Other·May 21, 2026

42 CFR §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. 22 CCR § 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. 22 CFR § 72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be implemented to ensure that patient related goals and facility objectives are achieved. 22 CFR § 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. On 4/8/2026, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility-reported incident indicating Resident 5 pushed Resident 3 in the hallway. The facility failed to: 1. Protect Resident 3 from being pushed to the floor by Resident 5, who displayed agitated (restlessness, emotional distress) behavior on 4/5/2026 at 8:10 a.m. 2. Implement Resident 5's care plan titled, "Increased Agitation" which indicated to assess the resident's behavior for triggers (cause) on 4/5/2026 at 8:10 a.m., when Resident 5 threw phone at a staff at the nurse's station, then walked to his room, threw breakfast tray to the floor, stating, "I want to go to the hospital now". 3. Implement its Policy and Procedure (P&P) titled "Abuse and Neglect Prohibition Policy," which indicated the facility staff must do all that was within their control to prevent occurrences of abuse for all residents, identify inappropriate resident behaviors, care plan, and monitor resident behaviors that may lead to conflict. As a result, on 4/5/2026 at 11:45 a.m., Resident 5 pushed Resident 3 to the floor and Resident 3 sustained a 1.5 centimeter (cm- a unit of measurement) cut to the right eyebrow. Resident 3 received six (6) sutures on his right eyebrow at a general acute care hospital (GACH). Resident 3 was an 82-year-old male, originally admitted to the facility on 12/22/2025 and readmitted on 4/2/2026. Resident 3's diagnoses included unspecified dementia (a progressive state of decline in mental abilities), depression (a serious, treatable mental health disorder characterized by persistent sadness, loss of interest in activities, and low energy), unspecified psychosis (a diagnosis used when a person exhibits symptoms of psychosis such as hallucinations, delusions, or disorganized thinking). A review of Residents 3's Minimum Data Set (MDS - a resident assessment tool), dated 4/5/2026, indicated Resident 3 had cognitive impairment. The MDS indicated Resident 3 required partial/ moderate assistance (Helper does less than half the effort) with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene The MDS indicated Resident 3 required supervision or touching assistance with transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). A review of Resident 3's Change of Condition (COC) dated 4/5/2026 at 11:45 a.m., indicated Resident 3 was walking in the corridor (hallway) when Resident 5 pushed Resident 3 from behind, and Resident 3's right-side of face hit on the hallway's handrail. Resident 3 sustained a cut to the right eyebrow with small amount of blood. 911 (Medical emergency phone number) was called and Resident 3 was transferred to a GACH for further evaluation and treatment. Resident 5 was a 59-year-old male, originally admitted to the facility on 11/17/2025 and readmitted on 3/20/2026. Resident 5's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought) bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and anxiety (the body's natural response to stress, manifesting as fear, worry, or restlessness). A review of Resident 5's Care Plan titled, "Increased Agitation manifested by throwing object at staff and yelling," dated 3/3/2026, indicated to assess for triggers, notify the physician (MD) of persistent or escalating behaviors, remove resident from overstimulating environment when agitation begins, transfer to GACH for further evaluation and treatment. A review of Resident 5's MDS, dated 3/24/2026, indicated Resident 5 had moderate cognitive impairment. The MDS indicated Resident 5 required partial/ moderate assistance with activities of daily living ADLs such as dressing, toilet use, personal hygiene The MDS indicated Resident 5 required supervision or touching assistance with transfer and bed mobility. A review of Resident 5's Progress Notes dated 4/5/2026 timed 8:10 a.m., indicated Resident 5 threw the phone he was using at the nursing station towards a nursing staff's head without provocation (act of angering or irritating). Resident 5 then walked to his room, removed a breakfast tray from the cart and threw it onto the floor, stating, "I want to go to the hospital now". A review of Resident 5's COCs did not indicate the facility created a COC on 4/5/2026 at 8:10 a.m., when Resident 5 threw the phone he was using, to a staff's head at the nurse's station, removed the breakfast tray from the cart and threw it onto the floor, stating, "I want to go to the hospital now." A review of Resident 5's care plan did not indicate