Other·April 12, 2023

On 3/14/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct an annual recertification survey. The facility failed to immediately report and no later than two hours, two incidents of allegation of resident to resident abuse to the California Department of Public Health (CDPH), to ombudsman (advocates for the residents of long-term care facilities), and to local law enforcement, for Residents 77 as evidenced by: 1. Resident 7 cursed and threw cups multiple times at Resident 77. 2. Resident 15 cursed and scratched Resident 77. 3. Resident 15 attempted to take Resident 77's computer. This deficient practice had the potential for delayed investigation and placed Resident 77 at increased risk for further abuse. A review of Resident 7's Admission Record indicated the facility initially admitted Resident 7 on 8/11/2022 and readmitted Resident 7 on 2/17/2023 with diagnoses including schizophrenia (a serious mental disorder in which people interpret reality abnormally), psychosis (to perceive or interpret reality in a very different way from people), hypertension (high blood pressure), muscle weakness, mood disorder, anxiety disorder, insomnia (difficulty falling or staying asleep), and encephalopathy (any disease of the brain that alters brain function or structure), nicotine dependence (is an addiction to tobacco products caused by the drug nicotine), and alcohol abuse. A review of Resident 7's Minimum Data Set (MDS- a standardized screening and assessment tool) dated 2/24/2023, indicated Resident 7 was unable to make daily decisions or make himself understood. Resident 7 required limited one staff assist with transfers from bed and ADLs. A review of Resident 15's Admission Record indicated the facility initially admitted Resident 15 on 6/21/2017 and readmitted Resident 15 on 2/13/2023 with diagnoses including psychosis, schizophrenia, bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and major depressive disorder (is a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 15's MDS dated 2/20/2023, indicated Resident 15 was unable to make daily decisions or make herself understood. Resident 15 required limited to extensive one staff assist with transfer from bed and for ADLs. A review of Resident 26's Admission Record indicated the facility admitted Resident 26 on 7/06/2022 with diagnoses including schizoaffective disorder, anxiety disorder, and insomnia. A review of Resident 26's MDS dated 1/12/2023, indicated Resident 26 had intact cognition. A review of Resident 77's Admission Record indicated the facility initially admitted Resident 77 on 4/20/2022 and readmitted Resident 77 on 1/11/2023 with diagnoses including muscle weakness, difficulty walking, and anxiety disorder (involves persistent and excessive worry that interferes with daily activities). A review of Resident 77's MDS dated 1/27/2023, indicated Resident 77 was cognitively (mental ability to make decisions of daily living) intact for making decisions regarding tasks of daily life and required assistance with transfers from bed and a staff person's physical assistance for activities of daily living (ADLs - bed mobility, transfers from bed, eating, dressing, toilet use, and personal hygiene). On 3/17/2023, at 8:23 a.m., during an interview, Resident 77 stated on multiple times, Resident 7 cursed her out, threatened her, and threw cups at her while she [Resident 7] was outside smoking. Resident 77 stated Resident 26 (roommate) always accompanied her and protected her from Resident 7 whenever she (Resident 77) went outside to smoke. Resident 77 stated she reported the incidents with Resident 7 to the Director of Nursing (DON), Licensed Vocational Nurse 1 (LVN 1), and the Social Services Director (SSD) on 1/6/2023 and 2/9/2023. On 3/17/2023, at 8:27 a.m., during an interview, Resident 26 stated she witnessed Resident 7 "mess" [curse at] with Resident 77. Resident 26 stated she always protected Resident 77 from Resident 7 whenever Resident 77 goes outside to smoke a cigarette. Resident 26 stated Resident 7 throws cups at Resident 77. On 3/17/2023, at 8:42 a.m., during an interview, Resident 77 stated in 12/2022 (unable to recall the date), Resident 15 entered her room, scratched her arm and tried to take her computer. Resident 77 further stated about two weeks ago Resident 15 entered her room and cursed her out. Resident 77 stated she reported Resident 77 to LVN 1 and the DON and nothing was done about it. Resident 77 stated Resident 15 returned