Health inspection·April 4, 2024

Code of Federal Regulations, Title 42, §483.12(a)(1) Freedom from Abuse, Neglect, and Exploitation §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, § 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, § 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. California Code of Regulations, Title 22, § 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 2/17/2024, 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 follow the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" and protect Resident 1 from physical abuse by failing to: 1. Ensure Registered Nurse (RN) 1, who was the alleged perpetrator, was placed on leave of absence and did not have contact with Resident 1 and other residents in the facility from 1/20/2024 to 2/17/2024. 2. Ensure Licensed Vocational Nurse (LVN) 1 thoroughly investigated and reported the alleged abuse to the Administrator (ADM), State Survey Agency, Law Enforcement, and Ombudsman when Resident 1's Family Member (FM 2) reported to LVN 1 that Resident 1 told FM 2 that a male staff member (RN 1) slapped Resident 1 on the face on 1/20/2024 at "around" 1:30 PM. As a result, Resident 1 felt worried that RN 1 might slap Resident 1 again. This had the potential to result in psychological (mental or emotional) and physical harm or injury, and placed Resident 1 at risk for further abuse from RN 1. A review of Resident 1's Admission Record (AR) indicated, the facility admitted Resident 1, a 46-year-old female, on 9/16/2022 with diagnoses that included Down Syndrome (genetic condition caused by having an extra chromosome [structures that carry genetic information] which was presented by growth, developmental, and learning delays that vary from mild to severe), contracture (fixed tightening of muscles, tendons, ligaments, or skin) of muscles, and pressure-induced deep tissue damage of the sacral (triangular shaped bone at end of the spine) region. A review of Resident 1's History and Physical (H&P) dated 9/20/2023 indicated, Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's MDS dated 12/24/2023 indicated, Resident 1 had moderately impaired cognitive skills (ability to think, learn, and process information). The MDS indicated, Resident 1 depended on the staff for chair/bed-to-chair transfers. A review of Resident 1's Nursing Notes (NN) dated 1/20/2024, timed at 2:00 PM, indicated, (on 1/20/2024) at "around" 1:30 PM, FM 2 reported to LVN 1 that Resident 1 stated a male nurse slapped Resident 1 on Resident 1's face during transfer from bed to wheelchair on 1/20/2024 (untimed). The NN indicated, Resident 1 had a female Certified Nursing Assistant (CNA, unidentified) on 1/20/2024 and no male CNAs touched Resident 1 during the 7:00 AM to 3:00 PM shift. The NN indicated, Resident 1 had no signs and symptoms of acute distress and was smiling at LVN 1 and the CNA (unidentified). A review of the facility's Monthly (Staffing) Schedule (MS) from 1/20/2024 to 2/17/2024, the MS indicated, RN 1 continued to work at the facility on 1/20/2024, 1/22/2024, 1/23/2024, 1/27/2024, 1/29/2024, 1/30/2024, 2/3/2024, 2/5/2024, 2/6/2024, 2/10/2024, 2/12/2024, 2/13/2024, and 2/17/2024 (total of 13 days). During an interview on 2/17/2024 at 10:30 AM with Resident 1 in Resident 1's room, Resident 1 stated a tall, male staff member (RN 1) slapped Resident 1 in the face during transfer from bed to wheelchair (unable to recall date and time). Resident 1 further stated Resident 1 was worried that RN 1 might hit Resident 1 again. During an interview on 2/17/2024 at 1:50 PM with another Family Member of Resident 1 (FM 1) in Resident 1's room, FM 1 stated Resident 1 told FM 2 that a male staff member slapped Resident 1 on the face on 1/20/2024 (during the 7:00 AM to 3:00 PM shift). FM 1 stated, FM 2 reported the alleged incident to LVN 1 on 1/20/2024 (untimed), and LVN 1 stated to FM 2 that Resident 1 "probably had a bad nightmare." During a concurrent interview and record review on 2/17/2024 at 2:59 PM with LVN 1, Resident 1's Nursing Note (NN) dated 1/20/2024, timed at 2:00 PM, was reviewed. LVN 1 stated Resident 1 stated RN 1 slapped