Health inspection·November 27, 2024

Code of Federal Regulations, Title 42, Section §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, 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. § 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. § 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 10/29/2024 at 8:30 AM, the California Department of Public Health (CDPH, the Department) conducted an unannounced abbreviated standard survey visit to investigate a facility reported incident regarding an allegation of resident abuse. As a result of the investigation, the Department determined the facility failed to protect Resident 1 from verbal (the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents) and physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) when Certified Nursing Assistant 1 (CNA 1) physically and verbally abused Resident 1 on 10/27/2024. As a result, the facility violated Resident 1’s right and there was a potential for mental and physical injury and physical and psychosocial decline to Resident 1. A review of Resident 1's "Admission Record (AR)," indicated Resident 1, a 49-year-old-male, was admitted to the facility on 12/20/2022, and readmitted on 7/29/2024, with diagnoses including chronic respiratory failure (when the lungs can't get enough oxygen into the blood), profound intellectual disability (limitations in cognitive functioning and skills) and anxiety disorder (group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear). A review of Resident 1's “Minimum Data Set (MDS, a resident assessment tool)," dated 9/27/2024, indicated Resident 1 was severely impaired in cognitive skills. The "MDS" indicated Resident 1 was dependent on staff for bathing, toileting, and oral and personal hygiene. A review of Resident 1's "SBAR (Situation-Background-Assessment-Recommendation) Communication Form (SBAR)," dated 10/27/2024 and timed at 8:00 p.m., indicated on 10/27/2024 (untimed), an allegation was made that Resident 1 experienced physical and verbal abuse. A review of Resident 1’s “Progress Notes (PN),” dated 10/27/2024 and timed at 9:20 p.m., indicated at 8:00 p.m., two sitters (a staff who provides supervision and/or companionship to residents who need extra care) reported that CNA 1 was being aggressive and verbally abusing Resident 1 during patient care. During an observation on 10/29/2024 at 9:04 a.m. inside Resident 1’s room, Resident 1 was asleep in bed. During a phone interview on 10/29/2024 at 10:22 a.m., CNA 1 stated, on 10/27/2024, CNA 1 started her workday at 7:30 a.m. and stayed over into the next shift until 8:00 p.m. CNA 1 stated Resident 1 was one of the residents CNA 1 was assigned to care for. CNA 1 stated Resident 1 was very agitated. CNA 1 stated due to Resident 1’s agitation, Resident 1 was assigned two sitters to stay with Resident 1. CNA 1 stated Resident 1 slept all day on 10/27/2024 until 5:00 p.m. CNA 1 stated, after 5:00 p.m., Resident 1 was “full of energy,” and kept trying to get up from the bed. CNA 1 stated at 7:30 p.m., Resident 1 was agitated and sliding out of Resident 1’s bed. CNA 1 stated at around 7:45 p.m., Resident 1 tried to get out of the bed and Resident 1 was sliding out of the bed at the foot of the bed. CNA 1 stated CNA 1 pulled Resident 1 back up to the head of the resident’s bed. CNA 1 denied being rough when providing care to Resident 1. CNA 1 denied cursing at Resident 1. CNA 1 stated the facility management informed CNA 1 that CNA 1 was suspended until an investigation was done regarding an allegation of abuse against CNA 1. During a phone interview on 10/29/2024 at 1:13 p.m., Sitter (S) 1 stated S1 saw CNA 1 mistreating Resident 1 in Resident 1’s room on 10/27/2024. S1 stated S1 stood at the foot of Resident 1’s bed while CNA 1 moved Resident 1 up in the bed. S1 stated CNA 1 grabbed Resident 1’s head while moving Resident 1 up in the bed. S1 stated Resident 1 was reaching out trying to grab at something. S1 stated CNA 1 got close to Resident 1’s face and yelled, “Stop it!” S1 stated CNA 1 said to Resident 1 that CNA 1 was tired of working with Resident 1 and stated, “I am tired of this s_ _ _ (derogatory statement).” S1 stated Resident 1 “kept fidgeting,” and CNA 1 grabbed the bed remote and acted like CNA 1 would hit Resident 1 with the bed remote. S1 stated Resident 1 kept trying to sit up in bed and CNA 1 kept pushing Resident 1 down in the bed. S1 stated CNA 1’s actions toward Resident 1 was abusive. S1 stated what CNA 1 did to Resident 1 made S1 feel uncomfortable. S1 stated CNA 1’s behavior was not the way to treat a resident. During a phone interview on 10/29/2024 at 1:45 p.m., S2 stated on the night of 10/27/2024, S2 observed CNA 1 provided care to Resident 1. S2 stated S2 stood at the foot of Resident 1’s bed and observed CNA 1 gripped Resident 1’s lower jaw with CNA 1’s thumbs and CNA 1’s fingers along the sides of Resident 1’s face. S2 stated CNA 1 “yanked” Resident 1’s head. S2 stated CNA 1 yelled, “Stop!.” to Resident 1 and cursed. S2 stated S2 saw CNA 1 grabbed the bed remote and shook the remote at Resident 1’s face. S2 described the incident as being like “a mom grabbing a sandal and threatening to hit a kid.” S2 stated CNA 1 told Resident 1 that CNA 1 was tired of taking care of Resident 1. S2 stated, “No matter how frustrated someone was with their work, they should not harm the resident.” A review of the facility's Policy and Procedure (P&P) titled, "Abuse, Neglect and Exploitation," dated 12/19/2022, indicated, "It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property." The P&P indicated, abuse, "means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.” As a result of the investigation, the Department determined the facility failed to protect Resident 1 from verbal and physical abuse when CNA 1 physically and verbally abused Resident 1 on 10/27/2024. As a result, the facility violated Resident 1’s right and there was a potential for mental and physical injury and physical and psychosocial decline to Resident 1. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.