Other·May 13, 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. 42 CFR §483.12(c) Reporting of Alleged Violations §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. § 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. Health and Safety Code (HSC) 1418.91 (a) (a)A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 4/1/2026, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility for a facility reported incident. During the investigation, the CDPH determined the facility failed to report the allegation of verbal abuse in a timely manner and separate Resident 1 and Resident 2 after the facility was informed by Resident 1 about the allegation. The facility failed to: 1.Separate Resident 1 and Resident 2 immediately when Licensed Vocational Nurse (LVN) 1 was notified by Certified Nursing Assistant (CNA) 1 about the alleged verbal abuse and altercation between Resident 1 and Resident 2 on 3/28/2026 at 5:30 a.m. 2.Follow the facility's policy and procedures (P&P) titled, "Resident to Resident Altercation," which indicated the staff will separate the residents if two residents were involved in an altercation and identify what happened. 3. Report allegation of verbal abuse in a timely manner. Resident 1 reported the verbal abuse to CNA 1 on 3/28/2026 at 5:00 a.m. CNA 1 reported it to LVN 1 on 3/28/2026 at around 5:30 a.m. LVN 1 then reported the allegation to Registered Nurse Supervisor (RNS) 1 on 3/28/2026 at 7:15 a.m. Report of Suspected Dependent Adult -Elder Abuse- California (SOC 341) form used by mandatory reporters to officially report suspected abuse, neglect, or financial exploitation of elders 65 years and above) was faxed on 3/28/2026 at 2:20 p.m.to the CDPH. 4.Follow the facility's P&P titled," Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating," which indicated allegations of abuse should be reported within two hours of an allegation involving abuse. As a result, Resident 1 was at risk for continued verbal abuse from Resident 2 that could lead to unnecessary fear and anxiety. Resident 1 a 65-year-old male admitted to the facility on 10/25/2026 to the facility with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or reduced control on one side of the body) following cerebral infarction (stroke-blood flow to a part of the brain is interrupted by a blockage or burst vessel) and major depressive disorder ( mental health condition characterized by persistent feeling of sadness). A review of Resident 1's History and Physical (H&P) dated 10/16/2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 1/16/2026, indicated Resident 1 required supervision or touching assistance (helper provides verbal cues) with eating, and substantial / maximal assistance (helper does more than half the effort) with transferring to and from a bed to chair or wheelchair. The MDS indicated Resident1 had the ability to understand others and express his ideas and wants. A review of Resident 1's Progress Notes dated 3/28/2026 timed at 5:21 a.m., indicated Resident 1 stated Resident 2 was antagonizing him and was calling him names like, "Faggot," and "Cry Baby." The Progress Notes indicated the author of the Progress Notes was LVN 1. A review of Resident 1's Progress Notes dated 3/28/2027 at 7:27 a.m., indicated LVN 1 reported to Registered Nurse Supervisor (RNS) 1 that Resident 1 and Resident 2 should have a room change due to alleged name calling directed at Resident 1. The notes also indicated RNS 1 will speak with both Resident 1 and Resident 2. A review of Resident 1's Change in Condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive [ability to think, understand, learn, and remember] behavioral, or functional status which without immediate intervention, may result in complications or death) Evaluation dated 3/28/2026 timed at 10:09 a.m., indicated around 9:30 a.m. to 10:00 a.m., RNS 1 interviewed Resident 1 and Resident 2. The COC indicated Resident 2 allegedly threatened Resident 1 by saying, "I will kill you." The COC indicated the Administrator, Director of Nursing, physician and family were notified. A review of Resident 1's Care Plan titled, "Resident 1 reports anger, irritation, or dislike towards Resident 2's yelling, insults, name calling and verbal threats," initiated on 3/30/2026, indicated the facility maintain a safe environment for all patients and separate patient if needed. The facility will use de-escalation techniques like a calm voice, non-threatening posture, encourage verbalization of feelings and provide a structured environment to reduce noise, and stimulation. Resident 2, a 80-year-old male admitted to the facility on 3/12/2026 with diagnoses including end stage renal disease (ESRD-irreversible kidney failure), diabetes mellitus, pleural effusion( abnormal buildup of excess fluid between the thin membranes lining the lungs and the chest cavity), and dependence on renal dialysis( patient must use a machine or a specialized treatment to filter their blood regularly because their kidneys stopped working well). A review of Resident 2's H&P dated 3/26/2026, indicated Resident 2 had fluctuating capacity to understand and make decisions. A review of Resident 2's MDS dated 3/27/2026, indicated Resident 2 had the ability to express ideas and wants and understand others. The MDS indicated Resident 2 required supervision with eating and substantial /maximal assistance with transferring to and from the bed to chair or wheelchair. A review of Resident 2's COC dated 3/28/2026 and timed at 10:20 a.m., indicated around 9:30 a.m.to 10:00 a.m. Resident 1 stated Resident 2 was allegedly threatening him by saying, "I will kill you." The COC indicated Resident 2 stated he did not say anything and Resident 1 started to scream. The COC indicated Resident 2 told Resident 1 to be quiet in a language other than English. A review of Resident 2's Care Plan titled, "The Resident has the potential