Health inspection·October 23, 2025

§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. §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. §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 8/26/2025, the California Department of Public Health (CDPH) received a facility reported incident (FRI) alleging abuse involving Resident 1and on 8/27/2025 a complaint alleging abuse involving Resident 1. On 9/9/2025, CDPH made an unannounced visit to investigate the FRI and the complaint. During the investigation, CDPH determined on 8/25/2025 at 7:20 p.m. 1. Resident 2 took milk and miscellaneous papers from Resident 1's corner desk. 2. Resident 1 reacted to Resident 2 removing his belongings and made a fist and swung at Resident 2. 3. Resident 2 punched Resident 1 in the face. As a result Resident 1 sustained purple discoloration on the left side of his nose. The facility failed to: A.Ensure Resident 2's episodes of wandering and taking items that did not belong to him were addressed in a care plan. B. Implement the facility's policy and procedure titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program", revised April 2021 which indicated residents have the right to be free from abuse and ensure Resident 1 and Resident 2 were free from abuse. A. A review of Resident 1's Admission Record indicated Resident 1 a 71-year-old male was initially admitted to the facility on 8/16/2024 and readmitted on 8/31/2025 with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), Heart failure, and major depressive disorder (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). The Admission Record indicated Resident 1's brother was the responsible party (RP-decision maker). A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/7/2025, indicated Resident 3 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating, required moderate assistance for oral hygiene and upper body dressing, and was dependent for toileting hygiene, bathing, and lower body dressing. B. A review of Resident 2's Admission record indicated Resident 2 a 57-year-old male, was initially admitted to the facility on 8/8/2025 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior)- bipolar (sometimes called manic-depressive disorder- mood swings that range from the lows of depression to elevated periods of emotional highs) type, and depression A review of Resident 2's History and Physical, dated 7/21/2025, indicated Resident 2 did not have the capacity to understand and make decisions. A review of Resident 2's MDS, dated 8/15/2025, indicated Resident 2 had severe cognitive impairment, required setup assistance when eating, required supervision for toileting and bathing, and required moderate assistance for dressing and oral hygiene. A review of Resident 2's Nursing Progress Note, dated 8/25/2025 at 8:27 p.m., indicated Resident 2 touched and removed Resident 1's belongings (papers and carton of milk) without permission resulting in Resident 2's aggressive behavior against Resident 1. During an interview on 9/9/2025 at 2:08 p.m., Certified Nurse Assistant (CNA) 1 stated Resident 2 was a wanderer and would walk around and take other residents' belongings, food and hot chocolate off snack carts. CNA 1 stated Resident 2 would get aggressive if he was not given what he wanted. During an interview on 9/9/2025 at 2:57 p.m., the MDS coordinator (MDSC) stated there was no Change of Conditions (COC's) completed that indicated Resident 2 wandered. MDSC stated if there was a COC about resident 2's wandering, the COC would have prompted a care plan for the wandering and made staff aware of this behavior. During an interview on 9/10/2025 at 2:19 p.m., the Social Services Director (SSD) stated Resident 2 liked to eat a lot and foraged for food and snacks a lot. The SSD stated because of Resident 2 grabbed the milk from Resident 1. During a concurrent observation and interview on 9/10/2025 at 2:51 p.m., with Resident 1, Resident 1 had purple discoloration on the left side of his nose. Resident 1 stated Resident 2 was known to walk around and grab waters, juices, and other items off of trays and snack carts. Resident 1 stated the staff knew about Resident 2's behavior. Resident 1 stated on 8/25/2025, Resident 2 grabbed his belongings from his table. Resident 1 stated he was so upset, he clenched his fist, waited for Resident 2 to walk back towards him, and attempted to punch Resident 2. During a review of the facilities P&P, titled Care Plans, Comprehensive Person-Centered, revised March 2022 the P&P indicated care plans are revised as information about the residents and the resident's conditions change. The P&P indicated the interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition. During a review of the facility's P&P, titled Safety and Supervision of Residents, revised July 2017 the P&P indicated the interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The P&P indicated the facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. The P&P indicated risk factors and environmental hazards include unsafe wandering. During a review of the facility's policy and procedure (P&P), titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, the P&P indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The P&P indicated the resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including other residents. The facility failed to: A. Ensure Resident 2's episodes of wandering and taking items that did not belong to him were addressed in a care plan. B. Implement the facility's policy and procedure titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program", revised April 2021 which indicated residents have the right to be free from abuse and ensure Resident 1 and Resident 2 were free from abuse. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.