Resident 1 on the face (on 1/20/2024 at "around" 1:30 PM). LVN 1 stated LVN 1 informed RN 1 of Resident 1's alleged physical abuse. LVN 1 stated LVN 1 and RN 1 assessed Resident 1 with no physical injuries. LVN 1 stated facility staff were required to protect Resident 1 by thoroughly investigating and reporting allegations of abuse to the ADM immediately. LVN 1 stated LVN 1 did not thoroughly investigate and report the allegation of abuse to the ADM nor sent RN 1 home. LVN 1 stated LVN 1 did not follow the facility's Abuse P&P. LVN 1 stated not reporting the alleged physical abuse and not removing the alleged abuse perpetrator (RN 1) from Resident 1 put Resident 1 at risk for the abuse to happen again. During an interview on 2/17/2024 at 4:48 PM with RN 1, RN 1 stated LVN 1 notified RN 1 of Resident 1's allegation of physical abuse. RN 1 stated RN 1 did not think Resident 1's allegation of physical abuse was "legitimate (legal/lawful/allowable)." RN 1 stated he did not slap Resident 1. RN 1 stated RN 1 did not report the alleged physical abuse to the ADM and did not follow the facility's Abuse P&P to protect Resident 1. During an interview on 2/17/2024 at 4:36 PM with the DON, the DON stated LVN 1, and RN 1 did not inform the DON of Resident 1's physical abuse allegation. The DON stated LVN 1 informed the ADON of the alleged physical abuse on 2/17/2024 (untimed, unable to recall the time), after the survey team identified the IJ situation. The DON stated the DON followed up with RN 1 on 2/17/2024 (untimed) and confirmed that RN 1 was aware of Resident 1's alleged physical abuse and did not report the alleged physical abuse to the DON or the ADM. The DON stated there were no other male CNAs who worked on 1/20/2024 and RN 1 was the only male nurse who worked on 1/20/2024. The DON stated the DON notified the local police department on 2/17/2024 (untimed) of the alleged physical abuse that occurred on 1/20/2024. The DON stated RN 1 did not report the incident of alleged physical abuse to the ADM and did not follow the facility's P&P titled, "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating." During an interview on 2/17/2024 at 5:53 PM with the ADON, the ADON stated Resident 1 had Down Syndrome, but could make some of Resident 1's need known. The ADON stated Resident 1 was alert, awake, engaged, and knew what was going on Resident 1's environment. A review of the facility's Nursing Staffing Assignment and Sign-In Sheet, (NSA Sign-In Sheet)" dated 1/20/2024, for 7:00 AM to 3:00 PM shift, the NSA Sign-In Sheet indicated, RN 1 was the only male nurse who worked on 1/20/2024 from 7:00 AM to 3:00 PM. A review of the facility's P&P titled, "Abuse, Neglect, Exploitation of Misappropriation-Reporting and Investigation," revised in 9/2022, the P&P indicated, all reports of resident abuse were reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The P&P indicated, if resident abuse was suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The P&P indicated, "immediately" was defined as within two hours of an allegation involving abuse. The P&P indicated, any employee who had been accused of resident abuse was placed on leave with no resident contact until the investigation was complete. The facility failed to follow the facility's P&P titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" and protect Resident 1 from physical abuse by failing to: 1. Ensure RN 1 was placed on leave of absence and did not have contact with Resident 1 and other residents in the facility from 1/20/2024 to 2/17/2024. 2. Ensure LVN 1 thoroughly investigated and reported the alleged abuse to the ADM, State Survey Agency, Law Enforcement, and Ombudsman when FM 2 reported to LVN 1 that Resident 1 told FM 2 that RN 1 slapped Resident 1 on the face on 1/20/2024 at "around" 1:30 PM. As a result, Resident 1 felt worried that RN 1 might slap Resident 1 again. This had the potential to result in psychological and physical harm or injury, and placed Resident 1 at risk for further abuse from RN 1. The above violations had a direct or immediate relationship to the health, safety, or security of Resident 1.