Other·May 7, 2026

§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. §72523(a) 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 4/1/2026 the California Department of Public Health (CDPH) received a complaint alleging a resident’s (Resident 1) Responsible Party (RP) reported a staff member (Certified Nursing Assistant [CNA 1]) placed a pillow over Resident 1’s mouth and laughed, at times CNA 1 was rough with Resident 1, and CNA 1 placed his hands over Resident 1’s mouth and nose within the past month, making Resident 1 fearful. On 4/1/2026, the CDPH conducted an announced visit to the facility to investigate the complaint allegation. During the investigation, the CDPH determined CNA 1 pinched Resident 1 on her face and pulled Resident 1’s hair while providing care to her on 3/22/2026. The facility did not protect Resident 1 from CNA 1 following the allegation of abuse. The facility failed to: 1. Ensure Resident 1 was not subject to abuse when CNA 1 pinched Resident 1’s face and pulled her hair during care on 3/22/2026. 2. Protect Resident 1 from possible intimidation following an allegation of abuse made against CNA 1 by Resident 1, Resident 1 and CNA 1 were placed in a room together during a meeting and Resident 1 accepted CNA 1’s apology for a “misunderstanding.” 3. Follow its Policy and Procedure (P/P), titled “Abuse Program Policy and Procedure” revised 6/25/2026, that indicated “…residents shall not be subjected to abuse by anyone, including but not limited to facility staff or other residents…The facility shall make reasonable efforts to protect the residents from harm during the investigation process.” These deficient practices compromised the integrity of the investigation, did not provide protective measures to Resident 1 during the investigation, minimized the severity of the allegations, and placed Resident 1 at risk for continued abuse, intimidation, guilt and fear of retaliation. These deficient practices had the potential for Resident 1 to experience physical and psychosocial harm. Resident 1, an 86 year old female, was initially admitted to the facility on 2/3/2025 and readmitted on 12/22/2025. Resident 1 had diagnoses including depression (a mood disorder that causes a persistent feeling of sadness or loss of interest), anxiety (feelings of fear, dread, or unease, often accompanied by physical symptoms like a rapid heart rate or tension) and dementia (a progressive state of decline in mental abilities). A review of Resident 1’s the Minimum Data Set ([MDS] a resident assessment tool), dated 2/10/2026, indicated Resident 1 had moderate cognitive impairment (a brain condition that causes subtle changes in thinking and memory, resulting in more difficulty with these functions than is expected for someone's age). Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity) on staff for toilet hygiene, showering, lower body dressing, and putting on and taking off footwear. A review of Resident 1’s History and Physical (H/P) dated 12/24/2025, indicated Resident 1 had a fluctuating capacity to understand and make medical decisions. A review of the facility’s undated Incident Investigation report, indicated on 3/22/2026 Resident 1 reported CNA 1 was inappropriate with her during care when CNA 1 possibly rough handled her, pulled her hair and other actions perceived as harmful. During a telephone interview on 4/1/2026 at 10:30 a.m., Resident 1’s RP stated she notified the Administrator (ADM) by telephone that Resident 1 told her (RP) on 3/22/2026 that CNA 1 placed a pillow on her face, pinched her cheek, and covered her nose and mouth with his hands, and she (Resident 1) was fearful of CNA 1. On 3/24/2026, Resident 1 called her and allowed her to listen via her (Resident 1) phone to a meeting held with Resident 1, CNA 1, and a staff member (Human Resources [HR] representative). She heard CNA 1 apologize and say the incident (pinching Resident 1’s cheek and pulling her hair while repositioning her) was a misunderstanding. Resident 1 sounded upset and said, “he is lying.” Later during the meeting Resident 1 accepted CNA 1’s apology. The RP stated she felt the meeting between Resident 1 and CNA 1 was inappropriate because the facility placed Resident 1 and CNA 1 in the same room and Resident 1 sounded pressured to forgive CNA 1. During an interview on 4/1/2026 at 11:50 a.m., the ADM stated Resident 1’s RP called her on 3/23/2026 at approximately 4:30 p.m. and reported that Resident 1 told her (RP) that CNA 1 placed a pillow on her face, pinched her cheek, handled her roughly, and engaged in other actions perceived as harmful. During a telephone interview on 4/2/2026 at 12 a.m., CNA 1 stated on 3/22/2026 he pinched Resident 1’s cheek because he wanted to show her endearment (a word, phrase, or act that expresses love, affection, or tenderness) because it was her birthday. His intention was to show her a friendly gesture but admitted he did not act professionally, and he did not explain to Resident 1 what he was doing while providing care to her. When he removed mucus from Resident 1’s nose she may have misunderstood what he was doing. CNA 1 stated when he repositioned Resident 1 in bed, he may have accidentally pulled her hair and caused a pillow to fall on her face. During an interview on 4/2/2026 at 9 a.m., Resident 1 stated CNA 1 pinched her cheek and covered her face with a pillow while providing care (3/22/2026) which made her to feel afraid of CNA 1. The facility held a meeting with her and CNA 1, during which CNA 1 asked for her forgiveness. Resident 1 stated she forgave him but did not want any further trouble and did not want CNA 1 to provide her care anymore. During an interview on 4/2/2026 at 3 p.m., the Director of Staff Development (DSD) stated on 3/23/2026 the ADM informed her of the allegation of abuse involving CNA 1 and Resident 1 and directed her to investigate. On 3/24/2026, she, the HR Representative and CNA 1 held a face-to-face meeting with Resident 1 and the RP listened via telephone. She (DSD) believed it was important for CNA 1 to apologize and clear up what she felt was a misunderstanding because, in her view, Resident 1 and CNA 1 previously had a good relationship. She did not consider the facility’s policy (Abuse Program) which indicated the resident and alleged perpetrator must be separated when she conducted the face-to-face meeting. A review of the facility's P/P titled "Abuse Program Policy and Procedure” revised 6/25/2025, indicated “the facility has established a system to prevent not only abuse but also those practices and omissions, neglect and misappropriation of property, that if left unchecked can lead to abuse. Residents shall not be subjected to abuse by anyone, including but not limited to facility staff, or other residents….. The facility shall make reasonable efforts to protect the residents from harm during the investigation process.” The facility failed to: 1. Ensure Resident 1 was not subject to abuse when CNA 1 pinched Resident 1’s face and pulled her hair during care on 3/22/2026. 2. Protect Resident 1 from possible intimidation following an allegation of abuse made against CNA 1 by Resident 1, Resident 1 and CNA 1 were placed in a room together during a meeting and Resident 1 accepted CNA 1’s apology for a “misunderstanding.” 3. Follow its P/P titled “Abuse Program Policy and Procedure” revised 6/25/2026, that indicated “…residents shall not be subjected to abuse by anyone, including but not limited to facility staff or other residents…The facility shall make reasonable efforts to protect the residents from harm during the investigation process.” These deficient practices compromised the integrity of the investigation, did not provide protective measures to Resident 1 during the investigation, minimized the severity of the allegations, and placed Resident 1 at risk for continued abuse, intimidation, guilt and fear of retaliation. These deficient practices had the potential for Resident 1 to experience physical and psychosocial harm. These failures had direct or immediate relationship to the health, safety and security of Resident 1.