Health inspection·April 10, 2025

The following reflects the findings of the California Department of Public Health during a Federal Recertification Survey, with investigation of seven (7) facility reported incidents CA00951795, CA00948970, CA00932431, CA00929676, CA00929601, CA00917143, and CA00898622. The Department substantiated facility reported incident CA00929601 and the findings are written under tag (F-600). Survey Event ID: XCT811 Exit Date: 3/21/25 40911 HFEN Janice Tovera State Citation B was written Code of Federal Regulations, §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. Cal. Code Regs. Tit. 22, § 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. Cal. Code Regs. Tit. 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. On 3/21/25, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to conduct a recertification survey and investigate seven Facility Reported Incidents. The Department determined the facility failed to ensure a resident's right to be free from verbal abuse for one of sixteen sampled residents (Resident 44) when, Resident 44 was cursed at by Licensed Nurse (LN) 5. This failure had the potential to cause emotional distress and could negatively affect Resident 44's psychosocial well-being. Review of Resident 44's "ADMISSION RECORD," indicated Resident 44 was admitted with diagnoses including depression (mental health condition characterized by persistent feelings of sadness) and anxiety (persistent worry) disorders. Review of Resident 44's "Minimum Data Set [an assessment tool]," dated 2/4/25, indicated Resident 44's Brief Interview for Mental Status score was 13 out of 15 suggesting an intact cognitive functioning (a person's mental processes, including thinking, learning, memory, and reasoning, are functioning normally and without any significant impairment). Review of Resident 44's "IDT [Interdisciplinary Team; a group of healthcare professionals] Note," dated 11/13/24, indicated, " ...On 11/1/2024 [Resident 44] notified SSD [social services director] that he had a complaint of CN [charge nurse; LN 5] who cursed at him a couple of days ago. Resident could notrecall [sic] what the disagreement was about. On the same day CN approached DON [director of nursing] stating she was not getting along with resident and that a couple of days ago resident was following CN and interrupting her conversations she was having with CNA [certified nursing assistant], CN stated she tried to redirect him, and resident was angry and cursing at CN ...CN then talked to SSD, asking resident not to bother CN during her shift ...On 11/7/2024- A CNA notified DSD [director of staff development] that she had heard CN on 11/1/2024 telling another CNA that she cursed at the resident ..." During a concurrent observation and interview on 3/20/25, at 1:33 p.m., with Resident 44 in his room, Resident 44 stated he did not have any disagreement with any staff member and stated he felt safe in the facility and had been cared for. Resident 44 stated he did not want to answer any further questions. During a concurrent interview and record review on 3/20/25, at 3:04 p.m., with the Administrator (ADM) and Director of Nursing (DON), Resident 44's "[Facility name] FACILITY EVENT REPORT [a detailed report regarding the investigation of the incident]," dated 11/8/24, was reviewed. The section of the facility event report titled, "Describe Incident ...," indicated, " ...the Social Services Director ...notified the Administrator that [Resident 44] complained this morning about [LN 5] cursing at him a couple of days prior, saying "I don't give a fuck" at the end of a disagreement [LN 5] and [Resident 44] had. When [name of the SSD] had asked [Resident 44] what the disagreement was about, [Resident 44] could not remember ...On the following Thursday afternoon, 11/7/24, a CNA confided to the DSD that she heard [LN 5] on 11/1/24 telling another CNA that she had told [Resident 44] to "fuck off" ..." The ADM explained, LN 5 admitted to Certified Nurse Assistant (CNA) 1 that she was working with at the time of the incident that LN 5 had used foul language toward Resident 44. The ADM stated, while LN 5 was explaining the events that had happened, CNA 2 had heard LN 5 admitting what she had done. The ADM further explained no staff had witnessed the disagreement between LN 5 and Resident 44. Further review of the facility event report in the section titled, "What is the outcome?," indicated, " ...Through record review and interviews, it can now be substantiated that [LN 5] used a curse word in her interaction with [Resident 44]. Because of [Resident 44's] past propensity for using that sort of language toward staff and becoming demanding when patience is required, it was believed that there was a disagreement between [Resident 44] and [LN 5] and that [Resident 44] needed a break from [LN 5] providing care for him; however, with other staff reporting [LN 5's] admission to using that language with [Resident 44], though denying it when asked, [LN 5] will not be returning to work at [facility name] ..." During an interview on 3/21/25, at 10:05 a.m., the DON stated verbal abuse could have a negative effect on residents. The DON stated the residents should feel safe and comfortable in their own home and the facility was their home. The DON further stated verbal abuse could affect the residents psychologically, emotionally, and could manifest physical symptoms such as increased blood pressure and increased breathing. The DON stated residents needed to feel safe in the facility. Review of the facility's policy and procedure titled, "Freedom from Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Policy and Procedure," revised 3/8/24, indicated, "...Each resident has the right to be free from abuse...VERBAL ABUSE: Verbal abuse includes the use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families. This would include use of swear words, making demeaning remarks about a person's appearance or use of such slang expressions such as "shut up" or "be quiet" ...All residents of [facility name] shall be free from verbal, mental, sexual, physical abuse ...Residents must not be subjected to abuse by anyone, including, but not limited to facility staff ..." Therefore, the Department determined the facility failed to ensure a resident's right to be free from verbal abuse when Resident 44 was cursed at by Licensed Nurse (LN) 5. This failure had the potential to cause emotional distress and could negatively affect Resident 44's psychosocial well-being. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Resident 44.