RNS) but could not remember exactly what she wrote on the Grievance report. CNA 2 stated she had not heard anything from SSD regarding her Grievance report. During an interview on 1/23/2025 at 3:42 p.m. CNA 1 stated she had taken care of Resident 1 and 2 multiple times. CNA 1 stated on 1/20/2025, she went to Resident 1 and Resident 2 room to see if the residents were done with dinner. CNA 1 stated Resident 2 said "yes mama," and Resident 1 responded "stop calling her mama." CNA 1 stated she took Resident 2 dinner tray out of the room, then "I heard a noise coming from Resident 1 and Resident 2 room." CNA 1 stated when she got back to the room Resident 2 was standing over Resident 1's bed. CNA 1 stated she immediately separated the residents and called the Assistant Director of Nurses (ADON) to come to the room. CNA 1 stated she should have reported to the charge nurse about Resident 1 telling Resident 2 to stop calling her "mama," she just did not get a chance to report as the incident happened so fast. CNA 1 stated staff should inform licensed staff right away when a resident has an issue with another resident because the residents could end up having a physical altercation. During a concurrent interview and record review on 1/23/2025 at 1:59 p.m., with RNS, CNA 2's Grievance Record dated 12/11/2024, was reviewed. RNS stated, CNA 2 told him about the verbal argument regarding coffee between Resident 1 and Resident 2. RNS stated he directed CNA 2 to write it down on a Grievance form and that he would give it to SSD. RNS stated he talked to Resident 1 and Resident 2 about the verbal argument and neither resident was mad. RNS confirmed there was no documentation in Resident 1 and Resident 2's clinical record regarding the incident on 12/11/2024. During a phone interview on 1/23/2025 at 10:40 a.m. Resident 1's Family Member (FM) 1, stated Resident 1 had an issue with Resident 2 wanting Resident 1 to turn television and lights off early (8 p.m.) and Resident 1 would not do it. FM 1 stated she was looking for another facility for Resident 1. During a phone interview on 1/23/2025 at 11:05 a.m. Resident 2's FM 2, stated Resident 2 would complain that Resident 1 would talk too loud to Resident 2. FM 2 stated Resident 2 was "hardheaded" and had a lot of health concerns. During a concurrent interview and record review on 1/24/2025 at 8:30 a.m. with SSD, Resident 2's Psychosocial/Social Services Note dated 11/19/24 was reviewed. The Psychosocial/Social Services Note dated 11/19/24 indicated Resident 2 was moved to a new room because of incompatibility with his roommate (Resident 4). The SSD stated Resident 2's room change was due to previous roommate (Resident 4) said that Resident 2 was too loud and mad