Health inspection·April 18, 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 3/5/2025, California Department Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident (FRI) regarding resident-to-resident abuse. As a result of the investigation, the Department found that the facility failed to: 1. Prevent Resident 2 from punching Resident 1 on 2/25/2025 in accordance with the facility's policy and procedure (P&P) titled, "Abuse, Neglect and Exploitation" (undated), which indicated "Each resident has the right to be free from abuse ..." 2. Ensure Certified Nursing Assistant (CNA 1) and Licensed Vocational Nurse (LVN) 1, who witnessed and heard Resident 1 and Resident 2 argument in a loud voice on 2/25/2025, at 6 a.m. intervened by separating both residents in accordance with Resident 1's Care Plan titled, "Resident 1 has episode of aggressive behavior, believes someone is going to hurt him" dated 12/29/24 and Resident 2's Care Plan which indicated Resident 2 has the potential to cause injury to others related to suicidal ideation dated 9/16/24. 3. Ensure CNA 1 supervised Resident 1 and Resident 2 on the facility's green patio on 2/25/25 per assignment. As a result, Resident 2 punched Resident 1 in the face. Resident 1 sustained a black eye discoloration, upper left cheek skin tear laceration, fracture (broken bone) of the nasal (nose) bones and fracture of the medial (towards the middle) wall of the left eye orbit (bones that surround the eye socket) and left maxillary (upper jawbone on the left side of the face) sinus bone, which required evaluation and treatment at a General Acute Care Hospital (GACH). A review of Resident 1's Admission Record, indicated Resident 1, a 67 year old male, was admitted to the facility on 2/23/23 and readmitted on 12/28/24, with diagnoses including unspecified dementia, (a progressive state of decline in mental abilities), schizophrenia ( a mental illness that is characterized by disturbances in thought) anxiety disorder (emotion characterized by feelings of tension, worried thoughts ) and suicidal ideation ( thoughts, or fantasies about ending one's life) A review of Resident 1's Minimum Data Set ([MDS] a resident's assessment tool) dated 12/4/24, indicated Resident 1 had impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) with toileting hygiene, shower, and personal hygiene. The MDS indicated Resident 1 required moderate assistance with walking 10 feet and had not attempted to walk 50 feet due to medical condition or safety concerns. A review of Resident 1's History and Physical (H&P), dated 12/29/24, indicated, Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1's Care Plan titled, "Resident 1 has episode of aggressive behavior, believes someone is going to hurt him" dated 12/29/24, indicated staff interventions including to decrease stimulation around Resident 1 by providing a calm environment, remove any resident in the immediate area that may be in danger when the resident becomes aggressive, and to provide and encourage appropriate activities for Resident 1 to release energy. A review of Resident 2's Admission Record, indicated Resident 2, a 66 year old male, was admitted to the facility on 1/19/24 and readmitted 9/14/24, with diagnoses including essential hypertension ( type of high blood pressure where the cause is unknown and develops gradually), blindness on one eye (lack of vision in one eye), paranoid schizophrenia ( a chronic mental illness characterized by persistent delusions [ fixed false beliefs that are not based on reality] and hallucinations { sensory experiences that are not real}) mood affective disorder (mental health disorder that affects a person's emotional state leading to long hours of extreme sadness), schizoaffective disorder ( a mental disorder that is characterized by disturbances in thoughts) and suicidal ideation. A review of Resident 2's MDS dated 10/22/2024, indicated Resident 2 had moderate cognitive impairment. The MDS indicated Resident 2 had delusions. The MDS indicated Resident 2 required moderate assistance with toileting hygiene, shower, upper and lower body dressing, and personal hygiene. Resident 2 required moderate assistance with bed mobility, bed to chair transfer and walking 50 feet with two turns. A review of Resident 2's Care Plan indicated Resident 2 has the potential to cause injury to others related to suicidal ideation dated 9/16/24, indicated interventions including to allow Resident 2 express his feelings, refocus his attention to something positive when the resident was depressed, check the environment for potential hazards, and attempt behavioral intervention if Resident 2 was manifesting behaviors. A review of Resident 2' s Care Plan titled, " Resident 2 has episodes of delusions and attempting to strike out at staff because Resident 2 believe people are against him," dated 9/16/2024, indicated staff interventions included alter resident's environment, provide activities or take resident for a walk if the resident was upset, approach Resident 2 calmly unhurriedly, and attempt to refocus Resident 2 to something positive when the resident is exhibiting behaviors. A review of Resident 1's Nursing Progress Notes dated 2/25/25 timed at 6:32 a.m., indicated Resident 1 notified licensed staff that he had a bloody nose. The Nursing Progress Notes indicated Resident 1 stated that he was hit because he would not give up his cigarettes. A review of Resident 1's Nursing Progress Notes dated 2/25/25 timed at 7 a.m., indicated Resident 1 had swelling on the upper left lateral side of the nose bridge measured 0.1 centimeters (cm by 0.2 cm, left side of the forehead swelling measured 4.0 cm by 3.0 cm and a left eye with black discoloration and swelling measured 5.0 cm by 2.0 cm. A review of Resident 1's Nursing Progress Notes dated 2/25/2025 timed at 7:28 a.m., indicated Resident 1 had a cut on his nose and a bump on his forehead. The Nursing Progress Notes