from hospital about two to three weeks ago and continued curse Resident 77 out. Resident 77 stated she did not tell anyone of the staff "because they do not do anything" and that Resident 26 witnessed the aforementioned incidents with Resident 15. On 3/17/2023, at 8:48 a.m., during an interview, LVN 1 stated she remembered Resident 77 telling her that Resident 15 was acting aggressive towards Resident 77 and that Resident 77 did not feel safe. LVN 1 stated she reported the incident to Registered Nurse Supervisor 2 (RNS 2) and the DON. LVN 1 verified and stated Resident 15's aggressive behavior towards Resident 77 was a form of abuse. LVN 1 stated she was a mandated reporter and should have immediately report the incident to the ADMIN, ombudsman, CDPH, and the police. On 3/17/2023, at 8:57 a.m., during an interview, LVN 1 stated she was aware of the incidents between Resident 77 and Resident 7. LVN 1 stated Resident 77 reported to her that Resident 7 cursed at Resident 77. LVN 1 stated she notified the DON and RNS 2 and should have immediately reported the incidents to the Administrator (ADMIN), CDPH, Ombudsman, and the police. On 3/17/2023, at 9:03 a.m., during an interview, LVN 1 stated on 1/23/2023, Resident 77 reported to her (LVN 1) that Resident 7 talked loudly at Resident 77 and that Resident 77 felt scared. LVN 1 further stated she did not notify the Ombudsman, CDPH, and police on 1/23/2023. LVN 1 stated she informed the DON and RNS 2 of the incident between Resident 77 and Resident 7. On 3/17/2023, at 9:19 a.m., during an interview, the DON stated all allegations of abuse must be immediately reported to the ombudsman, CDPH, and the police. On 3/17/2023, at 11:15 a.m., during an interview, Resident 77 stated Resident 7 yelled curse words and threw cups at Resident 77 multiple times and informed to LVN 1 and the DON multiple times and nothing was done about it. On 3/17/2023, at 11:15 a.m., during an interview, Resident 7 stated he cursed and threw things at Resident 77 because Resident 77 threatened him. Resident 7 stated he overhears Resident 77 and Resident 26's conversations and "they are talking about someone that sounds like me [Resident 7]." On 3/17/2023, at 1:35 p.m., during an interview, the ADMIN stated no one told him about the incidents with Resident 77. A review of the facility's in-service (required staff training) titled "Abuse/Manage Aggressive Behavior" dated 1/10/2023, indicated "staff must report Abuse within 2 hrs (two hours) and to review facility policy on resident abuse in accordance with state and federal regulations." A review of the facility's P&P titled "Abuse and Mistreatment of Residents" reviewed on 8/19/2022, indicated "to uphold a residence right to be free from verbal, sexual, and mental abuse, corporal punishment, and involuntary seclusion ... Verbal abuse is defined as any oral use of oral, written, or gesture language that willfully includes disparaging and derogatory terms to residents ..., examples of verbal abuse include but are not limited to threats of harm; saying things to frighten a resident, ... The Facility shall ensure reporting of all alleged and substantiated violations to the state agency and other agencies as required ... Any mandated reporter, in his or her professional capacity or within the scope of his or her employment has observed or has knowledge of an incident that reasonably appears to be a physical abuse, ... or is told by an elder or dependent adult that he/she has experienced behavior constituting physical abuse, or reasonably suspected abuse, shall report the known or suspected instant of abuse by telephone immediately or as soon as practically possible. The facility shall report the incident by notifying the CDPH within 2 (two) hours of the knowledge of such incident, ..." The facility failed to immediately report and no later than two hours, two incidents of allegation of resident to resident abuse to the CDPH, to ombudsman (advocates for the residents of long-term care facilities), and to local law enforcement, for Residents 77 as evidenced by: 1. Resident 7 cursed and threw cups multiple times at Resident 77. 2. Resident 15 cursed and scratched Resident 77. 3. Resident 15 attempted to take Resident 77's computer. This deficient practice had the potential for delayed investigation and placed Resident 77 at increased risk for further abuse. The above violations had direct or immediate relationship to the health, safety, or security of Resident 77.