Health inspection·January 8, 2025

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. §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion CRR§ 72523(a) 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. CCR§ 72311 - Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. During an annual recertification survey conducted on 12/16/2024 - 12/20/2024 the California Department of Health (CDPH) determined the facility failed to: 1. Ensure Resident 20, who had a history of aggressive behavior, did not verbally abuse Resident 75, who also had a history of aggressive behavior, by saying "Pendejo" (Spanish slang term like someone calling someone an idiot or a dummy) and scratched Resident 75's face when Resident 75 approached Resident 20. 2. Ensure Resident 75 was close to the nursing station as indicated in the untitled care plan intervention, initiated on 11/2/2024, to ensure closer monitoring of Resident 75 for aggression manifested by hitting staff. 3. Implement the facility policy and procedure (P&P) titled, "Abuse, Prevention and Prohibition Program," implemented 7/9/2024, which indicated the residents have the right to be free from abuse and the facility had zero tolerance for abuse and staff must not permit anyone to engage in verbal, mental, or physical abuse or mistreatment. As a result of these failures, Residents 75 and 20 had a physical altercation in Resident 20's room and Resident 75 sustained scratches on the face. Findings: A review of Resident 20 a 75-year-old male's Admission Record, indicated Resident 20 was admitted to the facility on 2/27/2023 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive state of decline in mental abilities). A review of Resident 20's Minimum Data Set (MDS), a resident assessment tool, dated 10/18/2024, indicated Resident 20's cognitive (ability to think and reason) skills for daily decision-making were severely impaired. The MDS indicated Resident 20 had physical behavioral symptoms directed toward others (for example hitting, kicking, scratching, grabbing) that occurred one to three days. The MDS indicated Resident 20 had verbal aggression symptoms toward others (for example threatening, screaming, or cursing) that occurred four to six days, but less than daily. The MDS indicated Resident 20 required a set up assistance with eating, partial assistance (helper does less than half the effort) with oral hygiene, showering, and personal hygiene. A review of Resident 75 a 73-year-old male's Admission Record indicated Resident 75 was admitted to the facility on 6/25/2024 with diagnoses including Dementia, major depressive disorder, generalized anxiety disorder, and psychotic disorder (serious mental illness that causes a person to lose touch with reality) not due to a substance or known condition. A review of Resident 75's MDS, dated 11/22/2024, indicated Resident 75's cognitive skills for daily decision-making were intact. The MDS indicated Resident 75 required set up assistance when eating, supervision (helper provides verbal cues) with oral hygiene, substantial assistance (helper does more than half the effort) with showering and toileting hygiene. A review of Resident 75's untitled care plan initiated on 10/31/2024, indicated Resident 20 was involved in a resident-to-resident altercation of hitting another resident and claiming to be hit by another resident. The care plan goal indicated other resident (unidentified) will feel safe through review date 3/3/225. The care plan intervention included to administer medications as ordered, intervene as needed to protect the rights and safety of others; approach in a calm manner, divert attention, remove from situation, and take to another location. A review of Resident 75's (untitled) care plan initiated on 11/2/2024, indicated the intervention to monitor the resident's aggressive behavior such as hitting staff. The care plan goal indicated resident would not show aggressive behavior. The care plan intervention included to keep the resident closer to the nursing station and encourage resident to express feelings without getting aggressive and disrespectful. A review of Resident 20's Care Conference Interdisciplinary (IDT Resident's health care team consisting of various specialties) Meeting notes, dated 12/2/2024 and timed at 4:17 p.m., indicated on 12/2/2024 Resident 20 was involved in an altercation with another resident (unidentified) and caused minor injuries to the other resident (unidentified). A review of a facility's document titled, "Interviews conducted by the DON (Director of Nursing)", on 12/2/2024 the document indicated Resident 75 stated he (Resident 75) went to the bathroom and heard someone saying "Pendejo (Spanish slang term like someone calling someone an idiot or a dummy) so Resident 75 stated he wheeled himself over to Resident 20's bedside and stated, "What's up?". The document indicated Resident 20 stated, "Pendejo" again. Resident 75 stated he (Resident 75) got up from his wheelchair and walked over to Resident 20 and Resident 20 scratched Resident 75 on the face. The document indicated Resident 75 stated he was unsure if he was able to hit Resident 20 and that he just felt Resident 20 scratched him and then staff came inside the room and separated Resident 75 from Resident 20. During an interview on 12/17/2024 at 2:56 p.m., Registered Nurse Supervisor (RNS) 1 stated Resident 75 went to the restroom and heard Resident 20 calling him "Pendejo". RNS 1 stated Resident 75 went to Resident 20's bedside and there was a physical altercation that resulted in Resident 75 sustaining scratches on the face. RNS 1 stated it was physical abuse that was why it was reported. During an observation and interview on 12/18/2024 at 12:13 p.m., with RNS 1, in the hallway, Resident 75's room was noted to be not adjacent to the nursing station. RNS 1 stated Resident 75's room was four rooms down the hall from the nursing station and not close to the station. During a concurrent interview and record review on 12/18/2024 at 12:15 p.m. with RNS 1, Resident 75's care plans were reviewed. Resident 75's care plan (untitled), initiated 11/2/2024, indicated the interventions included to monitor the resident for aggressive behavior such as hitting staff, to keep the resident closer to the nursing station and encourage resident to express feelings without getting aggressive and disrespectful. RNS 1 stated this care plan interventions were not implemented on 11/2/2024 like it should have been. RNS 1 stated the care plan interventions were implemented after a resident-to-resident altercation involving the Resident 75 on 12/2/2024. RNS 1 stated Resident 75's room should be closer to the nursing station and after the incident on 12/2/2024 the Resident 75 was moved closer to the nursing station for close monitoring. During an interview on 12/20/2024 at 12:30 p.m., the DON stated residents have the right to be free from abuse and abuse should be prevented. During a review of the facility's P&P titled, "Abuse, Prevention and Prohibition Program," implemented 7/9/2024, the P&P indicated residents have the right to be free from abuse. The facility has zero tolerance for abuse and staff must not permit anyone to engage in verbal, mental, or physical abuse or mistreatment. The facility was committed to protecting residents from abuse by anyone including other residents. The facility failed to: 1. Ensure Resident 20, who had a history of aggressive behavior, did not verbally abuse Resident 75, who also had a history of aggressive behavior, by saying "Pendejo" and scratched Resident 75 face when Resident 75 approach Resident 20. 2. Ensure Resident 75 was close to the nursing station as indicated in the untitled care plan intervention, initiated 11/2/2024, to ensure closer monitoring of Resident 75 for aggression manifested by hitting staff. 3. Implement the facility P&P titled, "Abuse, Prevention and Prohibition Program," implemented 7/9/2024, the P&P indicated residents have the right to be free from abuse. The facility has zero tolerance for abuse and staff must not permit anyone to engage in verbal, mental, or physical abuse or mistreatment. This violation had a direct relationship to the health, safety, or security of Resident 75 and Resident 20.