to be verbally aggressive, alleged threatening words, "I will kill you," to Resident 1 initiated 3/28/2026, indicated staff will intervene before agitation escalated by guiding away from sources of distress. During a telephone interview on 4/1/2026 at 11:07 a.m. LVN 1, stated Resident 1 and Resident 2 were arguing during her shift on 3/28/2026 at around 6:00 a.m. LVN 1 stated CNA 1 informed her during the 5:30 a.m. medication pass that Resident 1 and Resident 2 were arguing. LVN 1 stated she went to speak with both residents and learned from Resident 1 that Resident 2 had been calling him names (faggot and crybaby). LVN 1stated, she informed RNS 1, who arrived around 7:15 a.m., on 3/28/2026, to request a room change for both residents because they were arguing. LVN 1 stated she did not separate the residents immediately because she believed only the Social Service Director (SSD) or RNS 1 could authorize room changes. LVN 1 stated staff should report allegations of abuse to the abuse coordinator or the Director of Nursing (DON) immediately and separate the residents. LVN 1 stated keeping both residents in the same room after an alleged resident -to -resident altercation could escalate the verbal conflict and lead to potential harm. During a telephone interview on 4/1/2026 at 11:48 a.m., CNA 1 stated on 3/28/2026 at around 4:30 a.m., he answered Resident 1's call light. Resident 1 complained that Resident 2 was cursing at him and speaking to him rudely. On 3/28/2026 at 5.00a.m., CNA 1 reported the incident to LVN 1 CNA 1 stated Resident 1 and Resident 2 were not separated immediately. CNA 1 stated if residents were not separated immediately after an alleged resident -to -resident altercation, they may be at risk of injury or further abuse. CNA 1 stated any allegations of abuse should be reported immediately to avoid further occurrence of abuse. During interviews on 4/1/2026 at 9:00 a.m. and again at 2:29 p.m., Registered Nurse Supervisor (RNS) 1, stated the alleged resident altercation occurred on 3/27/2026 during the 11:00 p.m. to 7:00 a.m. shift. RNS 1 stated on 3/28/2026 around 7:15 a.m. to 7:30 a.m. LVN 1 informed her Resident 1 and Resident 2 were having misunderstandings and one of them should receive a room change. RNS 1 stated she did not report the incident immediately because she believed it was a misunderstanding rather than an abuse. She stated she did not talk to both residents right away for the same reason. RNS 1 stated on 3/28/2026 at 8:00 a.m. , Resident 2 was asleep, and she chose not to interview Resident 1 because she was concerned Resident 2 might wake up and become aggressive. Resident 2 had a strong personality, spoke loudly, could become rude, and was not sociable. She was aware the alleged abuse occurred at 5:30 a.m. on 3/28/2026. RNS 1 also stated staff should report allegations of abuse immediately so the facility can investigate promptly, and Resident 1 and Resident 2 should have been separated immediately. Failing to separate the residents could escalate the situation and lead to injury. RNS 1 stated not reporting an allegation of abuse immediately could place Resident 1 in danger and at risk of emotional distress. During a concurrent observation and interview on 4/1/2026 at 12:15 p.m. in Resident 1's room, Resident 1 sat on his bed and stated he never engaged in a conversation with Resident 2. Resident 2 called him "chicken," "chavala" (a Spanish word for woman), "not a man," and screamed at him. Resident 2 told him he would go to his bed and kick his behind when he was alone in the room. Resident1 stated he could no longer ignore the behavior and reported it to CNA 1 early in the morning on 3/28/2026 at approximately 5:00 a.m. He told the Social Service Director (SSD) that he felt depressed about what happened to him on 3/28/2026 and about having to move rooms when it was Resident 2's fault. A review of facility's policy and procedure (P&P) titled, "Resident-to-Resident Altercation, "revised 12/1016, indicated "All altercations including resident-to-resident abuse will be investigated and reported to the nursing supervisor, Director of Nursing, and to the Administrator." The P&P indicated the staff will separate the residents, will implement measures to calm the situation, and identify what might led to the aggressive conduct on the part of one or more individuals. A review of facility's P&P titled, "Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating, "revised 4/2021, indicated allegations of abuse, neglect, exploitation, misappropriation of resident property is suspected should be reported immediately to the administrator and to other officials according to state law. The P&P indicated immediately is defined as within two hours of an allegation involving abuse. The facility failed to: 1.Separate Resident 1 and Resident 2 immediately when LVN 1 was notified by CNA 1 about the alleged verbal abuse and altercation between Resident 1 and Resident 2 on 3/28/2026 at 5:30 a.m. 2.Follow the facility's P&P titled, "Resident to Resident Altercation," which indicated the staff will separate the residents if two residents are involved in an altercation and identify what happened. 3. Report allegation of verbal abuse in a timely manner. Resident 1 reported the verbal abuse to CNA 1 on 3/28/2026 at 5:00 a.m. CNA 1 reported it to LVN1 on 3/28/2026 at around 5:30 a.m. LVN 1 then reported the RNS1 on 3/28/2026 at 7:15 a.m. SOC 341 was faxed on 3/28/2026 at 2:20 p.m.to CDPH. 4.Follow the facility's P&P titled," Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating," which indicated allegations of abuse should be reported immediately. As a result, Resident 1 was at risk for continued verbal abuse from Resident 2 that could lead to unnecessary fear and anxiety. These violations presented a direct or immediate relationship to the health, safety, security, or welfare of Resident 1.