Health inspection·November 1, 2024

Regulations Violated: §72315(b); §72527(a)(10); 72523(a) 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. California Code of Regulations, Title 22, Section 72527. Nursing Service – Patient Care. (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. 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. On 9/17/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding an allegation of resident abuse. As a result of the investigation, the CDPH determined the facility failed to ensure Resident 5 was free from physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) in accordance with the facility's policies and procedures (P&P) titled, "Abuse Prohibition," and "Resident Rights," when Resident 6 "headbutted (a violent blow with the forehead or crown of the head especially into the face or head of another person)" and hit Resident 5 in the face with a closed fist. This violation resulted in Resident 5 experiencing slight swelling, redness, bleeding in the mouth, and pain on Resident 5's right cheek. 1. A review of Resident 5's Admission Record, indicated Resident 5, a 37-year-old male, was admitted to the facility on 8/12/2024, with multiple diagnoses including schizophrenia. A review of Resident 5's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/18/2024, indicated Resident 1 was cognitively intact and was independent with transfers, dressing, toilet use, and walking at least 150 feet. A review of Resident 5's History & Physical (H&P), dated 8/30/2024, indicated Resident 5 was alert and oriented. A review of Resident 5's Pain Evaluation Report (PER), dated 9/11/2024, timed at 4:44 pm, indicated Resident 5 had a pain level of 5 out of 10 (pain scale, 0 = no pain and 10 = worst pain ever felt) on Resident 5's right cheek. The PER indicated Resident 5's pain onset was acute and aching, requiring medication to make the pain better. The PER indicated under "Care Plan Focus/Goal," Resident 5 exhibited or was at risk for alternations in comfort related to right cheek pain. The PER indicated the facility's goal was for Resident 5 to not experience pain for five days. A review of Resident 5's Change in Condition Evaluation (CICE), dated 9/11/2024, timed at 4:45 pm, indicated on 9/11/2024 at 4:25 pm, Resident 5 was in the corridor reporting to staff (CNA 1) that his (Resident 5) roommate (Resident 6) had “headbutted” him (Resident 5) and made contact with him (Resident 5) while in Resident 5's room. The CICE indicated as he (Resident 5) was reporting to staff (CNA 1), the peer (Resident 6) came from behind him (Resident 5) and hit him (Resident 5) on the right side of the cheek with closed fist. A review of Resident 5's Progress Notes (PN), dated 9/11/2024, timed at 4:45 pm, indicated on 9/11/2024, licensed personnel assessed Resident 5 and noted slight swelling and redness on Resident 5's right cheek. The PN indicated Resident 5 complained of 5 out of 10 pain on the right cheek and facility staff applied a cold compress (to Resident 5’s right cheek) per first aid treatment. The PN indicated facility staff notified Resident 5’s physician and received an order for ibuprofen (medication used to treat pain, swelling, fever, and redness) as needed for pain. 2. A review of Resident 6's Admission Record, indicated Resident 6, a 31-year-old male, was admitted to the facility on 6/1/2023, with multiple diagnoses including unspecified schizophrenia and hyperglyceridemia. A review of Resident 6's H&P, dated 6/26/2024, indicated Resident 6 was alert and oriented. A review of Resident 6's MDS, dated 9/2/2024, indicated Resident 6 was cognitively intact and was independent with transfers, dressing, toilet use, and walking 150 feet. A review of Resident 6’s CICE, dated 9/11/2024, timed at 4:45 pm, indicated on 9/11/2024, untimed, Resident 6 “headbutted” peer (Resident 5) and hit him (Resident 5) with closed fist on the right side of Resident 5’s cheek. A review of Resident 6’s PN, dated 9/11/2024, timed at 4:45 pm, indicated on 9/11/2024 at 4:25 pm, Resident 6 went up to peer (Resident 5) while on the corridor and hit him (Resident 5) on the right side of Resident 5’s face with a closed fist. Peer (Resident 5) reported to staff that Resident 6 had “headbutted” him (Resident 5) earlier while in Resident 5’s and Resident 6’s shared bedroom. On 9/18/2024 at 11:15 am, an attempt was