Other·May 13, 2026

Code of Federal Regulations, Title 42, Section §483.12 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. California Code Regulations, 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 4/6/26, an unannounced visit was conducted at the facility to complete the annual recertification survey and investigate Facility Reported Incidents regarding abuse. The facility failed to ensure a resident's right to be free from verbal abuse (using negative words and language that cause harm including demeaning, disrespecting, frightening, and threatening words) for one of thirty-two sampled residents (Resident 68) when Licensed Nurse (LN) 3 and Certified Nurse Assistant (CNA) 1 witnessed a contracted staff (staff who are usually not considered official company employee and are not on the traditional payroll but hired by another company for a specific responsibility) from the housekeeping department who made inappropriate and threatening remarks toward Resident 68 on 3/28/26. This failure had the potential to cause emotional distress and could negatively affect Resident 68's psychosocial well-being. On 3/29/26, at 10:02 a.m., the Department received a facility reported incident regarding an alleged employee to resident verbal abuse. This reported incident was investigated during the facility's annual recertification survey with a start date of 4/6/26. During a record review of Resident 68's "ADMISSION RECORD," dated 4/9/26, the record indicated, Resident 68 was admitted to the facility with diagnoses including absence of right leg above knee, abnormal posture, and muscle weakness. During a record review of Resident 68's "Minimum Data Set," (MDS, an assessment tool) dated 1/27/26, the MDS revealed a Brief Interview for Mental Status (BIMS) score of 9, on a scale of 0 to 15 indicating Resident 68 had moderate cognitive impairment. During a record review of Resident 68's "Care Plan Report," (summarizes a person's health conditions, specific care needs, and current treatments for care) dated 1/22/26, the report indicated, Resident 68 presents with lower extremities weakness due to impaired balance affecting functional mobility, and Resident 68 would achieve modified independence (patient can perform task safely and independently) with wheelchair mobility. During a concurrent observation and interview on 4/6/26, at 12:42 p.m. with Resident 68 in the South Unit, Resident 68 was in his wheelchair and wheeling around the facility with his right leg amputated (loss or removal of a body part through surgery) above the knee. Resident 68 stated he was doing well and had no concerns. During a review of Resident 68's clinical record titled, "Interdisciplinary Care Conference," dated 3/30/26, the record indicated, "...Notified by Primary nurse of contracted staff member spoke inappropriate language towards resident while self-propelling in wheelchair across wet floor that staff member had completed mopping...Explained to staff of not to use inappropriate language towards residents..." During a record review of Resident 68's "Care Plan Report," dated 3/29/26, the report indicated, "...Staff to resident abuse [on] 3/28/26...Resident will indicate and/or staff will observe resident to experience no psycho-social distress...Encourage resident to verbalize feelings...Give support and reassurance..." During an interview on 4/9/26, at 7:36 a.m. with Resident 68, Resident 68 stated he did not recall any staff member treating him inappropriately. Resident 68 also stated no one was bothering him and that he felt safe here. During a phone interview on 4/9/26, at 10:18 a.m. with CNA 1, CNA 1 stated that it was during the evening shift and was about to clock out for his lunch when CNA 1 heard the contracted housekeeper (HSK) 1 saying profanity and cursing at Resident 68. CNA 1 stated HSK 1 had indicated Resident 68 to get off the floor because he was going to mop it. CNA 1 stated she heard HSK 1 verbally abusive towards Resident 68. During an interview on 4/9/26, at 10:34 a.m. with the Environmental Services District Manager for Health Care Services Group (EVS DM) together with the Housekeeper Supervisor (HSK), the EVS DM stated that their group oversees all their employees and had gone through extensive hiring processes. The HSK stated that she reviews applicants that would be a potential fit to the needs of the facility. The HSK also stated applicants would go through onboarding orientation and through this orientation a background check and health examination would be executed before hiring. The EVS DM stated this process would ensure that applicants were clear and promote safety among the residents in the facility. The EVS DM stated that she expected all contracted employees hired under their group should respect resident rights and all educational training related to working in a nursing home environment including prevention of any abuse should be observed and any broken practices will be addressed. The HSK stated HSK 1 should have respected resident rights and should have worked well with the facility staff and residents. During an interview on 4/9/26, at 10:49 a.m. with the Administrator (ADM), the ADM stated HSK 1 did not follow the proper process of mopping the floor. The ADM stated the rule was to mop the floor one side at a time and HSK 1 got frustrated when Resident 68 passed through the mopped floor. The ADM stated residents felt unsafe and their rights violated when residents were treated inappropriately. During a phone interview on 4/9/26, at 11:03 a.m. with LN 3, LN 3 stated the incident happened at about 7 pm and just came back from her lunch. LN 3 stated she noticed HSK 1 was mopping the floor and she had commented to HSK to mop half of the floor first and not the entire floor in case of emergency to prevent staff from slipping. LN 3 stated HSK 1 responded aggressively that the floor would dry up quickly. LN 3 explained HSK 1 continued mopping the floor while Resident 68 was in wheelchair wheeling himself on the mopped floor at the South Unit close to the nurses' station. LN 3 continued to explain that she then heard HSK 1 saying to Resident 68 to move his "ass" and to get off the "f***" floor. LN 3 stated she removed Resident 68 from the scene. LN 3 also stated that Resident 68 had indicated he was aware of what had happened. LN 3 further explained that she approached HSK 1 and told him to act professionally and not to talk to residents rudely because this was their home and they have the right to be treated well and not to say profanity. LN 3 stated HSK 1 responded and had indicated that the residents frustrated him and added the residents were lucky this was not a prison and if he was the correctional officer that he would beat them. LN 3 stated the residents have the right to be treated well and to feel safe because this place was their home. During a facility record review titled, "Follow-Up Interview with [HSK 1]," dated 4/2/26 at 12 p.m., the written statement by HSK 1 indicated, "...[HSK 1] was asked whether he understood that speaking aggressively to a patient could be considered abuse. He responded, "Yes"...[HSK 1] was then asked to confirm whether, in his written statement, he indicated that he "aggressively told [Resident 68] to move out of the way," [HSK 1] confirmed that those were his exact words..." This written statement by HSK 1 was signed by the ADM and the Director of Nursing (DON). During a review of the facility's Policy & Procedure (P&P) titled, "Abuse Prohibition," dated 2/23/21, the P&P indicated, "...HealthCare Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents...Verbal abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients...Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a patient..." Therefore, the facility failed to ensure a resident's right to be free from verbal abuse Resident 68, when Licensed Nurse (LN) 3 and Certified Nurse Assistant (CNA) 1 witnessed a contracted staff from the housekeeping department who made inappropriate and threatening remarks toward Resident 68 on 3/28/26. This failure had the potential to cause emotional distress and could negatively affect Resident 68's psychosocial well-being. This violation had a direct or immediate relationship to the health, safety, or security of Resident 68 and is a B citation.