Health inspection·March 6, 2024

Code of Federal Regulations, Title 42, Section 483.12(a)(1) §483.12(a)(1) 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. California Code of Regulations, Title 22, Section 72319. Nursing Service - Restraints and Postural Supports. (f) Seclusion, which is defined as the placement of a patient alone in a room, shall not be employed. California Code of Regulations, Title 22, 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, Title 22, 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. On 1/18/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding quality of care and resident abuse. As a result of the investigation, the CDPH determined the facility failed to ensure Residents 1, 2, and 3 were free from involuntary seclusion (separation of a resident from other residents or from her/his room or confinement to her/his room with or without roommates against the resident's will, or the will of the resident representative) by failing to: Ensure Certified Nurse Assistant (CNA) 1 did not use two utility/linen carts (material handling cart used for bedding, linens, and other supplies) to block the entrance/exit (only one entrance and exit) to Resident 1, 2 and 3’s Room (RM 1, not actual room) after CNA 1 witnessed Resident 1 spilling liquid on the floor. As a result, CNA 1 violated Resident 1, 2, and 3’s rights and prohibited (not allowed) Residents 1, 2, and 3 from leaving RM 1. These deficient practices had the potential for psychosocial (mental, emotional, social, and spiritual effects) harm, serious injury, serious harm, serious impairment, or death to Residents 1, 2, and 3. A review of Resident 1’s Admission Record (AR) indicated, the facility admitted Resident 1, a 67-year-old male, on 2/5/2010 with diagnoses of paranoid schizophrenia (serious mental illness in which people interpret reality abnormally), unspecified psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), and obsessive-compulsive personality disorder (a pervasive obsession with order, perfectionism, control, and specific ways of doing things). A review of Resident 1’s History and Physical (H&P) dated 2/19/2023 indicated, Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS - a standardized resident assessment and care screening tool), dated 11/17/2023 indicated, Resident 1 had severely impaired cognition. The MDS indicated, Resident 1 required partial/moderate assistance with toileting hygiene, showering/bathing self, and personal hygiene. The MDS indicated, Resident 1 required supervision or touching assistance with oral hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear. The MDS indicated, Resident 1 required setup or clean-up assistance with eating and required supervision or touching assistance with sitting to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, and walking 10 feet. A review of Resident 2’s AR indicated, the facility admitted Resident 2, a 74-year-old male, on 4/29/2022 with diagnoses of schizophrenia, major depressive disorder (serious illness that negatively affects how one feels, thinks and acts), and anxiety disorder (persistent feeling of dread or panic that can interfere with daily life). A review of Resident 2’s untitled care plan (CP) dated 5/2/2022 indicated, Resident 2 had ineffective coping related to a past traumatic incident, manifested by uncontrollable mood swings causing anger and paranoid thoughts, thinking someone was coming after Resident 2, causing stress. The CP interventions included to build a trusting relationship during day-to-day activities, encourage group activities, and provide a safe environment and atmosphere of acceptance. A review of Resident 2’s MDS dated 11/2/2023 indicated, Resident 2 had severely impaired cognition. The MDS indicated, Resident 2 required substantial/maximal assistance with showering/bathing self. The MDS indicated, Resident 2 required partial/moderate assistance with toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated, Resident 2 required supervision or touching assistance with oral hygiene. The MDS indicated, Resident 2 required setup or clean up assistance with eating and required supervision or touching assistance with rolling left to right, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, toilet transfers, and walking 10 feet. A review of Resident 3’s AR indicated, the facility admitted Resident 3, an 81-year-old male, on 6/18/2021 with diagnoses of paranoid schizophrenia, anxiety disorder, and major depressive disorder. A review of Resident 3’s H&P dated 6/10/2023 indicated, Resident 3 had the capacity to make decision for activities of daily living (ADL- the tasks of everyday life fundamental