Health inspection·January 16, 2025

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 12/5/2024 at 11:35 AM, the California Department of Public Health (CDPH, the Department) conducted an unannounced abbreviated standard survey to investigate a resident-to-resident altercation. As a result of the investigation, the Department determined the facility failed to ensure Resident 1 and Resident 2 were free from physical abuse (willful infliction of injury, deliberately aggressive or violent behavior with the intention to cause harm) in accordance with the facility's policy and procedure (P&P) titled "Abuse Prohibition Policy and Procedure" when on 11/19/24 Resident 1 pushed Resident 2 and Resident 2 reacted by hitting Resident 1 back. As a result, the deficient practice resulted in physical abuse, pain, and a bloody nose to Resident 1. A review of Resident 1's "Admission Record (AR)," indicated, Resident 1 was a 50 year-old male who was originally admitted to the facility on 10/12/11 and readmitted on 5/12/17 with multiple diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), unspecified, autistic disorder (a developmental brain disorder that affects how people interact with others, communicate, learn, and behave) and essential (primary) hypertension (high blood pressure). A review of Resident 1's "History and Physical (H&P)," dated 10/22/24, indicated, Resident 1 could not make own decisions but could make needs known. A review of Resident 1's "SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents)," dated 11/19/24, indicated Resident 1 had an altercation where Resident 1 elbowed Resident 2 and Resident 2 hit back. The "SBAR" indicated, Resident 1 had a new pain rated 5 out of 10 (pain scale 0 to 10, 0 means no pain and 10 means the worst possible pain felt) in Resident 1's nose and Resident 1 had a small amount of blood on Resident 1's "right nostril/face." A review of Resident 1's "Minimum Data Set (MDS, an assessment and screening tool)," dated 11/21/24 indicated, Resident 3's cognitive (ability to think and process information) status was moderately impaired. indicated, Resident 1 had behaviors of hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). A review of Resident 1's "Interdisciplinary Care Conference," (IDT [Interdisciplinary Team], a team of health care professions who work together to establish plans of care for residents), dated 11/21/24, timed at 11:20 a.m., indicated, Resident 1 elbowed Resident 2's back and Resident 1 was then struck twice by Resident 2 two times. A review of Resident 2's "AR," indicated, Resident 2 was a 37 year-old male who was admitted to the facility on 6/30/20 with multiple diagnoses including paranoid (unreasonably or obsessively anxious, suspicious, or mistrustful) schizophrenia, hyperlipidemia (high cholesterol, a condition in which there are high levels of lipids or fats in your blood), unspecified and myopia (nearsighted), unspecified eye. A review of Resident 2's "H&P," dated 6/10/24 indicated, Resident 2 had fluctuating capacity to understand and make decisions. A review of Resident 2's "SBAR," dated 11/19/24 indicated, at approximately 8:30 p.m., a staff (unidentified on the record) witnessed Resident 1 elbowed Resident 2 on the back once and Resident 2 turned around and hit Resident 1's body twice with Resident 2's closed fist. The "SBAR" indicated, Resident 2 was evaluated, and Resident 2 had no pain, issues or injuries noted. A review of Resident 2's "IDT," dated 11/21/24, timed at 11:26 a.m., indicated, Resident 2 was elbowed in Resident 2's back by Resident 1 and then Resident 2 struck Resident 1 twice on 11/19/24. A review of Resident 2's "MDS," dated 11/30/24, indicated, Resident 2's cognitive status was intact. During an interview on 12/5/24 at 12:57 p.m. with Resident 1, Resident 1 stated, Resident 1 elbowed Resident 2 in the hallway (corridor) because Resident 2 tapped Resident 1's top of head. Resident 1 could not remember the exact date of incident "September 6?" Resident 1 got up and walked away from the interview before the interview could be completed. During an interview on 12/5/24 at 1:16 p.m. with the Primary Counselor (PC), the PC stated, from what the PC heard and understood from Certified Nursing Assistant (CNA) 1, Resident 1 and Resident 2, Resident 1 admitted hitting Resident 2's back and Resident 2 reacted