Health inspection·September 19, 2024

The following reflects the findings of the California Department of Public Health (Department) during the investigation of a complaint. Complaint number: CA00914438. A Class B citation was issued. Regulatory Violations: 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. 22 CCR §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. 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. On 8/14/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding an allegation of resident-to-resident abuse. The facility failed to implement its policy and procedures (P&P) on abuse for Resident 1 and Resident 2. For Resident 1 and Resident 2, the facility failed to identify verbal abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) and report to the state survey agency (SSA) on 8/5/24, Resident 1 and Resident 2 were verbally abusive to each other. Resident 1 stated Resident 2 called him a "pedophile" (a mental disorder in which an adult has sexual fantasies about or engages in sexual acts with a prepubescent [before puberty] child) and in turn, Resident 1 called Resident 2 a derogatory (disrespectful/of low opinion) language. Resident 2 alleged that Resident 1 threatened Resident 2's life. These deficient practices resulted in Resident 1 felt bad and upset, Resident 2 he felt angry after Resident 1 threatened his life, and delay of the investigative process and placed the residents at risk for further abuse. 1.During a review of the Admission Record indicated the facility admitted Resident 1 on 6/17/24 with diagnoses including paraplegia (paralysis in lower part of the body) and anxiety disorder. During a review of the Minimum Data Set (MDS, standardized care and health screening tool) dated 6/24/24 indicated Resident 1 was cognitively (mental ability to make decisions of daily living) intact. Resident 1 was dependent (helper does all the effort) with toileting hygiene, shower/bathe, lower body dressing, putting on/off footwear, personal hygiene, substantial assistance (helper does more than half the effort) with upper body dressing and supervision (assistance provided throughout activity or intermittently) with oral hygiene and eating. During a review of the Nursing Progress Note dated 8/5/24 at 5:43 p.m., indicated Resident 1 complained that Resident 2 was "bothering him and keep arguing too hard." Resident 1 was offered room change but Resident 1 refused. During a review of the Nursing Progress Note dated 8/5/24 at 5:50 p.m., indicated on 8/5/24 at 5:50 p.m., Resident 1 had his radio on with loud volume. Resident 1 stated the loud volume was to "tune out" his roommate (Resident 2) because Resident 2 was yelling and calling him (Resident 1) names and threatening to report him to the police". Resident 1 stated that Resident 2 looked up Resident 1's personal records online and "... began badgering him (Resident 1) about his past repeatedly". Resident 1 defended himself by calling Resident 2 a derogatory name. Room change was offered again but Resident 1 refused. The Notes indicated frequent visual monitoring was provided to Resident 1 and Resident 2. During a review of the Social Services Note dated 8/6/24 at 1 p.m., indicated Resident 1 agreed to move to another room on 8/6/24 to Room B. 2. During a review of the Admission Record indicated the facility admitted Resident 2 on 12/17/21 with diagnoses including respiratory failure (when the lungs [breathing organ] cannot get enough oxygen into the blood) and chronic pain syndrome (pain that lasts longer than three months) During a review of the MDS dated 6/14/24 indicated Resident 2 was cognitively intact. Resident 2 needed supervision with eating, oral hygiene, toileting hygiene, shower/bathe, upper/lower body dressing, putting on/taking off footwear and independent with personal hygiene. During a review of Resident 2's Behavior Note dated 8/5/24 at 5:29 p.m., indicated Resident 2 was heard screaming on 8/5/29 at 5:29 p.m. at Resident 1. Resident 2 stated Resident 1 "threatened his life." Resident 2 stated he is now in fear and has called the police". The behavior note indicated Resident 2 refused to move to another room. Resident 2 keeps calling Resident 1 a "pedophile". The behavior noted indicated Resident 2 was heard talking on the phone and telling the person on the phone that Resident 1 was a pedophile. The behavior note indicated Resident 2 was trying to agitate Resident 1 and that Resident 2 refused to move to another room. During a review of the Resident 2's Behavior Note dated 8/5/24 at 6:34 p.m., indicated Resident 2 continue to be verbally aggressive towards Resident 1 on 8/5/24, calling Resident 1 a "pedophile" and Resident 2 stated that the