Health inspection·December 20, 2024

F604 Freedom from Abuse, Neglect, and Exploitation §483.10(e) Respect and Dignity. The Patient has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the Patient's medical symptoms, consistent with §483.12(a)(2). §483.12 The Patient has the right to be free from abuse, neglect, misappropriation of Patient 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 Patient’s medical symptoms. §483.12(a) The facility must— §483.12(a)(2) Ensure that the Patient is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the Patient’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

F607 Freedom from Abuse, Neglect, and Exploitation §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of Patients and misappropriation of Patient property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b)(4) Establish coordination with the QAPI program required under §483.75. §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. §483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. §483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act. On 11/13/2024 at 9:30AM, an unannounced visit was made by the California Department of Public Health [CDPH] to the facility to investigate a facility reported incident regarding an incident of an alleged use of Physical Restraints. As a result of the investigation, CDPH had determined the facility failed to ensure Patient 1 was free from the use of physical restraints (a manual method or device that limits a person's ability to move freely), in accordance with the facility’s policy and procedure titled “Restraints” by failing to: 1. Identify a situation that constitutes abuse when Certified Nurse Assistant [CNA] 1 had knowledge that Patient 1 was restrained/tied up to the wheelchair with a white sheet, on 11/9/24, during the 3 PM to 11 PM shift, as evidenced by a videoclip. CNA 1 did not untie (remove) the white sheet from Patient 1 and did not report the observation immediately to the licensed vocational nurse (LVN 1) or any other staff member in the facility. 2. Protect Patient 1 from potential harm that could result in an injury by not responding immediately to protect Patient 1 when CNA 1 witnessed Patient 1 restrained/tied up with a white sheet to the wheelchair on 11/9/24. Instead, CNA 1 recorded a video of Patient 1 while tied up with a white sheet to the wheelchair, inside another Patient’s [Patient 2] room. 3. Report all alleged violations of abuse immediately to the abuse coordinator [Administrator] and other State Agencies immediately or within two hours when CNA 1 had knowledge of Patient 1 being restrained/tied up with a white sheet on 11/9/2024. CNA 1 did not inform the abuse coordinator [Administrator] of witnessing Patient 1 tied up to the wheelchair on 11/9/2024. These failures resulted in Patient 1 experiencing abuse and had the potential to result in serious injury that included strangulation [occurs when something compresses the neck tightly enough to restrict airflow], accidental asphyxiation [compression of the chest wall] to Patient 1, who was cognitively impaired [difficulties with thinking, learning, remembering, and making decisions] and unable to verbalize needs. A review of Patient 1’s Admission Record [AR] the AR indicated she is a 88 year old female that had been admitted on 12/20/2018 and readmitted on 6/30/2023, with a primary diagnosis of dementia (loss of ability to think, remember and reason), anxiety disorder [an emotion characterized by feeling of worried thoughts and tension) and history of falling. A review of patient 1’s care plan revised on 1/3/2024, the care plan indicated Patient 1 was a “Wandering/Elopement [leaving without permission] Risk” as evidenced by attempts to leave the facility unattended, wanders aimlessly, and had impaired safety awareness. The care plan interventions included to allow Patient 1 to wander in safe surroundings within the facility, and to distract patient from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. The care plan interventions further indicated to monitor Patient 1’s whereabouts with visual checks at least every two hours for safety. A review of patient 1’s Minimum Data Set (MDS, a federally mandated Patient assessment tool) dated 9/11/2024, the MDS indicated the Patient had severely impaired cognition (thought process). The MDS indicated Patient 1 exhibited wandering behavior daily. A review of patient 1’s Multidisciplinary Care Conference (ID- Interdisciplinary Team) dated 9/6/2024, the IDT indicated the patient was confused and disoriented with a history of dementia and to keep Patient safe and comfortable by offering a physical and social environment that provides activities appropriate for the Patient’s cognitive functioning and interests. The care plan interventions