Health inspection·September 20, 2024

F609 (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

F656 §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 - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40. HSC § 1418.9 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. 22 CCR § 72311 § 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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. 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 8/5/2024 the California Department of Public Health (CDPH) received a complaint alleging the facility's Administrator (ADM) was aware that a resident (Resident 1) had a history of bullying, making threats (to kill or have residents killed), verbal abusive, and racial remarks towards residents over the last six months, but the ADM did not report the incidents to CDPH, and the local police department. On 8-7-2024 and 8-8-2024 CDPH received two Facility Reported Incidents (FRIs) reporting that Resident 1 made disrespectful comments toward his roommate (Resident 4) and cursed at another roommate (Resident 9). On 8/6/2024, the CDPH conducted an unannounced visit to the facility to investigate the complaint allegations. Upon investigation, CDPH determined the ADM was aware that Resident 1 had a history of verbally abusive behavior, bullying, harassment, and intimidating behaviors toward his roommates and continued to admit residents to Resident 1's room despite the resident's abusive behaviors. The ADM did not report the allegations of verbal abuse to the CDPH, or the local police department (PD). The facility failed to: 1. Ensure Residents 2, 3, 4, 7, 8 and 9 were not verbally abused by Resident 1 who had known behaviors of engaging in verbally abusive behaviors to residents who were admitted to his room. 2. Ensure residents were not admitted to Resident 1's room when Resident 1 had known verbally abusive, threatening, and harassing behaviors toward his roommates. 3. Ensure a care plan was developed for Resident 1, who had a history of verbal abuse, threatening, and harassing behaviors towards residents who were admitted to his room, with interventions to include not allowing admission of other residents to Resident 1's room. 4. Report the allegations of verbal abuse to CDPH, and the local police department within the regulated time frame of two hours, and report investigation findings to CDPH within five working days of the incident. 5. Ensure staff followed the facility's policy and procedure (P&P), titled, "Alleged and Suspected Abuse and Crime Reporting," and "Care Plan, Comprehensive" which indicated "each resident has the right to be free from abuse and neglect, to immediately report any incident of suspected or alleged abuse in accordance with Federal and State law, and it is the policy of this facility to develop, in conjunction with the resident and/or representative, the Comprehensive Resident Care Plan. The care plan is directed toward achieving and maintaining optimal status of health, functional ability, and quality of life." These deficient practices resulted in: 1. Residents 2, 3, 4, 7, 8, and 9's subjection to Resident 1's known and continued behavior of verbal abuse, bullying, harassment, racial slurs, and intimidation. 2. CDPH not being aware of the abuse allegations against Resident 1 that occurred between 2/22/2024 and 8/1/2024 until 8/6/2024. 3. CDPH's inability to investigate the allegations. 4. Residents who were admitted to Resident 1's room, at risk of verbal abuse, for pertinent information to be lost and/or forgotten, and other allegations of abuse to go unreported. a. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1, a fifty-three year old male, was admitted to the facility on 2/26/2022 with diagnosis including paraplegia (a chronic [lasting for a long time or constantly recurring] condition which causes a loss of muscle function in the lower half of the body, including both legs), depression (a mental health condition which causes persistent feeling of sadness, and loss of interest in activities a person normally enjoys), and a unspecified mood disorder (a disorder which describes a person's mood disturbances). A review of Resident 1's History and Physical (H&P) dated 11/28/2023, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 5/22/2024, indicated Resident 1's cognition was intact, and he had the ability to understand and be understood by others. The MDS indicated Resident 1 had behavioral symptoms that put others at risk for physical injury, significantly intruded on the privacy or activity of others, and significantly disrupted the care or living environment. A review of Resident 1's MDS dated 6/13/2024, indicated Resident 1 exhibited verbal behavioral symptoms directed toward others. A review of Resident 1's Clinical Record (Care Plan section), indicated Resident 1's Care Plans had no interventions preventing residents from being admitted to Resident 1's room. During a telephone interview on 8/5/2024 at 3:55 p.m., the Complainant stated on 7/17/2024 she received a phone call from the facility's Administrator (ADM) requesting guidance on how to handle Resident 1's behavior toward staff and other residents in the facility. The Complainant stated, the ADM told her Resident 1 bullies or abuses his roommates and other residents and calls the police on residents so he could have his own private room. The Complainant stated on 7/18/2024 she instructed the ADM to file a report with CDPH on behalf of all residents so the allegations of abuse could be thoroughly investigated. The Complainant stated, the ADM then rescinded his previous statement to her saying he never said anything happened with other residents, only that other residents have had "rough experiences" with Resident 1 in the past. During an interview on 8/8/2024 at 2:57 p.m., Resident 1 stated he did threaten to call immigration on one of his roommates (Resident 4) because he (Resident 1) felt Resident 4 spoke too loud and did not respect his rights because he (Resident 4) would not speak English. Resident 1 stated he mentioned to the ADM on several occasions that he had difficulty with roommates and sleeping at night. Resident 1 stated he liked to rest during the day and his roommates would not allow him to rest during the day. Resident 1 stated he requested