indicated Resident 1 stated "a big black guy" hit him after Resident 2 took Resident 1's cigarette. The Nursing Progress Notes indicated Resident 2 stated Resident 1 had kicked him in the past, so he (Resident 2) hit Resident 1. A review of Resident 1's Emergency Department (ED) Report dated 2/25/25 timed at 9:39 a.m., the ED report indicated Resident 1, arrived at the ED with a swollen left eye and complained of pain after being assaulted by another resident. A review of Resident 1's GACH's Emergency Department (ED) Notes dated 2/25/2025 indicated Resident 1 was sent to the GACH ED by emergency medical services (EMS) for an assault by another resident (Resident 2) who hit Resident 1in the face which resulted in left black eye with periorbital swelling, facial pain and swelling. A review of Resident 1's Computed Tomography ([CT] -diagnostic imaging procedure) report dated 2/25/25 and timed at 2:35 p.m., indicated Resident 1 had a nasal and fracture of the medial wall of the left orbital bone, and left maxillary sinus (a break in the bones surrounding the sinuses in the upper cheek area). During a concurrent observation and interview on 3/5/25 at 10:55 a.m., with Resident 1 in the activity room, Resident 1 was observed to have a laceration on the left upper cheek close to the nose and left eye. Resident 1 stated he did not know how he sustained his injuries. During an interview on 3/5/25 at 2:15 p.m., CNA 1 stated on 2/25/25 she witnessed the incident (argument) between Resident 1 and Resident 2 in the smoking patio, while she (CNA 1) was giving Licensed Vocational Nurse LVN 1 report on the residents' list with the risk for elopement (leaving a supervised area without permission or awareness). CNA 1 stated she observed Resident 1 and Resident 2 argue, but she (CNA 1) did not intervene because she did not know the argument would escalate (become more intense or serious) as it happened very fast, and Resident 2 punched Resident 1 in the face. CNA 1 stated Resident 1 liked to stay at a particular place on the patio and when another resident was at that place, Resident 1 would scream because he preferred to be the first one at that place. CNA 1 stated Resident 2 was quiet and not aggressive. CNA1 stated we were close enough to see what the residents were doing because they were sitting outside the green patio close to the dinning room area, and "LVN 1 and I were by the dining room area exchanging reports." During an interview on 3/5/25 at 2:30 p.m., LVN 1 stated on 2/25/25 while making rounds with CNA 1, he observed Resident 1 and Resident 2 arguing in the patio area. LVN 1 stated he did not know what they were arguing about. LVN 1 stated before he could separate them, Resident 2 punched Resident 1 on his left upper cheek bone, with his fist. LVN 1 stated Resident 1 was very upset and wanted to retaliate (make an attack or assault in return for a similar attack) at Resident 2 when LVN 1 was separating the two residents. LVN 1 stated residents should be separated immediately at the onset of argument and when they start to be aggressive. LVN 1 stated the incident should have been avoided if staff separated both residents as soon as the residents started arguing. LVN 1 stated Resident 1 had behavioral problems and a history of angry outburst. LVN 1 stated both residents should have not been left unsupervised. During an interview on 3/5/25 at 3 p.m., Director of Staff Development (DSD), stated when residents were having angry outbursts, the staff nearby or anyone should intervene immediately by separating the residents. The DSD stated there should be staff assigned on the patio to supervise residents because residents are always out on the patio. The DSD stated it was unusual behavior for Resident 2 to punch another resident as he was always quiet. The DSD stated when the staff hear loud and angry exchange or verbal outburst between residents, staff should intervene and deescalate (reduce the intensity of a conflict or potentially violent situation) the situation immediately. A review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect and Exploitation" (undated), the P&P indicated "each resident has the right to be free from abuse, misappropriation of resident property, and exploitation. The P&P, indicated the facility must: a. Train staff in appropriate interventions to deal with aggressive and catastrophic reactions by residents. b. Observe resident behavior and their reactions to other residents, roommates, tablemates. Place residents in accommodations and environments that keep them calm. c. Provide instruction to staff on care needs of residents. d. Assess monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect, such as residents with history of aggressive behaviors." The facility failed to: 1. Prevent Resident 2 from punching Resident 1 on 2/25/2025 in accordance with the facility's P&P titled, "Abuse, Neglect and Exploitation" (undated), which indicated "Each resident has the right to be free from abuse ... 2. Ensure CNA 1 and LVN 1, who witnessed and heard Resident 1 and Resident 2 argument in a loud voice on 2/25/2025, at 6 a.m. intervened by separating both residents in accordance with Resident 1's Care Plan titled, "Resident 1 has episode of aggressive behavior, believes someone is going to hurt him" dated 12/29/24 and Resident 2's Care Plan which indicated Resident 2 has the potential to cause injury to others related to suicidal ideation dated 9/16/24. 3. Ensure CNA 1 supervised Resident 1 and Resident 2 on the facility's green patio on 2/25/25 per assignment. As a result, Resident 2 punched Resident 1 in the face. Resident 1 sustained a black eye discoloration, upper left cheek skin tear laceration, fracture of the nasal bones and fracture of the medial wall of the left eye orbit and left maxillary sinus bone, which required evaluation and treatment at a GACH. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security for Resident 1