Health inspection·May 15, 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. (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. Code of Federal Regulations, Title 42 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 4/1/2025, an unannounced visit was conducted at the facility 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 3/18/2025. The facility failed to: 1. 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), when Resident 1 allegedly scratched Resident 2’s face on 3/18/2025. 2. Implement Resident 1’s care plan, dated 3/12/2025 by providing supervision and behavioral interventions when Resident 1 allegedly scratched Resident 2’s face. This resulted in Resident 2 had a scratch on his nose and had the potential to negatively affect Resident 1’s comfort, and psychosocial (having to do with the mental, emotional, social, and spiritual effects of a disease) well-being. A review of Resident 1’s Admission Record, indicated Resident 1, an 83-year-old-female, was admitted to the facility on 3/5/2025 with diagnoses that included Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and lack of coordination. A review of Resident 1 Care Plan for Resident 1 being verbally aggressive towards staff and Care Plan for Resident 1 with visual hallucinations initiated on 3/12/2025, the Care Plans indicated intervention to provide frequent visual checks for safety and comfort. A review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool), dated 3/18/2025, the MDS indicated Resident 1’s cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with eating. The MDS indicated Resident 1 is dependent (helper does all the effort) with oral hygiene, toileting hygiene, shower/bath, upper body dressing, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 is dependent with sit to stand and chair/bed to chair transfer. A review of Resident 1’s late entry progress notes dated 3/18/2025, timed 10:30 PM, documented by Licensed Vocational Nurse (LVN) 1, indicated a situation of alleged minor altercation. The progress notes indicated Resident 1 was observed exhibiting verbal aggression, yelling at staff, wandering the hallways and goes room to room. The progress notes indicated Certified Nurse Assistant (CNA) 1 followed Resident 1 closely and indicated Resident 1 abruptly entered Room A and scratched another resident (Resident 2) on the nose. The progress notes also indicated CNA 1 was unable to prevent the incident as it occurred suddenly. A review of Resident 2’s Admission Record, indicated Resident 2, a 63-year-old-male, was admitted to the facility on 6/26/2024 and readmitted on 1/31/2025 with diagnoses that included cellulitis (a common bacterial skin infection that affects the deeper layers of the skin and underlying tissues, often characterized by redness, swelling, pain, and warmth) of lower limbs, benign prostatic hyperplasia (common condition in men, particularly as they age, where the prostate gland [small gland located below the bladder], grows larger than normal), and gastro-esophageal reflux disease (when stomach contents, including acid, flow backward from the stomach). A review of Resident 2’s MDS dated 2/21/2025, the MDS indicated Resident 2’s cognitive skills was intact for daily decision making was with modified independence (some difficulty in new situations only). The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating. The MDS indicated Resident 2 required substantial/maximal assistance with oral hygiene, upper body dressing, and personal hygiene. The MDS also indicated Resident 2 is dependent with toileting hygiene, shower/bathe, lower body dressing, and putting on/taking off footwear. A review of Resident 2’s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 3/18/2025, by Registered Nurse (RN) 1, indicated a situation of alleged physical abuse by another resident, and sustained scratch on nose. The SBAR indicated treatment order to nose scratch was obtained from Resident 2’s Doctor. A review of Resident 2’s Treatment Administration Record for the month of March 2025, indicated a treatment to scratch in nose area, cleanse with normal saline (a sterile solution of 0.9% of sodium chloride in water used for hydration and wound cleaning/ flushing solution), solution, pat dry and leave open to air, once a day for 7 days, ordered on 3/19/2025. During a concurrent observation and interview on 4/1/2025 at 2:30 PM with Resident 2, in Resident 2’s room, Resident 2 was observed lying in bed, and Resident 2 stated “a female resident (Resident 1) came to my room a few nights ago, and she (Resident 1) scratched my face, and end up having scratched in my nose.” Resident 2 stated there was a staff (CNA 1) standing behind Resident 1’s wheelchair, and did not do anything to prevent Resident 1 from getting up from the wheelchair and attacked Resident 2 while he was laying in bed that night. During an interview on 4/1/2025 at 3:50 PM with CNA 1, CNA 1 stated he was working on 3/18/2025, evening shift (3 PM - 11 PM). CNA 1 stated CNA 1 was following Resident 1 who was sitting in wheelchair and wheeling himself (Resident 1) around, from west station where Resident 1’s room is, until Resident 1 entered east station and got up from wheelchair and entered Room A and attacked Resident 2 who was in bed. CNA 1 added, CNA 1 turned his head away from Resident 1 and when he turned back his head to look at Resident 1, Resident 1 was already standing next to Resident 2’s bed, and Resident 1 was attacking Resident 2’s face in scratching manner. During an interview on 4/1/2025 at 4 PM with LVN 2, LVN 2 stated he is familiar with Resident 1, and stated “He was not working when the incident of Resident 1 scratching Resident 2’s face on 3/18/2025.” LVN 2 added Resident 1 required supervision when Resident 1 started getting verbally aggressive because there is probability of Resident 1 becoming physically aggressive to staff and to other residents as well. LVN 2 also added, Resident 1 is new to the facility, and they are still monitoring Resident 1’s aggressive behavior and the staff following and supervising Resident 1 could have prevented Resident 1 from entering another resident’s room if that staff is really watching Resident 1. During an interview on 4/1/2025 at 4:10 PM with Registered Nurse (RN), RN stated she was made aware on 3/19/2025 that there was a resident-to-resident altercation between Resident 1 and 2 in Resident 2’s room (Room A). RN stated she went to Resident 2’s room, where the alleged incident happened, and RN observed Resident 2 in bed, with a scratch on Resident 2’s nose. RN stated Resident 2 claimed that Resident 1 attacked Resident 2, and that Resident 2 end up obtaining a scratch in his nose. RN stated based on the nurse’s notes that was documented, dated 3/18/2025, evening shift by LVN 1, RN stated that Resident 1 seemed to be out of her room that evening and is being followed by CNA 1, and suddenly, Resident 1 got up from the wheelchair and entered Room A, and attacked Resident 2 who was in bed. RN stated, Resident 1’s room is in another station (east station), and Resident 2 is in another station (west station), and the incident could have been prevented when licensed nurse and other staff members such as the CNAs working on that shift, redirected Resident 1 accordingly and maneuvered the wheelchair when Resident 1 seemed to be going further from her room or entering another resident’s room. During a concurrent interview and record review on 4/1/2025 at 4:15 PM with RN, Resident 1’s Care Plan for being verbally aggressive towards staff and Care Plan for Resident 1 with visual hallucinations initiated on 3/12/2025, the Care Plans indicated intervention to provide frequent visual checks for safety and comfort. RN stated, frequent visual checks meaning Resident 1 should have been supervised/ monitored at all times to ensure Resident 1’s safety and the safety of other residents in the facility. RN stated, on 3/12/2025, if CNA 1 did not turn away her glance from Resident 1 then CNA 1 could have intervened and prevented Resident 1 from scratching Resident 2 on the face. A review of the facility’s Policy and Procedure (P&P), titled “Abuse and Neglect Prevention Management,” revised in April 2024, indicated the facility will ensure our residents safe and free from abuse. The P&P indicated the residents have the right to be free from abuse by anyone, including staff members, other residents, visitors, volunteers, family, friends, or any other individual. A review of Facility’s P&P titled “Dementia-Clinical Management,” revised in April 2024, indicated the staff will monitor the individual with dementia. The facility failed to: 1. Ensure Resident 2 was free from physical abuse, when Resident 1 allegedly scratched Resident 2’s face on 3/18/2025. 2. Implement Resident 1’s care plan, dated 3/12/2025 by providing supervision and behavioral interventions when Resident 1 allegedly scratched Resident 2’s face. This resulted in Resident 2 had a scratch on his nose and had the potential to negatively affect Resident 1’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 patients or residents.