not to have a roommate, but the ADM refused to honor his request. b. A review of Resident 2's Face Sheet, indicated Resident 2, an 83-year-old male, was admitted to the facility on 4/15/2021 with diagnosis including unspecified dementia (impaired ability to remember, think, or make decisions which interfere with doing everyday activities) and major depressive disorder ([MDD] a mood disorder which causes a persistent feeling of sadness and loss of interest). A review of Resident 2's MDS dated 4/10/2024, indicated Resident 2's cognition was severely impaired. A review of Resident 2's H&P dated 7/22/2023, indicated Resident 2 could make his needs known but could not make medical decisions. During an interview on 8/6/2024 at 2:11 p.m., Certified Nurse Assistant (CNA 2) stated while care was provided to Resident 2, Resident 1 yelled, "It smells like s**t in here." CNA 2 stated they knew Resident 1 made the comment toward Resident 2 because Resident 2 had just had a bowel movement. CNA 2 felt that Resident 1 was disrespectful to Resident 2 and Resident 2 should not have to tolerate Resident 1's behavior. CNA 2 stated looking back, Resident 1's comments made towards Resident 2 should have reported to the charge nurse because what Resident 1 said could be considered as verbal abuse and no resident should have to be subjected to that. During an interview on 8/6/2024 at 2:34 p.m., CNA 3 stated Resident 1 had a long history of verbally harassing his roommates. CNA 3 stated on several occasions, Resident 1 would say to Resident 2, "You f***ing white boy, I don't want you in my room," and he would say "Pendejo" (a derogatory word used to insult someone and imply they were foolish, stupid, or incompetent) to Resident 2 as well as "f**ker." CNA 3 stated she didn't know why the facility kept putting residents in the room with Resident 1 because it was known that Resident 1 would verbally abuse his roommates so he could have the room to himself. c. A review of Resident 3's Face Sheet, indicated Resident 3, a sixty-year-old male, was admitted to the facility on 6/5/2024 with diagnoses including left side hemiplegia (one-sided paralysis [complete or partial loss of function especially when involving the motion or sensation in a part of the body] or weakness) and hemiparesis (weakness or inability to move one side of the body). The Face Sheet indicated Resident 3 was admitted to the same room as Resident 1. A review of Resident 3's MDS dated 7/15/2024, indicated Resident 3 had severe cognitive impairment and was sometimes able to understand and be understood by others. A review of Resident 1's Social Service Note dated 6/5/2024 and timed at 4:26 p.m., indicated Resident 1 turned the volume of his television very loud because Resident 3 and his family were speaking a language other than commonly spoken English. The Social Service Note indicated Resident 3, and his family had difficulty having a conversation because of the loud volume of the television, but Resident 1 refused to turn the volume down. The Social Service Note indicated Resident 3 was moved to another room. d. A review of Resident 4's Face Sheet, indicated Resident 4, a sixty-seven-year-old male, was admitted to the facility on 7/31/2024 and was admitted to the same room as Resident 1. A review of Resident 1's General Note dated 7/31/2024 and timed at 10:54 p.m., indicated Resident 1 made rude comments to Licensed Vocational Nurse (LVN 3) saying "You suck his d*ck mother f**ker" (referring and pointing to the Resident 4). A review of Resident 1's General Note dated 8/1/2024 and timed at 12:12 a.m., indicated Resident 1 made disrespectful comments to his roommate (Resident 4). The General Note indicated, Resident 1 turned the volume of his television to the loudest volume in order to make Resident 4 uncomfortable and upset. During an interview on 8/6/2024 at 1:22 p.m., Resident 4 stated, when he was in the room with Resident 1, Resident 1 called him a f***ing Mexican, then said he (Resident 1) was going to report him to immigration so he (Resident 4) would be deported. Resident 4 stated Resident 1 threatened him and said he had a gun and was going to kill him. Resident 4 stated he later found out that Resident 1 had a history of threatening several of his (Resident 1) previous roommates and he (Resident 4) would have preferred not to be in a room with Resident 1 knowing of his behaviors. e. A review of Resident 7's Face Sheet, indicated Resident 7, a seventy-two-year-old male, was admitted to the facility on 11/20/2015 with diagnoses including dementia. A review of Resident 7's MDS dated 7/19/2024, indicated Resident 7 cognitive skills for daily decision making was severely impaired. A review of Resident 7's Census List dated 6/19/2024, indicated Resident 7's was roommates with Resident 1. During an interview on 8/8/2024 at 2:47 p.m., Resident 7's Family Member (FM 1) stated they would report to the facility staff that Resident 1 was loud at night and would force her (FM 1) to keep the curtains in the room closed and lights in the room off during the day. FM 1 stated she felt Resident 7 was harassed by Resident 1 because he (Resident 1) forced herself and Resident 7 to go by his rules. FM 1 stated she was worried because Resident 7 could not speak for himself, and she was concerned that his health would decline. FM 1 stated they pleaded with staff on several occasions to have Resident 7's room changed, but it did not happen for several days. d. A review of Resident 8's Face Sheet, indicated Resident 8, a sixty-three-year-old male, was admitted to the facility on 2/21/2024 with diagnosis including schizophrenia (a mental health disorder which is characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and bipolar disorder (a serious mental illness which causes unusual shifts in mood). A review of Resident 8's MDS dated 2/27/2024, indicated Resident 8 had no cognitive impairment and usually had the ability to understand and was usually understood by others. A review of Resident 1's General Note dated 2/22/2024 and timed at 12:24 a.m., indicated Resident 1 verbally threatened his roommate (Resident 8). The General Note indicated Resident 1 screamed derogatory phrases at Resident 8 and Resident 8's family members. e. A review of Resident 9's Face Sheet, indicated Re