Health inspection·April 9, 2026

Event ID: 1F228C-H1 State Citation B was written. §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. 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. Title 22 § 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. Title 22 § 72527. Patients' Rights (a) Patient 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. Patient shall have the right: (10) To be free from mental and physical abuse. On 3/13/26, an unannounced visit was conducted at the facility to investigate a Facility Reported Incident regarding Resident/Patient/Client Abuse and a Complaint regarding Resident/Patient/Client Neglect. The facility failed to prevent abuse for one of three residents (Resident 1) when Licensed Vocational Nurse A (LVN A) hit and punched Resident 1's wound with his fist. This failure resulted in pain to Resident 1 and affected his psychosocial well-being. Review of Resident 1's Face Sheet indicated the resident was admitted to the facility with diagnoses including osteomyelitis (bone infection) of the vertebra (backbone). Review of Resident 1's Minimum Data Sheet (MDS, an assessment tool) dated 1/8/26 indicated his Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was 15, meaning he was cognitively intact. Review of Resident 1's Physician Order Report indicated he had treatment orders for a coccyx (tailbone, small bone at the base of the spine) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) and a left buttocks open wound. The report indicated Resident 1's treatment order, dated 2/24/26 indicated to cleanse the coccyx pressure injury with normal saline (a saltwater solution), apply Santyl ointment (used for wound care to help remove dead tissue), moistened gauze, and cover with foam dressing twice a day or as needed if soiled. The report also indicated Resident 1's treatment order, dated 2/24/26 indicated to cleanse the left buttocks wound with Dakins solution (used to clean wounds), apply Santyl ointment, collagen (protein used to encourage tissue growth for wound healing), and calcium alginate (absorbent dressing), cover with foam dressing twice a day or as needed. Review of a fax from the facility, "Report of Suspected Dependent Adult/Elder Abuse," dated 2/25/26 indicated Resident 1 alleged a nurse providing treatment for his wound hit his wound with his hand a few days ago. During an interview on 3/26/26 at 9:42 a.m., the administrator (ADM) stated Resident 1's allegation was substantiated. The ADM stated Resident 1 provided a video recording of the incident which showed LVN A hitting Resident 1's wound. The ADM stated they were going to terminate LVN A, but LVN A decided to resign. The ADM stated LVN A has been reported to the Board of Nursing. During a concurrent review of Resident 1's video recording on the ADM's phone showed LVN A standing on left side of Resident 1's bed while Resident 1 was lying on the bed face down. LVN A had gloves on both hands and was using his fingers on both hands to press down the tape around the wound dressing. LVN A used the back side of the fingers of his right hand to smooth out the tape on the dressing. Then LVN A made a fist with his right hand and punched Resident 1's wound on top of the dressing. Resident 1 screamed out in pain and shouted obscenities. LVN A pulled Resident 1's underwear and pants over his dressing. During an interview on 3/26/26 at 11:49 a.m., Resident 1 described how LVN A hit or punched him on his wound site when providing treatment for his wound. He stated prior to setting up the video recording on his cellphone, LVN A punched his wound three or four times. Resident 1 stated other times, LVN A would slap his wound. He stated he was afraid to report LVN A hitting his wound. Resident 1 stated another resident also witnessed LVN A hitting his wound multiple times. Resident 1 stated he told LVN A to stop and warned him, but LVN A still proceeded. Resident 1 stated sometimes LVN A would do his wound treatment and just leave. Resident 1 stated his pants would be down and LVN A would leave the curtain open and the door open, which would be humiliating. During an interview on 3/26/26 at 11:55 a.m., Resident 2 explained that he witnessed LVN A hitting Resident 1's wound. He stated LVN A would hit Resident 2 "across the backside." Resident 2 stated LVN A would also squeeze Resident 1's wound or slap Resident 1's wound. He stated he cannot put a number on how many times LVN A abused Resident 1 because he did not want to lie. Review of the facility's undated policy, "Abuse Prevention Program" indicated, "Our residents have the right to be free from abuse ..." It also indicated the administration will protect residents from abuse from anyone including staff, residents, family members, visitors, or any other individual. The facility failed to prevent abuse to Resident 1 when Licensed Vocational Nurse A (LVN A) hit and punched Resident 1's wound with his fist. This failure resulted in pain to Resident 1 and affected the resident's psychosocial well-being. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.