Health inspection·August 1, 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 6/21/2024 at 9:10 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 physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm), when Resident 2 hit Resident 1 in the face with a closed fist on 6/5/2024. As a result, there was a potential for serious mental and physical injury and a potential for a physical and psychosocial decline to Resident 1. Findings: A review of Resident 1's "Admission Record," (AR), the "AR" indicated Resident 1 was a 63 year-old male and was admitted to the facility on 10/8/2021 with multiple diagnoses including diabetes mellitus type 2 (disease that occurs when a person's blood sugar is too high), and epileptic syndrome with complex partial seizures (a type of seizure [sudden, uncontrolled burst of electrical activity in the brain] that results in a sudden absence of awareness regarding surroundings). A review of Resident 1's "History and Physical," (H&P) dated 12/9/2023, indicated Resident 1 was able to make decisions. A review of Resident 1's "Minimum Data Set" (MDS - a standardized assessment and care planning tool) dated 4/11/2024, indicated Resident 1 was dependent (helper does all the effort to complete the activity) for toileting and bathing. A review of Resident 1's "Change in Condition" (COC) form dated 6/5/2024, indicated Resident 1's roommate (Resident 2) hit Resident 1 in the face. During an interview on 6/21/2024 at 9:30 AM with Resident 1, Resident 1 stated Resident 1 was sitting up in bed and wanted the shared privacy curtain, located between Resident 1 and Resident 2, open to get more airflow due to Resident 1 feeling hot. Resident 1 stated Resident 2 was in a wheelchair and attempted to close the curtain when Resident 1 asked Resident 2 to keep it open. Resident 1 stated Resident 2 wheeled over to the right side of Resident 1's bed while Resident 1 grabbed the call light to get help from facility staff. Resident 1 stated Resident 2 dared Resident 1 to press the call light button, stood up from the wheelchair, and punched (strike with a closed fist) Resident 1 on the right side of Resident 1's face multiple times. Resident 1 stated a staff member came in after the last hit and separated Resident 1 and Resident 2. Resident 1 stated there were no injuries but Resident 1 felt soreness on the right side of the face where Resident 1 was hit. A review of Resident 2's AR indicated Resident 2 was a 58 year-old male and was admitted to the facility on 4/7/2021 with multiple diagnoses including paranoid schizophrenia (mental health disorder characterized by loss of contact with the environment, pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly) and major depressive disorder (a mood disorder the causes a persistent feeling of sadness and loss of interest). A review of Resident 2's MDS dated 4/10/2024 indicated Resident 2 was dependent for toileting and required partial assistance (helper does less than half the effort) to transfer from a sitting to standing position. A review of Resident 2's COC form dated 6/5/2024 indicated Resident 2 hit Resident 2's roommate (Resident 1) in the face. During an interview on 6/21/2024 at 11:40 AM with the Director of Staff Development (DSD), the DSD stated the DSD interviewed Resident 2 shortly after the allegation occurred between Resident 1 and Resident 2. The DSD stated during the interview (conducted during incident investigation), Resident 2 immediately admitted to hitting Resident 1 in the face because Resident 1 wanted the privacy curtain closed and Resident 1 was talking too much. During an interview on 6/21/2024 at 11:57 AM with the Social Services Director (SSD), the SSD stated the SSD interviewed Resident 2 and Resident 2 stated Resident 2 hit Resident 1 because Resident 2 was mad at Resident 1 for wanting the privacy curtain open. During an interview on 6/21/2024 at 1:25 PM with the Licensed Vocational Nurse (LVN), the LVN stated the LVN was present during the interview between Resident 2 and the DSD. The LVN stated Resident 2 stated Resident 2 was calm after the incident and during the interview. The LVN stated Resident 2 stated Resident 2 was angry at Resident 1 for wanting the curtain open and talking too much so Resident 2 stated Resident 2 hit Resident 1. During an interview on 6/21/2024 at 1:56 PM with the Director of Nursing (DON), the DON stated the DON interviewed Resident 1 first in Resident 1's room. The DON stated the DON assessed Resident 1 for injury and did not see any redness or swelling, and in the days following the incident, no marks were noted on Resident 1's face. A review of the facility's Policy and Procedure (P&P) titled, "Abuse, Neglect, Exploitation and Misappropriation," dated 4/2021, the P&P indicated residents have a 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. As a result of the investigation, the Department determined the facility failed to protect Resident 1 from physical abuse, when Resident 2 hit Resident 1 in the face with a closed fist on 6/5/2024. As a result, there was a potential for serious mental and physical injury and a potential for a decline in physical and psychosocial 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.