and hit Resident 1 in the face. The PC stated, the incident happened at around 8:00 to 8:10 p.m. the week before Thanksgiving. The PC stated, the PC was at the facility the night of the incident and did not witness the incident but saw Resident 1 go to the Nursing Station because Resident 1 had a bloody nose. The PC stated, Resident 1 tended to strike (sudden violent blow at someone) out at staff and other residents (in general) when Resident 1 was frustrated. The PC stated, Resident 1 would "cycle" where Resident 1 did well and went several months without problems and suddenly violated rules, was disrespected to staff, hit staff or residents, and rummaged through the trash. The PC stated, staff tried to give Resident 1 safe distance when Resident 1 had such cycles [of behavior]. The PC stated, Resident 2 "just reacted" and Resident 2 understood that Resident 2 had done something wrong. During an interview on 12/5/24 at 2:32 p.m. with Resident 2, Resident 2 stated, Resident 2 hit Resident 1 because Resident 1 hit Resident 2 in the back in the corridor "last week," "so I hit him back." Resident 2 stated, Resident 2 had never hit Resident 1's top of the head. During an interview on 12/5/24 at 3:12 p.m. with CNA 1, CNA 1 stated the day of the incident (11/19/24), CNA 1 and CNA 2 were sorting the clean laundry in the corridor outside of the dining room and Resident 2 was helping CNA 1 and CNA 2. CNA 1 stated, Resident 1 must have come from the Nursing Station and pushed Resident 2 to get out of Resident 1's way because Resident 2 was backing up and did not see Resident 1 approaching. CNA 1 stated, the incident happened in the corridor around 8:15 p.m. after snack distribution. CNA 1 stated, CNA 1 told "hey [Resident 1], don't do that" when CNA 1 saw Resident 1 pushed Resident 2. CNA 1 stated, Resident 2 reacted fast, turned around and punched Resident 1. CNA 1 stated, Resident 1 had been "cycling that day" and had been agitated. CNA 1 stated, CNA 1 did not separate Resident 1 and Resident 2 immediately after Resident 1 pushed Resident 2 because the incident happened so fast and "as long as we prompt them, they're pretty good at following." CNA 1 stated, CNA 1 and CNA 2 should have told Resident 1 and Resident 2 to go their separate ways and separated Resident 1 and Resident 2 immediately to prevent Resident 2 from fighting back and prevent the incident from escalating and stop the [physical] abuse. CNA 1 stated, CNA 1 and CNA 2 pulled Resident 1 and Resident 2 apart after Resident 2 hit Resident 1. A review of the facility's "Witness Interview Record (WIR)," dated, 11/19/24, timed at 8:10 p.m. with CNA 1, indicated, Resident 1 walked behind Resident 2 and Resident 1 elbowed Resident 2 on the back and Resident 2 right away reacted and went after Resident 1 and "threw punches." A review of the facility's "WIR," dated, 11/19/24, timed at 8:10 p.m. with CNA 2 indicated, Resident 2 was hit on the lower back by Resident 1 while Resident 1 was walking by Resident 2. Resident 2 then retaliated by striking Resident 1 a few times on the side of Resident 1's head. During a concurrent interview and record review on 12/5/24 at 4:20 p.m. with the Administrator (ADM), the facility's P&P titled, "Abuse Prohibition Policy and Procedure," effective date 2/23/21 indicated, the purpose of the P&P was to ensure that staff were doing all that was within their control to prevent occurrences of abuse ...for all patients. The P&P indicated, physical abuse included hitting, slapping, pinching, kicking etc. The ADM stated, staff must "physically" separate residents immediately upon witnessing an abuse for the security and safety of the residents. The ADM stated, if staff knew Resident 1 had been agitated that day prior to the incident, staff could have redirected Resident 1 away from Resident 2 and sent Resident 1 and Resident 2 their separate ways. As a result of the investigation, the Department determined the facility failed to ensure Resident 1 and Resident 2 were free from physical abuse in accordance with the facility's P&P titled "Abuse Prohibition Policy and Procedure" when on 11/19/24 Resident 1 pushed Resident 2 and Resident 2 reacted by hitting Resident 1 back. As a result, the deficient practice resulted in physical abuse, pain, and a bloody nose 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 3.