Health inspection·April 30, 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 3/19/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a Facility Reported Incident (FRI) regarding an alleged verbal abuse of Resident 1 towards Resident 2. During the investigation CDPH determined the facility failed to protect Resident 2's right to be free from verbal abuse. The facility failed to: 1. Ensure Resident 1, who had a history of verbal aggressive behavior towards staff and residents, did not verbally abuse Resident 2 in accordance with the policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation, and Misappropriation Prevention Program." As a result, Resident 1 verbally abused Resident 2 on 3/13/2025, which made Resident 2 feel unsafe, unprotected and placing Resident 1 and other residents at risk of ongoing verbal abuse from Resident 1. A review of Resident 1's Admission Record indicated Resident 1, a 52-year-old male, was admitted to the facility on 9/28/2018 with diagnoses including cerebral infarction (disruptive blood flow to the brain), obsessive compulsive disorder (a mental health condition characterized by intrusive thoughts and repetitive behaviors), and paranoid personality disorder (a mental condition in which a person has a long-term pattern of distrust and suspicion of others). A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/11/2025, indicated Resident 1's cognition (ability to think, understand, learn, and remember) was intact and required moderate assistance with toileting, dressing, and personal hygiene. A review of Resident 1's care plan titled, "Physical Abuse" initiated on 9/26/2024, indicated the goal for Resident 1 to verbalize understanding of the need to control physically abusive behavior and the resident will not harm self or others. Resident 1's care plan interventions to analyze key times, places, circumstances, triggers, and what deescalates behaviors, explore sources of resident's dissatisfaction/agitation, and always approach the resident in calm, unhurried manner, and do not argue with the resident. A review of Resident 1's care plan titled, "Resident 1 risk for violence" initiated on 3/14/2024, indicated the goal for Resident 1 was to make all efforts to express self calmly. The care plan interventions included for Resident 1 to attempt behavioral intervention if the resident becomes verbally/physically abusive, speak in a calm voice, and always approach the resident calmly and unhurriedly. A review of Resident 1's Change in Condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status which without immediate intervention, may result in complications or death) dated 12/23/2024 and timed at 5:04 a.m., indicated Resident 1 was exhibiting aggressive behavior, yelling at the staff, and daring other residents to fight. A review of Resident 1's COC dated 3/1/2025 and timed at 1:00 a.m., indicated Resident 1 was displaying disruptive behaviors by arguing, yelling, and screaming at the staff by wanting to fight the staff. The COC indicated police was called to the facility. A review of Resident 1's COC dated 3/13/2025 and timed 10:40 a.m., indicated Resident 1 was angry, agitated, and yelling using profanity towards Resident 2 on 3/13/2025. A review of Resident 2's Admission Record indicated Resident 2, a 57-year-old male, was admitted to the facility on 9/24/2024 with diagnoses including legal blindness (vision impairment), anxiety (feeling of uneasiness or worry), and leukemia (cancer of the body's blood-forming tissues). A review of Resident 2's MDS dated 12/30/2024, the MDS indicated Resident 2's cognition was intact, and he was dependent (helper does all the work) on staff for all activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). During an interview on 3/19/2025 at 11:43 a.m., Resident 2 stated Resident 1 yelled at him when he was in the bathroom to wash his hands on 3/13/2025. Resident 2 stated, Resident 1 was verbally mean to him in the past, especially when he uses their shared bathroom. During an interview on 3/19/2025 at 11:59 a.m., Resident 3 (Resident 1 and 2's roommate) stated that Resident 1 bullies Resident 2 due to his blindness. Resident 3 stated that Resident 1 frequently occupies the shared bathroom and becomes upset with both Resident 3 and the other roommates (Resident 2) when they use it. During a subsequent interview on 3/19/2025 at 1:15 p.m., Resident 3 stated he has had verbal altercations with Resident 1 in the past when he uses their shared bathroom in their room. Resident 3 stated Resident 1 yells and curses at him and it makes him feel uncomfortable. Resident 3 stated Resident 1 has random outbursts of yelling and screaming, and he does not like it because Resident 1 will curse at the other roommates when they use their shared bathroom. During an interview on 3/19/2025 at 1:25 p.m., a Certified Nurse Assistant (CNA) 1 stated Resident 1 had a history of cursing at other residents. CNA 1 stated Resident 1 should be in a room by himself because Resident 1 scares some of the residents. CNA 1 stated some of the female resident near Resident 1's room will verbalize they are worried that he will hurt someone and felt Resident 1 had his own room and should not share a bathroom with other residents to prevent Resident 1 verbally abusing other residents. CNA 1 stated Resident 1 prefers to share rooms with residents that are bed-bound. During an interview on 3/19/2025 at 1:45 p.m., Licensed Vocational Nurse (LVN) 1 stated Resident 1 has had verbal aggressiveness towards others. LVN 1 stated Resident 1 should be in a room alone for the safety of the other residents. LVN 1 stated this was not the first time Resident 1 has had altercations with a roommate. A review of the facility's P&P titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," revised 4/2021, indicated "Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse..." The facility failed to: 1. Ensure Resident 1, who had a history of verbal aggressive behavior towards staff and residents, did not verbally abuse Resident 2 in accordance with P&P titled, "Abuse, Neglect, Exploitation, and Misappropriation Prevention Program." As a result, Resident 1 verbally abused Resident 2, which made Resident 2 feel unsafe and unprotected, and placed g Resident 1 and other residents at risk of ongoing verbal abuse from Resident 1. These violations had a direct or immediate relationship to the health, safety, or security of residents.