Health inspection·April 16, 2025

F600 Federal Code Regulations §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. California Code of Regulations, Section 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. California Code of Regulations, Section 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. California Code of Regulations, Section 72527. Patient 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. On 3/7/2025, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a Facility Reported Incident regarding resident abuse. As a result of the investigation, the CDPH determined the facility failed to ensure Resident 1 was free from verbal and physical abuse according to the facility's Policy and Procedure (P&P) titled, "Abuse Prevention." Resident 1 was yelled and scratched on the right hand by Resident 2 on 3/4/2025, resulting in an open cut on Resident 1's right hand. Resident 1 experienced physical and verbal abuse from Resident 2. a. A review of Resident 1's Admission Record (AR) indicated Resident 1, an 89-year-old female was re-admitted to the facility on 4/25/2024 with diagnoses including osteoarthritis of both knees and anxiety. A review of Resident 1's History and Physical (H&P) dated 1/7/2025 indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS) dated 1/29/2025 indicated Resident 1 had moderately impaired cognition and required moderate assistance with toilet and personal hygiene, upper and lower body dressing and transfer from chair/bed-to-chair. A review of Resident 1's Care Plan (CP) titled, "Resident Care Plan," dated 3/4/2025 indicated Resident 1 had an "Allegation of Resident-to-Resident Altercation (with Resident 2)." A review of Resident 1's Physician’s Order (PO) dated 3/4/2025 at 9 am indicated for licensed staff to cleanse Resident 1's right hand with normal saline, pat dry, apply bacitracin ointment and cover with dry dressing every shift for 21 days. A review of Resident 1's Progress Notes (PN) dated 3/4/2025 at 3:47 pm indicated Resident 1 had a 0.1 centimeter (cm- unit of measurement) by 0.1 cm scratch on Resident 1's right hand. During a concurrent observation and interview on 3/6/2025 at 12:15 pm with Resident 1, Resident 1 had an open wound with exposed pink tissue on the top portion of Resident 1's right hand. Resident 1 stated on 3/4/2025, at around 3 am, Resident 1 and Resident 2 had a verbal disagreement regarding having the room light on. Resident 1 stated later that day (3/4/2025) at around 8 am, while the housekeeper was cleaning the room, Resident 2 approached Resident 1. Resident 1 stated Resident 2 screamed and yelled and hit Resident 1 on the hand. b. A review of Resident 2's AR indicated Resident 2, a 61-year-old female was admitted to the facility on 12/19/2022 and was readmitted on 2/27/2025 with diagnoses that included schizophrenia and depression. A review of Resident 2's PO dated 2/2/2025 indicated for staff to monitor Resident 2 for aggressive behavior manifested by hitting and pinching staff. A review of Resident 2’s PO dated 2/2/2025 indicated for staff to place Resident 2 on one-to-one (1:1) monitoring. A review of Resident 2's MDS dated 2/9/2025 indicated the resident was cognitively intact, had clear speech, and had the ability to understand and be understood. The MDS indicated Resident 2 required maximal assistance with chair/bed- to- chair transfers. A review of Resident 2's H&P dated 2/27/2025 indicated Resident 2 had the capacity to make medical decisions. A review of Resident 2's CP titled, "Resident Care Plan," dated 3/4/2025 indicated the resident had an allegation of Resident 2 scratching Resident 1. A review of Resident 2's "1:1 Monitoring Log (ML)," dated 3/4/2025 indicated at 8 am, Resident 2 went to the room and had conservation with Resident 1. The ML did not indicate a nurse’s initial between the hours of 7:30 am to 8 am. During a concurrent observation and interview on 3/7/2025 at 12:32 pm with Resident 2, Resident 2 was sitting in Resident 2's wheelchair, moving around the room independently. Resident 2 stated on 3/4/2025 at around 8 am while housekeeping staff was cleaning the room, Resident 2 told Resident 1 to stay in bed and not to use the restroom because housekeeping staff was cleaning. Resident 2 stated Resident 1 was sitting in a wheelchair next to Resident 2's bed. Resident 2 stated Resident 2 told Resident 1 to move because the housekeeping staff was going to mop the room. Resident 2 stated Resident 1 went to the restroom. Resident 2 stated Resident 2 did not touch Resident 1. During an interview on 3/7/2025 at 12:49 pm, with Resident 3, Resident 3 stated on 3/4/2025, while waiting for housekeeping staff to finish cleaning the room, Resident 3 was in the hallway and heard Resident 2 yell at Resident 1 inside the room. Resident 3 stated no staff was present to monitor the residents. During an interview on 3/7/2025 at 1:39 pm with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated CNA 3 was responsible for the one-to-one monitoring of Resident 2. CNA 3 stated on 3/4/2025, around 8 am, CNA 3 used the restroom without informing another staff member, leaving Resident 2 unattended. CNA 3 stated CNA 3 should have informed the nurse in charge that CNA 3 had to use the restroom and not leave Resident 2 unattended. During an interview on 3/7/2025 at 2 pm with the Director of Nursing (DON), the DON stated Resident 2 had an order for one-to-one monitoring. The DON stated CNA 3 was the staff member assigned to conduct 1:1 monitoring to Resident 2. The DON stated, CNA 3 needed to inform another staff member prior to leaving Resident 2 for safety concerns. A review of the facility's P&P titled, "Abuse Prevention," revised on 3/15/2018 indicated the facility shall uphold resident rights to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntarily seclusion. A review of the facility's P&P titled, "One-on-One Monitoring Policy," dated 3/2018 indicated the policy "aims to ensure the safety, well-being, and quality of care for residents requiring individualized monitoring within the facility." The P&P indicated, "Assigned staff: Designated staff members such as CNAs, shall be assigned to provide one-on-one monitoring to residents as ordered by healthcare providers ... Continuous Supervision: Staff providing one-on-one monitoring shall maintain continuous visual supervision of the resident, remaining within close proximity to intervene promptly in the event of a safe concern or medical emergency." As a result of the investigation, the CDPH determined the facility failed to ensure Resident 1 was free from verbal and physical abuse according to the facility's P&P titled, "Abuse Prevention." Resident 1 was yelled and scratched on the right hand by Resident 2, resulting in an open cut on Resident 1's right hand. Resident 1 experienced physical and verbal abuse from Resident 2. The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.