Health inspection·November 22, 2024

42 CFR §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. 22 CFR § 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. 22 CFR § 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. 22 CFR § 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. On 10/16/24 and 10/28/24, the California Department of Public Health (CDPH) received three facility reported incidents (FRI) regarding multiple resident-to-resident altercations. On 10/28/24 at 9:45 AM, the CDPH conducted an unannounced visit at the facility to investigate the FRIs. The facility failed to: 1. Ensure Resident 2 was free from Resident 7’s physical abuse. 2. Ensure Resident 1 was free from Resident 2’s physical abuse. 3. Ensure Resident 6 was free from Resident 2’s physical abuse. As a result, Resident 2 was punched in the face by Resident 7, Resident 1 suffered a left thumb wound, and Resident 6 was kicked, resulting in severe left leg pain. 1. Resident 2 was a 64-year old male admitted to the facility on 8/19/2024 with admitting diagnoses including cognitive (ability to think and reason) communication deficit and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 2’s History and Physical (H&P), dated 8/20/24, indicated Resident 2 could make his needs known but could not make medical decisions. A review of Resident 2’s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/26/24, indicated Resident 2 had moderately impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 2 also displayed inattention and disorganized thinking (unclear or illogical flow of ideas, unpredictable switching from subject to subject). The MDS further indicated Resident 2 could ambulate independently and needed help from staff to assist with functional cognition (cognitive skills required to complete those meaningful daily activities, directly related to behavior). A review of Resident 2’s care plan titled, “[Resident 2] has a behavior problem…increased agitation…attempting to take other residents snack and drinks”, dated 8/27/24, indicated staff were to intervene as necessary to protect the rights and safety of others. Resident 7 was a 68-year-old female admitted to the facility on 8/7/17 and re-admitted on 6/8/24 with admitting diagnoses including major depressive disorder, generalized muscle weakness, and lack of coordination. A review of Resident 7’s MDS, dated 8/20/24, indicated Resident 7 did not have cognitive impairments or disorganized thinking. The MDS further indicated Resident 7 required a wheelchair and was independent with mobility. During an interview on 10/29/24 at 11:45 AM, with Resident 7, Resident 7 stated that on 10/10/24 she entered her room and saw Resident 2 holding her container of instant coffee that she kept in her bedside cabinet. Resident 7 stated Resident 2 ran into her bathroom with the container, and she confronted him. Resident 7 stated she told Resident 2 the coffee belonged to her, and Resident 2 replied, “Yeah, I took it. So what?”. Resident 7 stated this upset her and she hit Resident 2 in the face. 2. Resident 1 was a 73-year old male admitted to the facility on 5/21/24 with admitting diagnoses including acquired absence of the right and left leg below the knee, and muscle wasting and atrophy (thinning of muscle mass). A review of Resident 1’s H&P, dated 5/21/24, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1’s MDS, dated 8/28/24, indicated Resident 1 did not have any cognitive impairment or disorganized thinking. The MDS further indicated Resident 1 required a wheelchair and was dependent on staff to transfer between surfaces. During an interview on 10/29/24 at 11:20 AM, with Resident 1, Resident 1 stated that on 10/11/24, while out in the smoking patio, Resident 2 took a cup of coffee from another resident. Resident 1 stated Resident 2 had a known history of stealing from other residents, and that staff were aware, but did not doing anything about it. Resident 1 stated that he went to confront Resident 2 for stealing the other resident’s coffee, and Resident 2 threw the stolen cup at Resident 1 and began to kick him. Resident 1 stated he sustained an injury to his right thumb. During a concurrent observation and interview on 10/30/24 at 12:35 PM, with the Director Of Nursing (DON), the facility’s camera footage from 10/11/24 was reviewed. The DON stated the camera footage from 10/11/24, at 9:55 AM, displayed Resident 2 throwing a cup of coffee at Resident 1, Resident 2 kicking Resident 1, and staff immediately breaking up the altercation. 3. Resident 6 was a 72-year old female admitted to the facility on 5/13/11 with admitting diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), generalized muscle weakness, and history of broken left leg. A review of Resident 6’s H&P, dated 5/28/24, indicated Resident 6 could make her needs known. A review of Resident 6’s MDS, dated 9/2/24, indicated Resident 6 did not have cognitive impairments or disorganized thinking. The MDS further indicated Resident 6 required substantial to maximal assistance from staff with mobility while in bed and between surfaces. A review of Resident 6’s COC, dated 10/26/24, indicated Resident 6 was involved in an altercation with Resident 2 and three other residents. The COC indicated Resident 6 complained of severe pain to her left leg. A review of Resident 2’s COC, dated 10/26/24, indicated Resident 2 was approached and assaulted by four other residents while in the smoking patio. During a concurrent observation and interview on 10/29/24 at 11:36 AM, with Resident 6, Resident 6 stated that on an unspecified date, Resident 2 went into her room to steal her jar of instant coffee. Resident 6 stated she confronted Resident 2, and Resident 2 emptied the coffee onto her bed. Resident6 was teary eye while recounting the story. Resident 6 stated she told an unidentified staff, and the staff told her she should lock her belongings up. While crying, Resident 6 stated, “Why should I have to lock up my stuff?”. Resident 6 stated she did not feel that her belongings were safe in the facility, and stated it happened multiple times. Resident 6 stated that during the altercation on 10/26/24, Resident 2 kicked her in her left leg causing severe pain. Resident 6 stated she did not feel safe in the facility with Resident 2 walking around. During an interview on 10/29/24 at 10:02 AM, with AS 2, AS 2 stated he was in the smoking patio on 10/26/24 when the resident-to-resident altercation between Resident 1, 2, 6, and 7 occurred. AS 2 stated he was unaware that Resident 1 and Resident 2 had a previous resident-to-resident altercation on 10/11/24, and stated he was not aware they needed to be kept separate from one another to prevent an additional altercation. AS 2 stated that after the resident-to-resident altercation on 10/26/24, Resident 2 was rushing to leave from the patio, and that the other residents involved stated Resident 2 tried to kick them. During an interview on 10/30/24 at 12:38 AM, with the DON, the DON stated staff were aware of Resident 2’s behavior of stealing from other residents, but his care plan had not been revised to address the stealing. The DON stated it was reasonable for the other residents to feel frustrated if they felt that their belongings were not safe, and stated their frustration could escalate to a physical altercation. A review of the facility’s P&P titled, “Abuse Prevention and Management”, dated 6/2024, indicated abuse included physical abuse (willful, deliberate infliction of injury), as well as misappropriation of resident property (wrongful, temporary, or permanent use of a resident’s belongings without the resident’s consent). The P&P indicated the facility was supposed to identify, correct, and intervene in situations where abuse and/or misappropriation of resident property was more likely to occur. The P&P indicated that in the event abuse or misappropriation of property occurred, the Administrator or their designee was supposed to provide a safe environment for the resident as indicated by the situation. The P&P further indicated that in the event the perpetrator was another resident, staff were supposed to separate the residents so that they did not interact with each other. The facility failed to: 1. Ensure Resident 2 was free from Resident 7’s physical abuse. 2. Ensure Resident 1 was free from Resident 2’s physical abuse. 3. Ensure Resident 6 was free from Resident 2’s physical abuse. As a result, Resident 2 was punched in the face by Resident 7, Resident 1 suffered a left thumb wound, and Resident 6 was kicked, resulting in severe left leg pain. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.