Health inspection·May 14, 2025

Code of Federal Regulations, Title 42, Section 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. (a) The facility must— (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property[.] 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, Section 72527 Patient’s 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. (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. California Code of Regulations, Title 22, Section 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 4/1/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility-reported-incident (FRI) about resident-to-resident physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another). The facility failed to protect Resident 1’s right to be free from physical abuse in accordance with facility’s policy and procedure titled, “Abuse Prevention and Management,” when on 3/21/2025 at 7 a.m., Resident 2 scratched Resident 1’s right lower foot. As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 had a scratched mark measuring 10 centimeters (cm- a unit of measurement) in length and 0.3 cm in width on Resident 1’s right lower foot that needed first aid (initial assistance and care given to a resident who has been injured) and daily wound treatments. Resident 1 was “visibly upset.” Resident 1 verbalized that when Resident 2 scratched Resident 1’s right lower foot it “brought (back) her (Resident 1) post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event)” from a previous incident (did not indicate the specific incident), “shook (emotionally or physically disturbed; upset)” her (Resident 1), and made her (Resident 1) “scared.” A review of Resident 1’s Admission Record (AR), indicated the facility admitted Resident 1, a 73-year-old female, on 2/12/2025 with diagnoses including parkinsonism (a broad term that refers to brain conditions that caused slowed movements, rigidity [stiffness], and tremors), quadriplegia (a severe medical condition characterized by the partial or total loss of function in all four limbs [arms and legs] and the torso [the main part of the body that contains the chest, abdomen, pelvis, and back]), and depression (a persistent state of sadness and loss of interest that can significantly affect how you feel, think, and behave, making it hard to enjoy life or carry out daily activities). A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool) dated 2/16/2025, indicated Resident 1 had intact cognition (refers to the mental processes involved in knowing, learning, and understanding). The MDS indicated Resident 1 was dependent (helper does all the effort and resident does none of the effort to complete the activity) with toileting hygiene, and shower. A review of Resident 1’s Change in Condition (COC- when there is a sudden change in a resident’s condition) Evaluation, dated 3/21/2025 at 7:50 a.m., indicated Resident 1 “stated” Resident 2, a roommate, “scratched” Resident 1’s right lower foot while Resident 2 exited Residents 1 and 2’s room accompanied by a staff member (name not indicated). The COC Evaluation indicated there was a noted red line (no other descriptions indicated) in Resident 1’s right lower foot and staff (Licensed Vocational Nurse [LVN] 2) cleaned the skin area (the skin area with the red line). A review of Resident 1’s COC Evaluation, dated 3/21/2025 at 8:30 a.m., indicated Resident 1 had a red line scratched mark measuring 10 cm in length by 0.3 cm in width which Resident 1 got from Resident 2 who scratched Resident 1’s right lower foot. A review of Resident 1’s Order Summary Report (OSR), dated 3/21/2025, indicated Resident 1’s Physician/Medical Doctor (MD) 1 ordered to clean Resident 1’s right foot red line scratched mark with normal saline (a mixture of water and salt with a salt concentration of 0.9 percent [% - per one hundred], for every 1 liter [L – 1,000 milliliter, a unit of measurement] of water, there are nine grams [unit of measurement] of salt), pat dry, apply bacitracin ointment (a topical antibiotic ointment, essentially a cream, used to prevent infection in minor skin injuries like cuts, scrapes, and burns), and leave the wound open to air every day shift for 21 days. A review of Resident 1’s Skin Check (SC), dated 3/21/2025 at 4:47 p.m., indicated Resident 1’s right lower foot was noted with a red line scratched mark measuring 10 cm in length by 0.3 cm in width. A review of Resident 1’s Psychiatric Follow Up Note (PN – a clinical document used by mental health professionals to record the progress of a resident’s treatment after the initial evaluation), dated 3/21/2025, indicated Resident 1 alleged that her roommate (Resident 2) became agitated and while staff was managing Resident 2’s behavior (the way in which one acts or conducts oneself, especially toward others), Resident 2 scratched Resident 1’s foot (right lower foot). The PN indicated Resident 1 “did not answer questions when prompted (encourage to say something) as she (Resident 1) was visibly upset.” The PN indicated Resident 1 had a diagnosis of “depression.” A review of Resident 1’s Treatment Administration Record (TAR - a daily documentation record used by a licensed nurse to document treatments given to a resident), dated 3/2025, indicated on 3/21/2025 Resident 