Health inspection·April 11, 2025

Code of Federal Regulations, Title 42 22 CCR § 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 CCR § 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, Section F600 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. §483.12(a) The facility must— §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. On 2/28/2025, an unannounced visit was conducted to investigate a facility reported incident regarding an allegation of a resident-to-resident physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) incident which happened on 2/23/2025. The facility failed to ensure Resident 2 was free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) from Resident 1, when Resident 1 allegedly grabbed Resident 2 by the neck and shook Resident 2 on 2/23/2025. This resulted in Resident 2 had a scratch to left side of the neck and had the potential to negatively affect Resident 2’s comfort and psychosocial (the influence of social factors on an individual's mind or behavior, and to the interrelation of behavioral and social factors) well-being which can lead to hospitalization and/ or death. A review of Resident 1's Admission Record, indicated Resident 1, a 77-year-old-male, was admitted to the facility on 2/7/2024 with diagnoses that included psychosis (a mental health condition characterized by a loss of contact with reality), encephalopathy (a medical condition characterized by a general dysfunction of the brain) and acute kidney failure (a sudden loss of kidney function). A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/15/2024, the MDS indicated Resident 1’s cognitive (ability to think and reason) skills for daily decision making was moderately impaired (decisions poor; cues/supervision required). The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up) with eating, oral hygiene and personal hygiene. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues; resident completes activity) with toileting hygiene, shower/bath, upper body dressing, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 is independent with lying to sitting on side of bed, sit to stand, walk 10 feet (unit of measurement), walk 50 feet with two turns, and walk 50 feet. 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 2/23/2025, timed 8:20 AM, documented by LVN 1, indicated a situation of alleged minor altercation. The SBAR indicated Resident 1 is confused. The SBAR indicated while LVN 1 is walking down the hall, she heard loud voices coming from Resident 1 and 2’s room. The SBAR also indicated LVN 1 observed Resident 1 was standing next to his bed and Resident 2 is sitting on his bed. Resident 1 stated “I grabbed him (Resident 2) and I shook him.” A review of Resident 2's Admission Record, indicated Resident 2, a 68-year-old-male, was admitted to the facility on 12/4/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing Problems) and difficulty in walking. A review of Resident 2's MDS dated 12/13/2024, the MDS indicated Resident 2’s cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 2 required supervision or touching assistance with eating, oral hygiene, toileting hygiene, shower/bath, upper body dressing, lower body dressing, and putting on/taking off footwear and personal hygiene. The MDS indicated Resident 2 required supervision or touching assistance with walk 10 feet, walk 50 feet with two turns, and walk 50 feet. A review of Resident 2’s SBAR dated 2/23/2025, timed 8:13 AM, documented by LVN 1, indicated a situation of alleged minor altercation with resident (Resident 1), and Resident 2 was noted with scratch to left side of neck. The SBAR indicated Resident 2 is alert and oriented to person, time, and place. The SBAR indicated Resident 2 stated “He (Resident 1) grabbed me.” A review of Resident 2’s Skin only evaluation, dated 2/23/2025, timed 9:31 AM, indicated a skin issue of left neck scratch, measured 5 centimeters (cm, unit of measurement) in length by width of 0.1 cm. A review of Resident 2’s order summary report, dated 2/28/2025, timed 11:20 AM, indicated a treatment order to left side of neck, cleanse with normal saline and pat dry, apply triple antibiotic to area and leave open to air daily for 5 days, with order date of 2/23/2025. During an observation on 2/28/2025 at 8 AM with Resident 2, in Resident 2’s room, Resident 2 was observed sitting in bed, and Resident 2 refused to be interviewed when asked about the incident with Resident 1. During an interview on 2/28/2025 at 12:50 PM with LVN 2, LVN 2 stated he was working on the second floor on 2/23/2025 and LVN 2 was informed the alleged physical abuse of Resident 1 and Resident 2. LVN 2 stated LVN 1 was the first staff who heard the altercation and who went to Resident 1 and 2’s room to check what was going on. During an interview on 2/28/2025 at 1:05 PM with Certified Nurse Assistant (CNA) 1, CNA 1 stated, on 2/23/2025 morning, around 7 AM, CNA 1 was passing breakfast trays when he heard Licensed Vocational Nurse (LVN) 1 asked assistance in Resident 1 and 2‘s room. During a concurrent observation in Resident 2’s room and interview on 2/28/2025 at 2 PM with Resident 2, a scratch on the resident’s neck was observed. Resident 2 stated that his previous roommate (Resident 1), grabbed him by the neck (unable to recall when), and that is how he obtained the left neck scratch. During an interview with Director of Nursing (DON) on 2/28/2025 at 4:45 PM, the DON stated she was made aware on 2/23/2025 by LVN 1 that there was a resident-to-resident altercation between Resident 1 and Resident 2 in their room. The DON stated she went to Resident 2’s room, where the alleged incident happened, and the DON observed Resident 2 in bed, with a scratch on Resident 2’s left neck. The DON stated Resident 2 claimed that Resident 1 tried to choke him, and that Resident 1 end up obtaining a scratch in his left side of the neck. A review of the facility’s Policy and Procedure (P&P), titled “Abuse prevention and reporting,” dated 8/1/2007, indicated the facility shall uphold resident's right to be free from any form of verbal (use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability), sexual (non-consensual sexual contact of any type with a resident), physical, and mental abuse, corporal punishment (physical punishment), and involuntary seclusion (forced confinement of a person in a room or area). The P&P also indicated the facility shall establish system to prevent patient abuse including those practices and omissions, neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident) and misappropriation of property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident’s belongings or money without the resident’s consent) that if left unchecked, may lead to abuse. The P&P also indicated residents shall not be subjected to abuse by anyone, including, but not limited to, facility staff; other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals. The facility failed to ensure Resident 2 was free from physical abuse, when Resident 1 allegedly grabbed Resident 2 by the neck and shook Resident 2 on 2/23/2025. This resulted in Resident 2 had a scratch to left side of the neck and had the potential to negatively affect Resident 2’s comfort and psychosocial well-being which can lead to hospitalization and/ or death. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 2.