Health inspection·January 30, 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. (a) The facility must— (a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 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. 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. CCR § 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. On 1/6/2025, the California Department of Public Health (CDPH) received a facility entity reported incident (FRI) with allegation of resident abuse. On 1/7/2024 at 8:00 a.m., an unannounced visit was made to the facility to investigate the FRI allegation. The facility failed to: 1. Ensure staff assigned to supervise the residents on the smoking patio, including Certified Nursing Assistant (CNA) 3, were present on the smoking patio to protect Resident 11 from physical abuse by Resident 54. On 1/6/2025 at 2:15 p.m., while on the smoking patio, Resident 54 hit Resident 11 on the nose. 2. Ensure staff followed the facility’s Policy and Procedure titled (P/P) titled, “Abuse Neglect, Exploitation and Misappropriation Prevention Program” dated May 2024, indicating residents have the right to be free from physical abuse. As a result, Resident 11 sustained a nosebleed and had to be sent out to the general acute care hospital (GACH) on 1/7/2025 for further evaluation and treatment. Findings: A review of Resident 11’s Admission Record indicated Resident 11 was admitted to the facility on 7/13/2021 and readmitted on 10/24/2024 with diagnoses including schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), and insomnia (trouble falling asleep or staying asleep). A review of Resident 11’s Minimum Data Set ([MDS], a resident assessment tool), dated 10/16/2024, indicated Resident 11 had severe cognitive (thinking process) impairment. The MDS also indicated Resident 11 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity) for self-care abilities such as eating and needed moderate assistance (helper does less than half the effort. helper lifts, hold or supports trunk or limbs but provides less than half the effort) for self-care abilities such as oral hygiene, toileting hygiene, upper and lower body dressing, putting on and taking off footwear and personal hygiene and mobility such as rolling left and right, sit to lying position, lying to sitting position, sit to stand position, and transfers. A review of Resident 11’s history and physical (H&P) dated 10/7/2024, indicated Resident 11 did not have the capacity to understand and make decisions. A review of Resident 11’s Interdisciplinary Team ([IDT]a team of members from different departments working together to set goals, make decisions to ensure residents receive the best care) Note dated 1/7/2025 indicated on 1/6/2025 nursing staff was in the Court Station patio to supervise residents during their smoke break, when they heard screaming. The IDT Note indicated staff immediately assessed Resident 11 and noted Resident 11 was in his wheelchair with blood coming from his nose. The IDT Note indicated Resident 11 reported that he had an altercation with Resident 54. The IDT Note indicated Residents 11 and Resident 54 were kept separated and assessed for injuries. The IDT Note indicated Resident 11 was noted with a hematoma (a dark area on the skin due to broken blood vessels pooling under the skin) on the bridge of Resident 11’s nose and abrasion (wound) on the third metacarpal (bones of the hand). Resident 11’s X-ray (diagnostic imaging test) completed on 1/6/2025 revealed no facial bones were broken. The IDT Notes indicated a Physician’s Order was given to transfer the resident to the hospital for further evaluation and treatment. A review of Resident 11’s Order Summary Report, indicated “may transfer to hospital for further evaluation and treatment related to X-ray results ordered on 1/7/2025.” A review of Resident 11’s GACH records dated 1/7/2025, indicated Resident 11’s chief complaint was nasal injury, and that the resident got in an altercation with another resident with subsequent nose injury and bleeding. The facility sent Resident 11 for further tests to rule out intracranial (within the brain) bleeding. A review of Resident 54’s Admission Record indicated Resident 54 was admitted to the facility on 9/29/2021 and readmitted on 10/21/2021 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder, schizophrenia, and anxiety disorder. A review of Resident 54’s MDS, dated 10/4/2024, indicated Resident 54 had an intact cognitive ability. The MDS also indicated Resident 54 required supervision for self-care abilities such as eating, and oral hygiene and needed moderate assistance for self-care abilities such as toileting, shower/bathe, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS also indicated Resident 54 required supervision for mobility such as rolling left