police are going to take Resident 1 away. The behavior note indicated Resident 2 was verbally attacking staff, and Resident 1 and that Resident 2 was threatening Resident 1. During an interview on 8/14/24 at 8:38 a.m., Resident 1 stated he had argument with Resident 2 on 8/5/24. Resident 1 stated Resident 2 called him a "pedophile" and Resident 2 "kept screaming at me". Resident 1 stated he felt bad and upset. Resident 1 stated the facility moved him to Room B and he felt happier. During an interview on 8/14/24 at 10:18 a.m., the Social Service Designee (SSD) stated that on 8/5/24, Resident 1 and Resident 2 were having an argument. The SSD stated Resident 1 and Resident 2 were offered a room change but both residents refused. The SSD stated on 8/6/24, Resident 1 agreed to move to another room. During an interview on 8/14/24 at 11:34 a.m., the Director of Nursing (DON) stated the incident between Resident 1 and Resident 2 was not reported to the SSA. During an interview on 8/14/24 at 12:50 p.m., the Administrator (ADM) stated Resident 1 and Resident 2 were calling each other names and, "they were just bickering like two college roommates". The ADM stated the incident between Resident 1 and Resident 2 was not reported to the SSA because there was no physical fighting. The ADM stated any allegation of abuse should be reported within two hours to the SSA. During an interview on 8/15/24 at 10:05 a.m., Resident 2 stated Resident 1 was racist and called him a derogatory name. Resident 2 stated Resident 1 threatened his life. Resident 2 stated he felt angry with Resident 1, but when Resident 1 was moved to another room he felt safe. During a telephone interview on 8/15/24 at 11:22 a.m., Licensed Vocational Nurse (LVN 1) stated on 8/5/24, during her shift (5:29 p.m.) she heard yelling coming from Resident 1 and Resident 2's room. Resident 2 was calling Resident 1 a "pedophile". LVN 2 stated Resident 1 was on the phone and informed the person he was talking with that Resident 1 was a pedophile. LVN 1 also stated that Resident 2 stated that Resident 1 threatened Resident 2's life and that Resident 2 was scared. LVN 1 stated room change was offered to Resident 1 and Resident 2, but both refused to move. LVN 1 stated Resident 1 and Resident 2 were monitored to ensure they were safe. LVN 1 stated she informed all the department heads about the incident. During a review of the facility's policy and procedures (P&P) titled Resident to Resident Altercations, revised on 5/24, indicated, "all altercations, including those that may represent resident-to-resident abuse shall be investigated and reported to the nursing supervisor, the director of nursing services and to the administrator." The same Policy indicated, "report incidents, findings and corrective measures to appropriate agencies as outlined in the facility's abuse reporting." During a review of the facility's P&P titled Abuse Investigation and Reporting revised on 3/24 indicated all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ("abuse") shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management." The same Policy indicated, "all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator or his/her designee to the following persons or agencies that includes: a. The state licensing/certification agency responsible for surveying/licensing the facility. b. The local/State ombudsman c. The resident's representative d. Adult Protective Services (where state law provides jurisdiction in long-term care) e. Law enforcement officials f. The resident's attending physician g. The facility medical director." During a review of the same P&P indicated, "an alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately but not later than: a. two hours if the alleged violation involves abuse or has resulted in serious bodily injury. b. 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury." The facility failed to implement its P&P on abuse for Resident 1 and Resident 2. For Resident 1 and Resident 2, the facility failed to identify verbal abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) and report to the state survey agency (SSA) on 8/5/24, Resident 1 and Resident 2 were verbally abusive to each other. Resident 1 stated Resident 2 called him a "pedophile" and in turn, Resident 1 called Resident 2 a derogatory language. Resident 2 alleged that Resident 1 threatened Resident 2's life. These deficient practices resulted in Resident 1 felt bad and upset, Resident 2 he felt angry after Resident 1 threatened his life, and delay of the investigative process and placed the residents at risk for further abuse. This violation had a direct relationship to the health, safety, and security of Resident 2.