further indicated to reassure the Patient that she was safe in the facility, loved and wanted. A review of Patient 1’s Wandering Risk Assessment (a tool to identify Patients who are at risk of wandering dated 9/11/2024, the Assessment indicated Patient 1 was disoriented and does not understand surroundings. The Assessment indicated Patient 1 was a known wanderer with a history of wandering. During a concurrent observation and interview with Patient 1 on 11/13/2024 at 9:57 AM, at the facility’s Dining Room, Patient 1 was observed walking steadily. Patient 1 stated she did not recall anything and could not remember being tied with a white sheet to the wheelchair. During a telephone interview with CNA 1 on 11/13/2024 at 10:29 AM, CNA 1 stated on 11/9/2024, at around dinner time (8 PM), during the 3 PM to 11 PM shift, CNA 1 found Patient 1 inside another Patient’s [Patient 2] room and witnessed Patient 1 tied up with a white sheet to the wheelchair which was tied at the back with a knot. CNA 1 further stated that she recorded a videoclip of the incident [Patient 1 while tied up to the wheelchair]. CNA 1 stated “Patient 1 appeared scared at the time.” CNA 1 stated that on 11/9/2024, CNA 1 had called the Administrator on the phone from the facility’s parking lot after witnessing Patient 1 tied up to the wheelchair. CNA 1 stated when she returned from the parking lot, CNA 1 stated “someone had removed the sheet” from patient 1. CNA 1 stated, she did not inform the Administrator about what she had witnessed, Patient 1 tied up with a white sheet to the wheelchair. CNA1 stated she did not notify the Charge Nurse or any of the facility staff on duty that evening [11/9/2024] about witnessing Patient 1 tied up with a white sheet to the wheelchair. CNA 1 stated it was not until the following Monday, on 11/11/2024, when she informed the Administrator, in person, that she witnessed Patient 1 tied up with a white sheet to the wheelchair on 11/9/2024. CNA 1 stated that she informed the Administrator of taking a videoclip while Patient 1 was tied up. On 11/13/2024, at 10:58 AM, during a review of the videoclip shared via instant messaging [iMessage – a communication technique that facilitates text-based communication to include multimedia content such as photos, videos, and audio recording] by CNA 1, the videoclip showed Patient 1 sitting on a wheelchair inside a room, in front of the television, with a white sheet around the Patient with a knot tied to the back of the wheelchair. The recorder [CNA1] continued going around Patient 1 showing a full 360-degree angle [a view in every direction] of Patient 1 tied down with a white sheet while sitting on the wheelchair. The part of the videoclip recording at 00:28 [timecode] mark, showed an individual (unknown) pushing Patient 1’s hands away from the Patient’s chest showing full view of the white sheet tied across the Patient’s chest. During another telephone interview on 11/13/2024 at 11:15 AM with CNA 1, CNA 1 stated the time she witnessed Patient 1 with a white sheet tied to the back of the wheelchair on 11/9/2024, was around 8 PM. CNA 1 stated she saw Patient 1 inside another Patient’s [Patient 2] room sitting on a wheelchair with a white sheet wrapped around Patients 1’s abdomen/chest area tied in a knot at the back of the wheelchair. CNA 1 stated she recorded a video of Patient 1 tied up, as proof to show the Administrator of the alleged abuse. CNA 1 stated after recording a video of Patient 1 she did not report it to the charge nurses or LVN 1 or any facility staff in the facility because CNA 1 was afraid, they [other facility staff] would untie Patient 1 and deny ever tying her. During the same interview, on 11/13/2024 at 11:15 AM, CNA 1 stated she stepped out of the facility to go to the facility’s parking lot to call the Administrator on 11/9/2024, because she knew to report any type of abuse she witnessed to the facility's Administrator. CNA 1 stated she spoke to the Administrator over the phone and informed the Administrator that he had to come to the facility right away, to see with his own eyes what was happening to Patient 1. CNA 1 further stated she did not tell the Administrator what she observed, and told the Administrator, “It was an urgent matter concerning Patient 1” and that he had to come in person to the facility to witness with his own eyes. CNA 1 stated the Administrator informed her [CNA 1], that he would talk to CNA 1 on Monday [11/11/2024]. CNA 1 stated after ending the phone conversation, CNA 1 sent another text message to the Administrator asking him to come to the facility because it was “something very important” and wanted the Administrator to see with his own eyes. CNA 1 stated the Administrator did not respond to her text message. CNA 1 stated that when she