and right, sit to lying position, lying to sitting on the side of bed, sit to stand position and transfers. A review of Resident 54’s H&P dated 2/12/2024, indicated Resident 54 was able to make decisions. A review of Resident 54’s Psychology (medical field specializing in treatment of mental illness) Consult Note dated 12/8/2024, indicated Resident 54 was referred to be seen by social services staff following verbal confrontations with staff involving money. The Psychology Consult Note indicated Resident 54 did not acknowledge or remember verbal disputes with staff members. The Psychology Consult Note indicated Resident 54 presented with agitation (restlessness, uneasiness) hyper-verbal speech (speaking quickly and frequently, sometimes to the point of interrupting others) and had symptoms including paranoia (severe distrust of others not rooted in reality) and a response to auditory hallucinations (hearing things that do not exist in realty). A review of Resident 54’s IDT Note dated 1/7/2025, indicated that Resident 54 was involved in a physical altercation with Resident 11. The IDT Notes indicated the residents were separated and assessed for injuries. The IDT Note indicated Resident 54 stated he asked Resident 11 if he took his money and then struck Resident 11 on the nose with a closed hand. The IDT Note indicated Nursing staff performed head to toe assessment with no injuries noted and Resident 54 was sent out to the GACH for further evaluation and treatment due to physical aggression. A review of Resident 54’s Order Summary Report, indicated there was an order dated 1/6/2025 to transfer Resident 54 to a GACH for further evaluation related to aggression. During a concurrent observation and interview on 1/8/2025 at 9:06 a.m., with Resident 11, in his room, Resident 11 was sitting in his wheelchair. Resident 11’s nose appeared a little swollen at the bridge of his nose. Resident 11 stated on 1/7/2025 he was sent to the hospital for his nose because he could not breathe well through the nose. During an interview on 1/10/2025 at 5:19 p.m., the Director of Nursing (DON) stated the Assistant Director of Nursing (ADON) 1 was around the smoking patio area when the altercation between Resident 11 and Resident 54 happened on the smoking patio area. The DON stated that CNA 3 should have been on the smoking patio area as well but was attending to another resident in his room (unknown) when Resident 54 told CNA 3 that Resident 11 took his money. The DON stated he got a call from CNA 3 that Resident 54 hit Resident 11 and he (DON) went to the smoking patio area to assess the residents. During a telephone interview on 1/13/2025 at 10:27 a.m., CNA 4 stated he was in the hallway of the unit by the smoking patio area charting when the incident happened. CNA 4 stated that CNA 3 went to him in the hallway and told him that Resident 54 hit Resident 11. CNA 4 stated he ran to the smoking patio area that was located outside and saw Resident 11’s face full of blood. CNA 4 stated he took Resident 11 to his room to clean him up. During a telephone interview on 1/13/2025 at 10:49 a.m., ADON 1 stated he was in the smoking patio area walking, doing his rounds when Resident 54 hit Resident 11 on 1/6/2025. ADON 1 stated he had his back turned to the residents during the altercation as he was attending to another resident in the smoking patio area. ADON 1 stated the incident happened so fast that he did not see Resident 54 hit Resident 11 but heard the incident happened behind him. ADON 1 stated Resident 54 rushed back inside the unit and staff came to render first aid to Resident 11. ADON 1 stated the DON and Administrator were notified and came to assess the situation. A review of the facility’s P/P titled, “Abuse Neglect, Exploitation and Misappropriation Prevention Program” dated May 2024, the P/P indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms……protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to facility staff; other residents; any other individual……ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates. The facility failed to: 1. Ensure staff assigned to supervise the residents on the smoking patio, including CNA 3, were present on the smoking patio to protect Resident 11 from physical abuse by Resident 54. On 1/6/2025 at 2:15 p.m., while on the smoking patio, Resident 54 hit Resident 11 on the nose. 2. Ensure staff followed the facility’s P/P titled, “Abuse Neglect, Exploitation and Misappropriation Prevention Program” dated May 2024, indicating residents have the right to be free from physical abuse. As a result, Resident 11 sustained a nosebleed and had to be sent out to the GACH on 1/7/2025 for further evaluation and treatment. This violation had a direct or immediate relationship to the health, safety, or security of the residents.