1’s right foot scratch was cleaned with normal saline, patted dry, bacitracin ointment applied, and left the wound open to air. A review of Resident 2’s AR, indicated the facility admitted Resident 2, an 84-year-old female, on 4/16/2024 and readmitted the resident on 5/13/2024, with diagnoses that included dementia (a general term for a decline in mental ability that interferes with daily life, encompassing symptoms like trouble remembering, thinking, or making decisions), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities, and other symptoms that significantly affect daily functioning), and general anxiety disorder (a mental health condition that produces fear, worry, and a constant feeling of being overwhelmed). A review of Resident 2’s MDS, dated 1/8/2025, indicated Resident 2 had severely impaired cognition (a significant and substantial decline in a person’s ability to think, learn, remember, and make decisions, which significantly impacts their daily functioning). The MDS indicated Resident 2 needed substantial/maximal assistance with sit to stand. A review of Resident 2’s COC Evaluation, dated 3/21/2025 at 7 a.m., indicated Resident 2 was noted with episode of increased aggression through striking out for no apparent reason. The COC indicated Resident 2 was noted yelling and screaming to Certified Nurse Assistant (CNA) 1 and was combative. During an interview on 4/1/2025 at 11 a.m., Resident 1 stated she did not recall the date of the incident, but it was early in the morning at around 6 a.m. Resident 1 saw her roommate, Resident 2, swing a detachable bed remote control at CNA 1. Resident 1 stated Resident 2 was walking out of the room to the door with CNA 1, when Resident 2 turned towards Resident 1 and scratched Resident 1’s right foot. Resident 1 stated she was lying in bed and could not defend herself. Resident 1 stated, she sustained a 10 cm-scratch. During an interview on 4/1/2025 at 2:14 p.m., Resident 1 stated the incident with Resident 2 scratching Resident 1’s right lower foot “brought (back) her PTSD from a previous incident.” Resident 1 stated it (Resident 2 scratching her right lower foot) “shook” her and made her (Resident 1) “scared.” During an interview on 4/1/2025 at 2:23 p.m., CNA 1 stated she worked on 3/20/2025 from 11 p.m. to 7 a.m. and was assigned to care for Residents 1 and 2. CNA 1 stated on 3/21/2025 at around 6:45 a.m., Resident 2 sat up in Resident 2’s bed upset and began to shout and yell at the Housekeeper (HK) 1 who was cleaning Resident 1 and Resident 2’s room. CNA 1 stated Resident 2 stood up wanting to walk, grabbed the detachable remote control of the bed, and began to swing the bed remote control at CNA 1. CNA 1 stated LVN 2 and LVN 3 came to Resident 2’s room. CNA 1 stated Resident 2 had the bed remote control in Resident 2’s left hand and was walking towards the door. CNA 1 stated she and the LVNs (LVNs 2 and 3) were walking around Resident 2 to support Resident 2 from falling but were also avoiding getting hit by Resident 2. CNA 1 stated she saw Resident 2 walk all the way to Resident 1’s bed (nearest the door) and scratched Resident 1’s foot (right lower foot). CNA 1 stated Resident 1 said, “She (Resident 2) scratched my foot.” During an interview on 4/1/2025 at 3:57 p.m., the Director of Nursing (DON) stated Resident 2 scratched Resident 1’s right lower foot on 3/21/2025 at around 7 a.m. to 7:30 a.m. The DON stated she saw Resident 1 on 3/21/2025 at around 9 a.m. in the hallway and Resident 1 told her (DON) Resident 2 scratched Resident 1’s right lower foot. The DON stated Resident 2 scratching Resident 1’s right lower foot is considered physical abuse. The DON stated the facility does not allow abuse because Resident 1 can psychosocially (refers to how both the psychological [relating to the mental and emotional state] and social factors contribute to a person’s overall well-being, development, and functioning) feel unsafe in Resident 1’s environment and the potential for further harm. During a review of the current facility-provided Policy and Procedures (P&P) titled, “Abuse Prevention and Management,” revised on 5/30/2024 and effective on 6/12/2024, the P&P indicated “The facility does not condone any form of resident abuse….” During a review of the facility’s P&P titled, “Reporting Abuse,” last reviewed on 4/4/2024, the P&P indicated, “The facility will ensure that the resident has the right to be free from … physical … abuse….” The facility failed to protect Resident 1’s right to be free from physical abuse in accordance with facility’s policy and procedure titled, “Abuse Prevention and Management,” when on 3/21/2025 at 7 a.m., Resident 2 scratched Resident 1’s right lower foot. As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 had a scratched mark measuring 10 cm in length and 0.3 cm in width on Resident 1’s right lower foot that needed first aid and daily wound treatments. Resident 1 was “visibly upset.” Resident 1 verbalized that when Resident 2 scratched Resident 1’s right lower foot it “brought (back) her (Resident 1) PTSD” from a previous incident (did not indicate the specific incident), “shook” her (Resident 1), and made her (Resident 1) “scared.” The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.