Health inspection·March 7, 2025

F600 §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. § 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. § 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. 22 CCR § 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. On 1/16/2025 the California Department of Public Health (CDPH) received a facility reported incident (FRI) alleging Certified Nurse Assistant (CNA) 6 was verbally aggressive towards Resident 45. On 1/21/2025, CDPH during unannounced annual recertification survey investigated the FRI allegation. Upon investigation, CDPH determined the facility failed to protect Resident 45's right to be free from verbal abuse when CNA 6 told Resident 45 "he will sticks enemas up his butt" and threatened him that he will "beat him up when no one was around." The facility failed to: 1. Protect Resident 45's right to be free from verbal abuse when CNA 6 told Resident 45 he will "sticks enemas up his butt" and threatened him that he "will beat him up when no one was around." 2. Follow policy and procedure (P&P) titled "Abuse Prohibition" dated 10/25/2025, which indicated "Health Care Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents." 3. Follow policy and procedure (P&P) titled, "Dignity " dated 2/2021, which indicated, "Residents are treated with dignity and respect at all times. Staff speak respectfully to residents at all times." As a result, CNA 6 verbally abused Resident 45 making Resident 45 feeling unsafe and unprotected and placed Resident 45 and other residents at risk for continued verbal abuse by CNA 6. A review of Resident 45's Admission Record indicated Resident 45, a 39 year old male, was admitted to the facility on 7/14/2022 with diagnoses including quadriplegia (paralysis from the neck down, including legs and arms, usually due to a spinal cord injury), anxiety (a feeling of fear, dread, or uneasiness that can be normal reaction to stress), and depression (a constant feeling of sadness and loss of interest). A review of Resident 45's Minimum Data Set ([MDS]- a resident assessment tool) dated 12/26/2024, indicated Resident 45 was cognitively (ability to think, understand, learn, and remember) intact. The MDS indicated Resident 45 was dependent (helper does all the effort) on staff with Activities of Daily Living ([ADL] activities such as bathing, dressing, and toileting a person performs daily). During an interview on 1/27/2025 at 2:00 p.m., Resident 45 stated he overheard CNA 6 calling him a rat, and he replied to CNA 6 by calling CNA 6 "faggot" and telling CNA 6 at least he does not stick d**k up his a**. CNA 6 replied to Resident 45 by telling him "he sticks enemas up his (Resident 45) butt." Resident 45 stated CNA 6 told him "he was going to beat him up when no one was around" which made him feel scared. During an interview on 1/28/2025 at 3:53 p.m., the Administrator (ADM) stated when she interviewed CNA 6, he verbally confirmed that he told Resident 45 that he "sticks enemas up his butt" and told Resident 45 he needed "to check himself." The ADM stated CNA 6 verbally admitted that he was wrong in the way he spoke with Resident 45. During an interview on 1/29/2025 at 11:26 a.m., the Director of Nursing (DON) stated CNA 6 and Resident 45 got into a verbal altercation on 1/16/2025. The DON stated CNA 6 admitted making inappropriate comments to Resident 45 and his response to Resident 45 was wrong. During an interview on 1/29/2025 at 12:15 p.m., Resident 37 (Resident 45's roommate) stated he overheard the verbal altercation between CNA 6 and Resident 45. Resident 37 stated he overheard CNA 6 told Resident 45 that "he sticks enemas up his butt," and Resident 45 and CNA 6 then began cursing at one another. A review of the facility's policy and procedure (P&P) titled, "Abuse Prohibition," dated 10/25/2024, the P&P indicated, "Health Care 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 a patient or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability." A review of the facility's P&P titled, "Dignity," dated February 2021, indicated, "Residents are treated with dignity and respect at all times. Staff speak respectfully to residents at all times." A review of the facility's P&P titled, "Resident Rights," dated 12/2021, indicated, "Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from abuse, neglect, misappropriation of property, and exploitation." The facility failed to: 1. Protect Resident 45's right to be free from verbal abuse when CNA 6 told Resident 45 he will sticks enemas up his butt and threatened him that he will beat him up when no one was around. 2. Follow P&P titled "Abuse Prohibition" dated 10/25/2025, which indicated "Health Care Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents." 3. Follow P&P titled, "Dignity "dated 2/2021, which indicated, "Residents are treated with dignity and respect at all times. Staff speak respectfully to residents at all times." As a result, CNA 6 verbally abused Resident 45 making Resident 45 feeling unsafe and unprotected and placed Resident 45 and other residents at risk for continued verbal abuse by CNA 6. These violations had a direct or immediate relationship to the health, safety, or security of Resident 45.