Health inspection·May 14, 2025

F600 Free from Abuse and Neglect Section 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. (a) The facility must - (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; Title 22, Section 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, Section 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, Section 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 3/4/25 at 10:22 a.m., an unannounced visit was conducted at the facility to investigate an entity reported incident regarding employee to resident abuse. The department determined the facility failed to ensure one of four sampled residents (Resident 1) was free from abuse, when Certified Nursing Assistant (CNA) 1 hit Resident 1 in the face. This failure resulted in Resident 1 sustaining a cut on his nose bridge about half an inch in length, a bruise under his left eye, and expressing feeling "like a piece of crap." A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on 10/31/24 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the left non-dominant side and generalized muscle weakness. A review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool), dated 2/5/25, indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 12 out of 15 with mild memory impairment. During an observation on 3/4/25 at 10:37 a.m., Resident 1 had a cut on his nose bridge, about half an inch in length, and a bruise under his left eye, green and purple in color. During an interview on 3/4/25 at 10:37 a.m., Resident 1 stated on 3/3/25 between 1 a.m. to 3 a.m., he pressed the call light button because he needed to be changed. Resident 1 did not want help from CNA 1 because CNA 1 was "rough." CNA 1 was mad and angry and "yanked" the call button out of Resident 1's hand. Resident 1 added CNA 1 hit himself with the call button and blamed Resident 1, then "punched" Resident 1 in the face and "it wasn't a light hit ..." Resident 1 further stated CNA 1 then "mocked" him, told him "you're a big baby." Resident 1 felt "like a piece of crap" and stated CNA 1 "probably did not care at all." A review of Resident 2's admission record indicated Resident 2 was admitted to the facility in November 2024. A review of Resident 2's MDS, dated 2/9/25, indicated Resident 2 had a BIMS score of 15 out of 15 with good memory. During an interview on 3/4/25 at 11:28 a.m. with Resident 2 (Resident 1's roommate), Resident 2 confirmed he was awake when CNA 1 was arguing with Resident 1 and stated Resident 1 yelled and asked CNA 1 "why he hit him." Resident 2 further stated CNA 1 told Resident 1 "you're just a baby, you can't do anything for yourself." A review of Resident 1's progress note, dated 3/3/25 at 8:38 a.m., indicated Resident 1 was noted with left lower eye swelling and discoloration and an abrasion to the bridge of nose. The note further indicated Resident 1 stated he had an argument and physical contact with staff that resulted in the discoloration and abrasion to his nose. A review of Resident 1's progress note, dated 3/3/25 at 10:37 a.m., indicated Resident 1 reported "a bruise that was not there" and stated "overnight staff" hit him with his hand. During an interview on 3/4/25 at 11:48 a.m., CNA 2 stated Resident 1 told him he did not like CNA 1 because he was rough. During an interview on 3/4/25 at 12 p.m., Licensed Nurse (LN) 1 stated Resident 1 usually advocated for himself, but today he was acting "more timid." A review of Resident 1's "Nursing- Weekly Summary," dated 3/2/25, indicated Resident 1's skin was intact with no issues. During an interview on 3/4/25 at 2:10 p.m., CNA 3 stated she assisted Resident 1 during her morning shift on 3/2/25 and Resident 1 did not have any bruises or cuts on his face. CNA 3 further stated on 3/3/25 at around 7:05 a.m. she was surprised when she saw Resident 1's face with a cut on the nose bridge and a bruise on his left eye. During an interview on 3/4/25 at 3:08 p.m., LN 2 confirmed she did not see a cut on Resident 1's nose bridge or a bruise on his left eye on 3/2/25 during the p.m. shift. During an interview on 3/4/25 at 3:06 p.m., the Administrator (ADM) stated he interviewed nursing staff and confirmed that Resident 1 did not have a cut on his nose bridge and a bruise under his left eye on 3/2/25. A review of the facility's policy titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," revised in April 2021, indicated, "Residents have the right to be free from abuse ... This includes but not limited to freedom from ...verbal, mental ... or physical abuse..." Therefore, the department determined the facility failed to ensure Resident 1 was free from abuse when CNA 1 hit Resident 1 in the face. This failure resulted in Resident 1 sustaining a cut on his nose bridge about half an inch in length, a bruise under his left eye, and expressing feeling "like a piece of crap." The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.