Health inspection·March 17, 2025

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by anyone. 22CCR §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. 22CCR §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. 22CCR §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. The California Department of Public Health (CDPH) received an entity reported incident (ERI) on 2/5/2025, indicating Resident 1 was punched in the face by Resident 2. On 2/19/2025 at 7:30 a.m., the CDPH conducted an unannounced investigation at the facility. The facility failed to: 1. Implement its policy and procedure (P&P) titled, “Abuse-Prevention, Screening, and Training Program,” which indicated the facility will not condone any form of resident abuse or neglect. 2. Ensure staff followed Resident 2’s Care Plan titled, “Resident has a behavior problem pacing in hallway with increased agitation” which indicated the staff will anticipate Resident 2’s needs, and provide a 1:1 sitter, to protect the rights and safety of others. As a result, Resident 2 punched Resident 1 in the face. Resident 1 was a 72-year-old female, initially admitted to the facility on 11/9/2023 and readmitted on 9/17/2024 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life). A review of Resident 1’s Minimum Data Set ([MDS] – a resident assessment tool), dated 11/16/2024, indicated Resident 1’s cognitive (ability to think and reason) skills for daily decision making was intact (decisions consistent and reasonable). The MDS indicated Resident 1 was independent (resident completed the activity with no assistance from a helper) with eating, oral hygiene, and personal hygiene. A review of Resident 1’s Situation, Background, Assessment, and Recommendation form (SBAR) dated 2/4/2025, at 11:54 p.m., indicated Resident 1 was utilizing the phone when she got hit in the face by another resident. During an interview on 2/19/2025 at 8:40 a.m., with Resident 1, Resident 1 stated she was on the phone and Resident 2 passed by and hit her on the right side of her face. Resident 2 was a 65-year-old male, initially admitted to the facility on 8/19/2024, and readmitted on 1/7/2025 with diagnoses including schizophrenia and major depressive disorder. A review of Resident 2’s MDS, dated 11/26/2024, indicated Resident 2’s cognition was moderately impaired. The MDS indicated Resident 2 had wandering behaviors. The MDS indicated Resident 2 required setup assistance from staff with eating, oral hygiene, and lower body dressing. A review of Resident 2’s care plan titled, “Resident has a behavior problem pacing in hallway with increased agitation,” dated 1/1/25, indicated Resident 2 will have no evidence of behavioral problems. The staff interventions included a 1:1 sitter and to intervene as necessary to protect the rights and safety of others. During a concurrent observation and interview on 2/19/2025 at 11:37 a.m., with Licensed Vocational Nurse 1 (LVN 1), the facility’s video surveillance footage, dated 2/4/2025 at 7:13 p.m. was reviewed. LVN 1 stated Resident 1 was going back to her room after she used the phone at nurse station, when Resident 2 was walking in the hallway, and suddenly hit Resident 1 in the face. LVN 1 stated the staff did not provide a close supervision to Resident 2 to avoid the incident. LVN 1 stated the sitter was not able intervene promptly to prevent Resident 2 from hitting Resident 1 because he (LVN 1) was too far away from Resident 2. LVN 1 stated the sitter was supposed to maintain a safe distance by Resident 2 for the safety of other residents. During an interview on 2/19/2025 at 11:51 a.m., with the Director of Nursing (DON), the DON stated when a resident was on 1:1 monitoring, the staff was supposed to always be close or near to the resident, observe, and redirect the resident’s behavior. The DON stated he placed Resident 2 on 1:1 supervision because the resident had the tendency to pace in the hallway with aggressive behavior and steal other residents’ cigarettes. The DON stated staff was not able to prevent Resident 2 from punching Resident 1 because Resident 2 suddenly displayed aggressive behaviors, without any reason. The DON stated the facility must provide appropriate supervision to meet the needs of the residents. The DON stated regardless of any situation, residents had the right to be free from any type of abuse. A review of the facility’s P&P titled, “Abuse-Prevention, Screening, and Training Program,” dated 7/2018, indicated the facility will not condone any form of resident abuse or neglect. The P&P indicated physical abuse included hitting, slapping, punching, and/or kicking. The P&P indicated the facility will address the health, safety, welfare, dignity, and respect of residents by preventing abuse. The facility failed to: 1. Implement its P&P titled, “Abuse-Prevention, Screening, and Training Program,” which indicated the facility will not condone any form of resident abuse or neglect. 2. Ensure staff followed Resident 2’s Care Plan titled, “Resident has a behavior problem pacing in hallway with increased agitation” which indicated the staff will anticipate Resident 2’s needs and provide a 1:1 sitter, to protect the rights and safety of others As a result, Resident 2 punched Resident 1 in the face. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.