went back inside the facility to check on Patient 1, CNA 1 observed Patient 1 was back in her room lying in bed. CNA 1 stated she did not know who from the facility had untied and returned Patient 1 back to her room. During an interview with the DON on 11/13/2024 at 11:30 AM, the DON stated she was not aware of Patient 1 being tied to the wheelchair until 11/11/2024. The DON stated the Administrator had called her on 11/9/2024 and informed her that there was a “CNA incident” [the phone call that the Administrator received from CNA 1] that happened at the facility, and that the Administrator and the DON would follow up the following Monday, on 11/11/2024. The DON stated, on 11/11/2024, the Administrator and the DON met with CNA 1 to discuss what CNA 1 wanted to discuss on 11/9/2024. The DON stated CNA 1 informed both the Administrator and the DON about witnessing Patient 1 tied up to the wheelchair on 11/9/2024 and briefly shared the videoclip of Patient 1 during that evening. The DON stated when CNA 1 was asked why she had not reported the abuse incident earlier, on 11/9/2024, CNA 1 stated that she preferred to report Patient 1’s incident [abuse] in person. The DON stated there was a delay of three days when CNA 1 decided to report witnessing Patient 1 tied up to the wheelchair on 11/11/2024. During an interview with the Administrator on 11/13/2024, at 11:45 AM, the Administrator stated he received a text message from CNA 1 on 11/9/2024 at around 5 PM informing him that CNA 1 had “proof of something very important.” The Administrator stated that at 6:22 PM, CNA 1 texted him again stating this was not about CNA 1 but about a Patient [did not indicate a specific Patient’s name]. Administrator stated he called CNA1 back at around 6:24 PM and asked about her concerns in the text message. The Administrator stated that CNA1 informed him, there was no emergency, and the issue was not urgent and stated CNA 1 would discuss the situation to the Administrator that following Monday, 11/11/2024. The Administrator stated he called the DON to inform her of the CNA 1’s phone call and that they would talk to CNA 1 on Monday [11/11/24]. During the same interview with the Administrator on 11/13/2024 at 11:45 AM, the Administrator stated on 11/11/2024 at 3:13 PM, CNA 1 came to his office and showed the DON and himself, the videoclip of the incident [being tied up to the wheelchair] involving Patient 1. The Administrator stated he informed CNA 1 that the videoclip CNA 1 showed was abuse and should have been reported by CNA 1 immediately to the proper authorities [abuse coordinator and other State Agencies] as soon as it was witnessed in accordance with the facility’s policy and procedure [P&P]. During a concurrent interview on 11/13/2024 at 2:15 PM with the Administrator, the Administrator stated he had started an investigation on 11/11/2024 regarding Patient 1’s abuse incident on 11/9/2024, that was reported to the Administrator on 11/11/2024 by CNA 1. The Administrator stated he had place CNA 1 on suspension (temporarily removed from their job duties, usually while an investigation is underway) on 11/11/2024, but had not suspended CNA 2 who was the assigned CNA for Patient 1 during the 3 PM to 11 PM shift, on 11/9/2024 (4 days after the abuse incident). The Administrator stated that he did not suspend CNA 2 right away because CNA 2 was not scheduled to work until Thursday, 11/14/2024. During an interview with LVN 1 on 11/14/2024 at 1:15 PM, LVN 1 stated she was working on a Saturday, dated 11/9/2024, during the 3 PM to 11 PM shift, as a Charge Nurse. LVN 1 stated no one had come forward to report seeing any Patient in a “sheet restraint.” LVN 1 stated, the Administrator called her at the facility on 11/9/2024 and gave her instructions to make rounds to ensure the safety of the Patients. LVN 1 stated, she had asked CNA 1 if there were any issues she wanted to discuss or report on 11/9/2024, but CNA1 stated it was not an emergency and refused to discuss the matter with LVN 1. During a review of the facility’s P&P titled “Restraints” revised on 11/1/2017, the P&P indicated Patients shall be provided an environment that is restraint- free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measures shall be used. During a review of the facility’s P&P titled “Abuse Prevention and Prohibition Program” revised on 10/24/2022, the P&P indicated each Patient has the right to be free from mistreatment, neglect, abuse, involuntary seclusion. Anyone who suspects that an abuse has been committed against a Patient must immediately report this information to the Administrator and to the Director of Nursing Services. The P&P indicated it is the Administrator’s responsibility to ensure the proper authorities and individuals are notified immediately or wit