a care plan was created after the incident on 4/5/2026 at 8:10 a.m. A review of Resident 5's COC indicated on 4/5/2026 at 12:00 p.m., Resident 5 walked behind Resident 3 while in the hallway and pushed Resident 3 down. Resident 5 stated that Resident 3 was "Evil...and deserved it." The physician recommended for Resident 5 to be transferred via 5150 (process allows designated professionals, such as peace officers or mental health professionals, to detain individuals who are experiencing mental health crisis and meet certain criteria, including being a danger to themselves or others, or being gravely disabled) for behavioral issues. During an interview on 4/9/2026 at 2:15 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated in the morning (time not specified) of 4/5/2026, Resident 5 came to the nurse's station asking for papers, appeared agitated and attempted to make a phone call to his brother saying, "I need help" and "I feel evil spirits inside me." When Resident 5 returned to his room, he tossed (threw) the breakfast tray into the hallway and threw the water pitcher in his room. Around lunchtime, on 4/5/2026 (time not specified), another nurse (unidentified) informed him that Resident 5 pushed Resident 3 to the floor. LVN 4 stated that when he asked Resident 5 why he pushed Resident 3, Resident 5 responded, "He (Resident 3) was evil and needed to fall." LVN 4 stated Resident 5 should have been monitored closely for the safety of all residents, after the resident showed signs of agitation. During an interview on 4/9/2026 at 2:19 p.m., with RN 1, RN 1 stated on 4/5/2026 at 8:10 a.m., the nurses did not assess Resident 5's condition or remain with Resident 5 when Resident 5 was observed agitated. The nurse did not call to inform the doctor of Resident 5's agitated behavior. Nurses should have conducted rounds at least every 30 minutes to ensure the safety of Resident 5 and other residents. If these interventions were implemented, it could have prevented the physical abuse toward Resident 3. RN 1 stated transferring Resident 5 to the hospital sooner was important. During a concurrent interview and record review on 4/9/2026 at 3:00 p.m., with the Director of Nursing (DON), Resident 5's progress notes dated 4/5/2026 at 8:10 a.m., was reviewed. The DON stated the facility did not create a COC about Resident 5's agitated behavior on 4/5/2026 at 8:10 a.m., and the doctor was not notified to obtain medication order to help calm the resident. The DON stated that nurses did not continuously monitor Resident 5 when he was agitated. The nurses should have placed him (Resident 5) on one-to-one (1:1-when a staff member is assigned to directly supervise no more than one resident and stay within very close proximity to ensure constant supervision and immediate intervention if needed, for safety reasons) supervision. The DON stated that implementing these nursing interventions could have prevented potential abuse toward other residents. During an interview on 4/9/2026 at 3:11 p.m., with the Assistant Administrator (AADM), the AADM stated that on 4/5/2026 at 8:10 a.m., the nurses should have placed Resident 5 on one-to-one/ sitter supervision when Resident 5 showed aggression towards the staff for all other residents' safety. A review of the facility's P&P titled, "Abuse and Neglect Prohibition Policy," dated 6/2022, indicated it prohibited abuse for all residents and ensured staff did all that was within their control to prevent occurrences of abuse for all residents. The facility should prevent abuse by identifying inappropriate resident behaviors, such as the use of derogatory language, and by assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect, including residents with a history of aggressive behaviors. The facility failed to: 1. Protect Resident 3 from being pushed to the floor by Resident 5, who displayed agitated behavior on 4/5/2026 at 8:10 a.m. 2. Implement Resident 5's care plan titled, "Increased Agitation" which indicated to assess the resident's behavior for triggers (cause) on 4/5/2026 at 8:10 a.m., when Resident 5 threw phone at a staff at the nurse's station, then walked to his room, threw breakfast tray to the floor, stating, "I want to go to the hospital now". 3. Implement its P&P titled "Abuse and Neglect Prohibition Policy," which indicated the facility staff must do all that was within their control to prevent occurrences of abuse for all residents, identify inappropriate resident behaviors, care plan, and monitor resident behaviors that may lead to conflict. As a result, on 4/5/2026 at 11:45 a.m., Resident 5 pushed Resident 3 to the floor and Resident 3 sustained a 1.5 cm cut to the right eyebrow. Resident 3 received 6 sutures on his right eyebrow at a GACH. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of the resident.