to caring for oneself). A review of Resident 3’s MDS dated 12/21/2023 indicated, Resident 3 had moderately impaired cognition. The MDS indicated, Resident 3 required partial/moderate assistance with showering/bathing self. The MDS indicated, Resident 3 required supervision or touching assistance with oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated, Resident 3 required setup or clean-up assistance with eating. The MDS indicated, Resident 3 required supervision or touching assistance with toilet transfers. The MDS indicated, Resident 3 required setup or clean-up assistance with rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, and walking 10 feet. During a concurrent observation and interview on 1/18/2024 at 9:50 am, while on a tour with the Social Services Director (SSD), two blue utility/linen carts were tied to the hallway siderail and the strike plate hole in front of RM 1’s doorway. The SSD stated two utility carts were blocking RM 1’s doorway. The SSD stated there was a clear trash bag that tied both utility carts together, a clear trash bag that tied the left utility cart to the inside of RM 1’s strike plate hole, and a clear trash bag that tied the right utility cart to the right siderail in the hallway. The SSD stated the SSD was unclear why there were trash bags tying two utility carts in place to block RM 1’s doorway. During a concurrent observation and interview on 1/18/2024 at 9:52 am with CNA 1, in front of RM 1’s doorway, there were two utility carts blocking the doorway. CNA 1 stated the utility carts were tied with clear trash bags. CNA 1 stated the Residents in RM 1 (Residents 1, 2, and 3) could not get out the room unless CNA 1 or another staff member untied the three trash bags and moved the two utility carts out of RM 1’s doorway. CNA 1 stated the purpose of blocking RM 1’s doorway was to block Resident 1 from coming out of RM 1 due to Resident 1’s behavioral issues. CNA 1 stated Resident 1 stole other residents’ cups and while walking, Resident 1 spilled water on the floor. During an interview on 1/18/2024 at 10:03 am with Licensed Vocational Nurse (LVN) 1, in front of Resident 1’s doorway, LVN 1 stated CNA 1 informed LVN 1 that CNA 1 barricaded (blocked) Resident 1’s doorway with two utility carts and tied the carts with trash bags to keep Resident 1 in the room. LVN 1 stated, CNA 1 needed to keep Resident 1 in the room while housekeeping staff cleaned the floor because Resident 1 spilled liquid from Resident 1’s cups all over the floor. LVN 1 stated blocking RM 1’s doorway could lead to injury to Resident 1 in an emergency. During a concurrent observation and interview on 1/18/2024 at 10:11 am with LVN 2, in front of RM 1’s doorway, LVN 2 untied three, clear trash bags anchored to two utility carts in RM 1’s doorway. LVN 2 stated Residents 1, 2, and 3 were in RM 1 at the time RM 1’s doorway was blocked. LVN 2 stated Residents 2 and 3 were “trapped” inside RM 1 with Resident 1 and could not get out of the room. LVN 2 stated blocking Residents 1, 2, and 3 in their room was a type of abuse used for staff convenience. During an interview on 1/18/2024 at 10:18 am with Resident 2, Resident 2 stated Resident 2 did not know why staff blocked RM 1’s doorway so Resident 2 could not get out of the room. Resident 2 stated Resident 2 did not like it “when staff did that.” Resident 2 stated staff were not nice, and it made Resident 2 feel terrible when staff blocked the doorway. Resident 2 stated Resident 2 wished staff would stop blocking the doorway because it did not make sense when he was trapped in the room with Resident 1. Resident 2 stated Resident 2 did not know how to ask for help when Resident 2 wanted to get out of the room or needed assistance. During an interview on 1/18/2024 at 11:38 am with CNA 1, CNA 1 stated Resident 3 would yell and scream to be let out of the room to smoke cigarettes when the doorway was barricaded. During an interview on 11/18/2024 at 11:56 am with CNA 3, CNA 3 stated CNA 1 barricaded Resident 1’s doorway because housekeeping staff had to spend time cleaning up whatever Resident 1 dropped on the floor. CNA 3 stated “this happened every day.” CNA 3 stated when CNA 3 saw RM 1’s doorway barricaded, CNA 3 untied the utility carts, but CNA 3 would get yelled at by other nursing staff. CNA 3 stated barricading Resident 1 inside RM 1 was abuse in the form of involuntary seclusion. CNA 3 stated Resident 3 liked to smoke cigarettes and when RM 1 was blocked by the utility/linen carts, Resident 3 could not go out to smoke. CNA 3 stated Resident 3 had to yell and scream until staff eventually let Resident 3 out of the room to smoke. During an interview