Health inspection·June 4, 2025

The following reflects the findings of the California Department of Public Health during the investigation of: Facility Reported incident (FRI) CA00958817. Representing the Department, HFEN 515141 and HFES 39111. State Citation B was written. 42 C.F.R. § 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. 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 § 72523. Nursing Service-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 5/1/25 at 9:05 A.M., an unannounced onsite visit was conducted related to an allegation of staff-to-resident verbal abuse. It was determined the facility failed to ensure: 1. Resident 1 was free from verbal and mental abuse when Certified Nursing Assistant (CNA) 2 yelled at Resident 1 and made humiliating comments to the resident regarding their weight and size. 2. Staff were fully trained to correctly identify mental, emotional, and verbal abuse. 3. All Charge Nurses were adequately trained to collect pertinent information to make an accurate determination of abuse. 4. Policies titled: Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised April 2021 and Identifying Types of Abuse revised September 2022, were implemented. As a result: 1. Resident 1 cried, experienced depressed mood, psychosocial (the influence of social factors on an individual's mind or behavior) distress, and felt unsafe in the facility and "worthless." 2. CNA 2 was permitted to finish her eight-hour shift, providing care to other residents after the incident involving Resident 1, which had the potential for other residents to experience abuse. A review of Residents 1's Admission Record dated 5/1/25, indicated the resident was readmitted to the facility on 1/29/25. On 5/1/25 at 10:15 A.M., an observation and interview were conducted with Resident 1 while inside the resident's room. Resident 1's husband was also present. Resident 1 stated there was an incident that occurred around 11 P.M. (on 4/22/25) after she had requested help to be pulled up in bed. Resident 1 stated CNA 1 was her assigned CNA and CNA 1 went to get assistance. Resident 1 stated CNA 1 entered her room with CNA 2. Resident 1 stated CNA 2 told her, "Oh, it's you. You been here long enough and should be able to pull yourself up." Resident 1 stated CNA 2 laughed and pointed at her while saying, "Look at you, you're four times bigger than me." Resident 1 stated CNA 2 told her she did not want to break her back by pulling her up and that the resident was "too big." Resident 1 was observed wiping her tears away during the interview. Resident 1 stated after the incident occurred, she called her husband on the phone and told him what had happened. Resident 1 stated, "I just want to go home with my family." Resident's 1 husband stated they had been married for 47 years, and that this incident had a bad effect on his wife. Resident 1 stated when the incident occurred, she was in disbelief at first and then she "felt bad" and it made her feel "worthless." Resident 1 stated the incident felt like abuse because CNA 2 had been yelling at her, it happened at night, and she was alone and in a helpless state. Resident 1 stated, "I didn't feel safe." Resident 1 further stated, "Everyone knows [CNA 2] is rude. Even housekeepers know [this]." On 5/1/25 at 10:35 A.M., an interview was conducted with the Housekeeper (HK). The HK stated when she was cleaning a resident's room on another unit, about three to four weeks ago, a resident told her CNA 2 was rude to them. The HK stated she did not report what the resident told her to anyone. A review of CNA 2's employee file indicated: -Employee Counseling Form dated 5/6/24, and signed by CNA 2 indicated, "...2. Employee was rude to a family member...." -Employee Disciplinary Action Form dated 4/2/25, indicated, "...concerns regarding your ongoing comments about resident [sic] and staff. It has been observed and reported that you have repeatedly spoken about residents in a negative manner...Corrective Action Plan [:] Speak about residents respectfully at all times, regardless of frustrations or concerns. Bring up any care-related concerns to management or nursing leadership privately...." CNA 2 refused to sign the form. -Employee Disciplinary Action Form dated 4/10/25, indicated, "...This disciplinary action is being issued due to ongoing unprofessional conduct that is detrimental to team cohesion and the overall work environment...." CNA 2 refused to sign the form. -(Facility Name) Notice of Termination of Employment dated 4/28/25, indicated, "...Following a resident's [Resident 1] complaint, an internal investigation determined that verbal comments were made which in turn negatively affected the resident's emotional well-being, causing her significant distress...." On 5/1/25 at 12:11 P.M., a telephone interview was conducted with CNA 2. CNA 2 stated CNA 1 had asked for assistance to pull Resident 1 up in bed and, "She's overweight this patient." CNA 2 stated she did not want to hurt her back and that, "This lady [Resident 1] is more than 400 pounds. I can get hurt." CNA 2 denied making any comments about Resident 1 in front of the resident. CNA 2 was asked about her training on how to pull up a resident in bed and CNA 2 did not answer the question. CNA 2 spoke non-stop and frequently did not answer interview questions. CNA 2 was asked about the disciplinary actions in her employee file. CNA 2 changed the topic. CNA 2 was again asked about the contents of her employee file and CNA 2 denied there being any disciplinary actions in her file. CNA 2 stated she did go back to Resident 1's room with the charge nurse and a different CNA and assisted in pulling Resident 1 up in bed. CNA 2 stated the resident was "fine." CNA 2 further stated, "I never called [Resident 1] fat." On 5/1/25 at 3:15 P.M., a telephone interview was conducted with CNA 1. CNA 1 stated around 11:00 P.M., on 4/22/25, at the start of her shift, she asked CNA 2 for help to pull Resident 1 up in bed. CNA 1 stated they were in the hallway outside of Resident 1's room when CNA 2 stated she was not going to break her back. CNA 1 stated CNA 2 continued talking loudly and stated, "The resident's 500 times my weight." CNA 1 stated CNA 2 followed her into Resident 1's room while stating, "How could someone let themselves get that big?" CNA 1 stated that CNA 2 told Resident 1, "We're not going to do this, you're going to do it. Don't you see how big you are?" CNA 1 stated Resident 1 started crying while CNA 2 kept talking about how big Resident 1 was. CNA 1 stated CNA 2 would not stop talking about the resident's