Health inspection·August 13, 2025

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. The facility must— (a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, 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 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. 22 CCR §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 6/25/2025, the California Department of Public Health (CDPH) received a Facility Reported Incident indicating Resident 4 allegedly hit Resident 3 with a hanger after Resident 3 pulled Resident 4’s curtains and call light. On 6/27/2025, the CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: Adhere to its policies and procedures and protect the resident’s right to be free from physical abuse when Resident 4 physically attacked Resident 3. As a result, Resident 3 sustained welts (raised, red, or skin-colored bumps that appear on the skin) to his left arm after Resident 4 hit him with a clothing hanger. Resident 3 was a 70-year-old male, originally admitted to the facility on 6/15/21 and readmitted on 12/17/23 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (a feeling of worry or fear, often about potential future problems), and dementia (a progressive state of decline in mental abilities) with other behavioral disturbance. A review of Resident 3’s Care Plan, dated 3/19/2024, titled, “the resident has been physically aggressive by throwing his food tray at nursing staff,” and indicated interventions including anticipating resident’s needs, monitor/documenting observed behavior, and attempting interventions in his behavior log. The interventions also indicated that when the resident becomes agitated, staff will intervene before agitation escalates. A review of Resident 3’s History and Physical (H&P) dated 5/23/2025, the H&P indicated Resident 3 had fluctuating capacity to understand and make medical decisions. A review of Resident 3’s Minimum Data Set (MDS - a comprehensive quarterly resident assessment), dated 6/4/2025, indicated Resident 3 had the ability to make himself understood and the ability to understand others. A review of Resident 3’s Change of Condition Evaluation (COC) dated 6/25/2025, indicated Resident 3 exhibited behavioral changes when he pulled on another resident’s call light, curtain, and yanked his bed. The COC indicated Resident 3 had a left arm open scratch and a sad and frightened facial expression. The COC indicated Resident 3 showed facial grimacing when his left arm was touched during assessment. A review of Resident 3’s Skin Check (an assessment of the residents’ skin), dated 6/25/2025, indicated Resident 3 had three welts measuring 8.0 cm, and 0.4 cm (centimeter-a unit of measurement), in length on the left outer forearm after Resident 3 was hit with a clothing hanger by Resident 4. The assessment indicated one of the welts included a scratch. A review of Resident 3’s Order Summary Report, dated 6/25/2025, directed staff to cleanse the left arm open scratch and apply Bacitracin ointment (a topical antibiotic used to prevent and treat minor skin infections from cuts, scrapes, and burns) for 14 days, one time a day until finished. Resident 4 was a 74-year-old male, originally admitted to the facility on 6/17/2021 and readmitted on 1/31/2023 with diagnoses including polyarthritis (swelling or tenderness in five or more joints causing pain or stiffness that gets worse with age), cardiomegaly (an enlarged heart), and left leg above knee amputation (surgical removal of the leg when it is severely damaged). A review of Resident 4’s H&P, dated 10/28/2024, indicated Resident 4 had the capacity to understand and make medical decisions. A review of Resident 4’s MDS, dated 4/22/2025, indicated Resident 4 had the ability to make himself understood and the ability to understand others. A review of Resident 4’s COC, dated 6/25/2025, indicated Resident 4 allegedly hit another resident (Resident 3) with a clothing hanger. The COC indicated staff will monitor Resident 4 for 72 hours. During a concurrent observation and interview, on 6/27/2025, at 4:08 pm, in Resident 3’s room, Resident 3 was observed lying in bed with a small, dry, scab (a crusty protective covering) on the left arm. Resident 3 stated he was lying in his bed a few days prior when Resident 4 hit him with a hanger. Resident 3 stated Resident 4 accused him of throwing dirty towels under his bed. Resident 3 stated he sustained a bruise and had pain in his left arm after Resident 4 hit him with a hanger. Resident 3 stated it made him feel scared and afraid. During an interview on 6/27/2025 at 4:23 pm in Resident 4’s room, Resident 4 stated a few days ago he hit Resident 3 because Resident 3 was pulling and pushing his (Resident 4’s) bed and pulling on the privacy curtains and call light. Resident 4 stated Resident 3 had done this several times before and had thrown dirty towels under his bed, but he did not report it to staff. During an interview on 7/2/2025 at 1:40 pm, with LVN 1, the LVN stated “no resident should be abused”. LVN 1 stated welts and bruises are signs and symptoms of physical abuse. LVN 1 stated Resident 4 should not have hit Resident 3 with a hanger. A review of the facility’s Policy & Procedure (P&P) titled, “Abuse Prevention and Prohibition Program” revised 8/1/2023, indicated “Each resident has the right to be free from abuse, neglect, or misappropriation of resident property.” The P&P indicated welts and bruises are signs and symptoms of physical abuse. The P&P indicated “The Administrator is the Abuse Coordinator. In -order- to facilitate reporting, ensure confidentiality, and promote order at the Facility, the Administrator, or his/her designee, shall be the individual who reports known or suspected instances of abuse of residents at the Facility to the proper authorities.” A review of the facility’s P&P titled, “Behavior – Management” revised 5/1/2018, indicated “When the resident exhibits behaviors, the Licensed Nurse will document the resident’s behavior in the medical record and include the following as indicated: Any precipitating factors, interventions used to redirect behavior, the resident’s response to the intervention, notification of attending physician and responsible party as indicated, update the plan of care as indicated. A review of the facility’s P&P titled “Resident – Resident Altercations” revised 8/1/2023indicated “Facility staff monitors residents for aggressive or inappropriate behavior toward other residents, family members, visitors, and facility staff.” The facility failed to: 1.Adhere to its policies and procedures and protect the resident’s right to be free from physical abuse when Resident 4 physically attacked Resident 3. These violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result for Resident 3 and other residents.