on 1/18/2024 at 12:12 pm with Resident 3, Resident 3 stated Resident 3 liked to smoke. Resident 3 stated it made Resident 3 “really mad and upset” because Resident 3 had to yell and scream to get someone to let Resident 3 out of RM 1 to smoke. Resident 3 stated it generally took over 15 minutes for staff to let Resident 3 out of the room. Resident 3 stated it felt like staff forget about “everyone” in RM 1. Resident 3 stated it was “stupid” Resident 3 had to ask for permission to leave the room and Resident 3 hated it. During an interview on 1/18/2024 at 12:31 pm with the Infection Prevention Nurse (IPN), the IPN stated the IPN had put the utility carts in RM 1’s doorway before, but never tied the carts with trash bags. The IPN stated this practice (blocking RM 1’s doorway) was done by the IPN and other staff to “diminish” Resident 1’s traffic around the facility because Resident 1 walked around the facility with cups of water and spilled the water everywhere. The IPN stated the utility carts were generally put in RM 1’s doorway in the morning when staff were busy. During a concurrent observation and interview on 1/18/2024 at 12:47 pm with the Director of Nursing (DON) and Admissions Director (AD), the facility’s security footage of Camera Two was reviewed. The DON stated on 1/18/2024 at 8:29:14 am, Resident 1 went into RM 1. The DON stated on 1/18/2024 at 8:30:11 am, CNA 1 held a trash bag in CNA 1’s hands. The DON stated on 1/18/2024 at 8:31:46 am, CNA 1 moved two utility carts into the doorway of RM 1. During a concurrent interview and record review on 1/18/2024 at 2:49 pm with LVN 2, Residents 1, 2, and 3’s AR were reviewed. Residents 1, 2, and 3 had diagnoses of schizophrenia and Residents 2 and 3 had anxiety. LVN 2 stated Residents 1, 2, and 3’s schizophrenia could have been exacerbated from being barricaded in RM 1. LVN 2 stated Residents 2 and 3 could have anxiety attacks (intense feeling of dread, fear, or discomfort, with a feeling of losing control or that one’s life is in danger when no threat is present) and pass out. LVN 2 stated staff would not know if a medical emergency (illness or injuries that need care right away) was happening in RM 1 because the residents (Residents 1, 2, and 3) were barricaded inside. During an interview on 1/16/2024 at 3:18 pm, with the DON, the DON stated the utility carts were supposed to be used for linens, towels, and blankets for the residents. The DON stated utility carts were to be stored in the hallways along the walls. The DON stated the utility carts were not supposed to be used to block RM 1’s doorway and barricade Residents 1, 2, and 3 inside their room. The DON stated “doing so was abuse” in the form of involuntary seclusion. The DON stated Residents 1, 2, and 3 who were involuntarily secluded to their rooms were at risk for depression, anxiety, and negative behaviors. The DON stated Residents 1, 2, and 3 who had diagnoses such as schizophrenia, depression, and anxiety were at higher risk of having an exacerbation of their illness symptoms by being involuntarily secluded in their room. The DON stated Residents 1, 2, and 3 could become “entangled” by the barricade and become injured or die when Residents 1, 2, and 3 attempt to get out. A review of the facility’s policy and procedure (PP) titled, “Involuntary Seclusion,” undated, indicated the goal was to ensure all residents would be free of involuntary seclusion. The P&P indicated, examples of involuntary seclusion included confining a resident to his or her room as form of punishment or for staff convenience, and any attempt to keep a resident confined to a certain area by blocking the exit with furniture or a closed door. The PP indicated, secluding, or confining a resident against his or her will was prohibited. A review of the facility’s PP titled, “Resident Rights,” revised in 2/2021, indicated employees shall treat all residents with kindness, respect, and dignity. The PP indicated, residents had the right to be free from involuntary seclusion. The facility failed to ensure Residents 1, 2, and 3 were free from involuntary seclusion by failing to: Ensure CNA 1 did not use two utility/linen carts to block the entrance/exit to Resident 1, 2, and 3’s Room after CNA 1 witnessed Resident 1 spilling liquid on the floor. As a result, CNA 1 violated Resident 1, 2, and 3’s rights and prohibited Residents 1, 2, and 3 from leaving RM 1. These deficient practices had the potential for psychosocial harm, serious injury, serious harm, serious impairment, or death to Residents 1, 2, and 3. The above violations had a direct or immediate relationship to the health, safety, or security of Residents 1, 2, and 3.