made to interview CNA 1, however CNA 1 was unavailable, and the facility refused to provide CNA 1’s contact information. During a concurrent observation and interview on 9/18/2024 at 11:51 am with Resident 6, Resident 6 stated, "I meant to “headbutt” Resident 5 because he (Resident 5) overpowered me when I was holding him (Resident 5) down. I “headbutted” him in our room then hit (closed fist) him (Resident 5) in the face outside in the hallway." Resident 6 stated Resident 6 was not hearing voices. Resident 6 stated Resident 5 was "pussy footing (move cautiously or carefully)" around me (Resident 6), and I just got tired of it." During an interview on 9/18/2024 at 11:59 am with Primary Counselor (PC) 1, PC 1 stated PC 1 did not witness Resident 6 hit Resident 5 but was present immediately after the incident. PC 1 stated Resident 5 informed PC 1 that Resident 6 punched Resident 5 in the face with a closed fist. PC 1 stated Resident 5's mouth was bleeding from a cut inside Resident 5's mouth. PC 1 stated Resident 6 reported to PC 1 that Resident 6 went to Resident 5's side and grabbed Resident 5's arms and “headbutted” Resident 5. PC 1 stated per Resident 6, Resident 6 followed Resident 5 as Resident 5 walked out of Resident 5’s and Resident 6’s room and hit Resident 5 in the face with a closed fist. PC 1 stated any type of abuse including physical abuse was "not ok." PC 1 stated abuse could harm residents and others and could get the residents "in trouble." During a concurrent observation and interview on 9/18/2024 at 12:33 pm with Resident 5, Resident 5 stated Resident 5 was in bed lying down when Resident 6 came in the room and grabbed both Resident 5's arms, started shaking Resident 5, and “headbutted” him (Resident 5) on the forehead. Resident 5 stated Resident 5 pushed Resident 6 off, broke free, and walked out of the room and informed Certified Nurse Assistant (CNA) 1 of the abuse. Resident 5 stated in the hallway, directly in front of CNA 1, Resident 6 walked behind Resident 5 and "punched me on the right cheek with his fist." Resident 5 stated, "My face started to swell up and I tasted blood." During an interview on 9/18/2024 at 3:33 pm with Registered Nurse (RN) 1, RN 1 stated on 9/11/2024, RN 1 assessed Resident 5 and Resident 6 after the altercation with each other. RN 1 stated Resident 6 did not have any injuries. RN 1 stated Resident 5's cheek was reddened and swollen, and Resident 5 had bleeding in the mouth. RN 1 stated residents in the facility should not get "hit, chocked, or headbutted." RN 1 stated physical abuse was not allowed in the facility because hurting, wounding, or threatening others can make residents irate. RN 1 stated residents needed to be protected from other residents, staff, instruments, or any danger because the residents were under the facility’s care. During an interview on 9/18/2024 at 3:45 pm with the Director of Nursing (DON), the DON stated abuse was defined as a willful attempt, intentionally or unintentionally, to cause verbal, or physical injury that can mentally or physically harm someone else. The DON stated residents needed to be protected from any abuse (physical, mental, financial, exploitation, verbal) because everyone should be free from abuse, especially the residents because everyone had the right to feel safe in the building. A review of the facility's P&P titled, "Abuse Prohibition," dated 7/22/2024, the P&P indicated, "HealthCare Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents." The P&P indicated, "The Center will implement an abuse prohibition program through the following: ...Prevention of occurrences." A review of the facility's P&P titled, "Resident Rights," dated 12/2021, the P&P indicated, "Federal and state laws guarantee certain basic right to all residents of this facility. These rights include the resident's right to: ...be free from abuse, neglect, misappropriation of property and exploitation..." The facility failed to ensure Resident 5 was free from physical abuse in accordance with the facility's P&P titled, "Abuse Prohibition," and "Resident Rights," when Resident 6 "headbutted" and hit Resident 5 in the face with a closed fist. This violation resulted in Resident 5 experiencing slight swelling, redness, bleeding in the mouth, and pain on Resident 5's right cheek. This violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 5.