weight and the resident kept crying. CNA 1 stated, "I couldn't take it anymore and told [CNA 2] she was rude and to get out of my resident's room." CNA 1 stated this was the first time she had worked with CNA 2. CNA 1 stated she had reported the incident to the Charge Nurse (CN) 3 and she also emailed the Director of Staff Development (DSD) about the incident. CNA 1 stated she was emotional after witnessing the incident and had to take a break. CNA 1 stated based on her facility-provided abuse prevention training, the incident was emotional abuse. CNA 1 stated the incident was, "Emotionally damaging [to] the resident." CNA 1 stated Resident 1 was very sweet, never got mad, and was considerate. CNA 1 stated Resident 1 was not the type to complain and if she had not spoken up, the resident would have kept it inside and not said anything about it. On 5/1/25 at 3:42 P.M., a telephone interview was conducted with CN 3. CN 3 stated she was in charge of the building during the night shift (11 P.M. to 7 A.M.). CN 3 stated around the start of the shift on 4/22/25, CNA 1 reported to her that CNA 2 was rude to Resident 1 and had made the resident cry. CN 3 stated she asked CNA 2 what had happened, and CNA 2 stated that she did not say anything to Resident 1. CN 3 stated she spoke to Resident 1 about the incident and the resident did not want to talk about what had occurred. CN 3 was informed of what Resident 1 and CNA 1 said had happened on 4/22/25. CN 3 stated, "Oh no, that's abuse." CN 3 stated based on her facility-provided abuse prevention training, the incident on 4/22/25 that occurred between CNA 2 and Resident 1 was verbal, emotional, and mental abuse. CN 3 stated if she had known all the details of what had happened, she would have sent CNA 2 home. CN 3 stated CNA 2 had worked the whole night shift providing care to residents. On 5/5/25 at 10:12 A.M., an interview was conducted with the DSD. The DSD stated she was involved in investigating the incident that occurred on 4/22/25 between Resident 1 and CNA 2. The DSD stated it had been determined that verbal abuse had occurred, and that Resident 1 had suffered emotional distress. The DSD stated Resident 1 frequently became teary-eyed since the incident. The DSD stated prior to the incident Resident 1 seemed happier. The DSD stated this incident affected Resident 1 and, "It was verbal and mental abuse." The DSD stated CNA 2 had a history of negatively talking about residents, constantly complaining about management and staff, and speaking loudly where everyone could hear. The DSD stated on 4/2/25 and 4/10/25, CNA 2 was given written warnings about her behavior. The DSD stated she had received an email from CNA 1 after midnight (4/23/25) indicating that unnecessary comments were made by CNA 2 to Resident 1. The DSD stated, "In my head, I thought [CNA 2] was being negative again and I could address it the morning." The DSD stated there should have been additional training provided to Licensed Nurses in the CN position on how to gather all the facts and to report to the Director of Operations (DOO) and the Director of Nursing (DON) for additional guidance to determine if abuse had occurred so appropriate action could take place. The DSD stated rudeness should be covered in the abuse prevention training. The DSD stated staff needed to be able to tell the difference between rudeness and abuse and report it. On 5/5/25 at 11:00 A.M., an interview was conducted with the DOO and the DON. The DOO stated initially they did not think what happened on 4/22/25 to Resident 1 was as bad as it was. The DOO stated the incident was abuse considering how Resident 1 perceived the incident and how it made her feel. The DON stated what happened was, "Verbal abuse as [Resident 1] experienced emotional distress from it." The DOO stated during the incident CN 3 could have asked more questions and tried to gather more details of the situation and "dig deeper." The DOO stated gathering more details would have provided CN 3 with enough information to make the decision to send CNA 2 home. The DOO stated the CN should have reached out to the DOO and the DON for guidance in identifying CNA 2's behavior as abuse. The DOO stated the facility abuse prevention training should include more focused training to ask more thorough questions to understand the full scope of the situation for staff in charge of the building. The DOO stated all staff should be trained and capable of identifying verbal and mental abuse. A review of the facility's policy titled Identifying Types of Abuse revised September 2022, indicated, "As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents. 1. Abuse of any kind against residents is strictly prohibited...1. Mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. 2. Verbal abuse may be considered to be a type of mental abuse... 3. Examples of mental and verbal abuse include, but are not limited to: a. Harassing a resident; b. Mocking, insulting, ridiculing; c. Yelling or hovering over a resident, with the intent to intimidate...4. Staff are trained on abuse reporting and investigation...." A review of facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised April 2021, indicated, "Residents have the right to be free from abuse...5. Establish and maintain a culture of compassion and caring for all residents...6. Provide staff orientation and training/orientation programs that include...identification and reporting of abuse...10. Protect residents from any further harm during investigations...." In violation of the above cited standards, the facility failed to ensure: 1. Resident 1 was free from verbal and mental abuse when CNA 2 yelled at Resident 1 and made humiliating comments to the resident regarding their weight and size. 2. Staff were fully trained to correctly identify mental, emotional, and verbal abuse. 3. All Charge Nurses were adequately trained to collect pertinent information to make an accurate determination of abuse. 4. Policies titled: Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised April 2021 and Identifying Types of Abuse revised September 2022, were implemented. As a result: 1. Resident 1 cried, experienced depressed mood, psychosocial (the influence of social factors on an individual's mind or behavior) distress, and felt unsafe in the facility and "worthless." 2. CNA 2 was permitted to finish her eight-hour shift, providing care to other residents after the incident involving Resident 1, which had the potential for other residents to experience abuse. These violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a patient.