Health inspection·April 1, 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. The facility must- (a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 22CCR §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. 22CCR §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. On 2/19/2025, the California Department of Public Health (CDPH) received a Facility Reported Incident indicating Certified Nursing Assistant (CNA) 1 verbally abused Resident 1 by yelling and cursing at the resident. On 2/26/2025, the CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: 1. Ensure Resident 1 was free from verbal abuse (verbal violence) when CNA 1 yelled and cursed at the resident. As a result, Resident 1 felt upset and had the potential to feel guarded (cautious with emotions), unsafe, and experience psychosocial (mental, emotional, and social) harm. a). Resident 1 was a 63- year- old male, originally admitted to the facility on 4/28/2023 and readmitted on 7/17/2023. Resident 1's diagnoses included partial amputation of the right foot (involves surgically removing part of the foot), functional quadriplegia (inability to move due a physical disability), and diabetes mellitus ([DM] -a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1's "History and Physical (H&P)," dated 7/19/2024, 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 2/1/2025, indicated Resident 1's cognition (ability to learn, reason, remember, understand, and make decisions) was intact. The MDS indicated Resident 1's verbal behavioral symptoms directed toward others were not exhibited. The MDS indicated Resident 1 required supervision for dressing and personal hygiene. A review of Resident 1's progress notes, dated 2/19/2025, indicated resident had a verbal disagreement with his caregiver (CNA1) regarding the placement of the Resident 2's wheelchair. The progress notes indicated resident expressed loudly that the wheelchair obstructs his passage on the way out of the room. The progress notes indicated CNA1 loudly expressed the necessity of moving it to feed Resident 2. A review of Resident 1's Change of Condition (COC) dated 2/19/2025, indicated Resident 1 had a verbal disagreement with CNA1 regarding the placement of Resident 2's wheelchair. The COC indicated the resident expressed that the wheelchair obstructs his passage to get out of the room. The COC indicated a disagreement escalated where CNA1's voice started to get louder and louder, and CNA 1 yelled at Resident 1. A review of CNA 1's Performance Correction Notice, dated 2/21/2025, indicated the CNA 1 commented, "I am also a human being. I don't allow anyone to disrespect me." The Performance Correction Notice indicated on 2/19/2025, CNA 1 was verbally aggressive and disrespectful towards a resident. The Performance Correction Notice indicated it was a direct violation of resident rights, the company's code of conduct, was unacceptable and grounds for immediate termination. During an interview on 2/26/2025 at 11:25 a.m., with Resident 1, Resident 1 stated on 2/19/2025, Resident 2's wheelchair was blocking the bathroom door, and he (Resident 1) was not able to exit the bathroom. Resident 1 stated as he was trying to exit out of the bathroom, CNA 1 began raising her voice at him stating she will leave the wheelchair at the bathroom door. Resident 1 stated he felt "a bit upset". During an interview on 2/26/2025 at 12:33 p.m., with Licensed Vocation Nurse (LVN) 1, LVN 1 stated on 2/19/2025 around 8:00 a.m., he heard CNA 1 yelling at Resident 1 about the placement of Resident 2's wheelchair. LVN 1 stated, CNA 1 should have explained to the resident why she needed to move the wheelchair without yelling. LVN 1 stated when staff yell at residents, it was considered verbal abuse, and it could make a resident feel guarded and unsafe. During an interview on 2/26/2025 at 1:56 p.m., with Registered Nurse (RN) 1, RN 1 stated on 2/19/2025 (time not specified), CNA 1 yelled at Resident 1, "You're not the only one in this room!" RN 1 stated the CNA 1 was being verbally abusive and should have left and reported to the charge nurse about the issue. During an interview on 2/26/2025 at 2:23 p.m., with Assistant Director of Nursing (ADON), the ADON stated CNA 1 had yelled at Resident 1, "You're not the only one in here!" The ADON stated CNA 1 should have listened to the needs of resident by moving the wheelchair out of his way. The ADON stated CNA 1 yelling at Resident 1 could affect him psychosocially. During an interview on 3/12/2025 at 3:00 p.m., with Administrator (ADM), the ADM stated on 2/19/2025 around 8:30 a.m., the staff (unidentified) had witnessed CNA 1 in Resident 1's room screaming and yelling at Resident 1. The ADM stated the CNA 1 had used the "F word," while screaming at Resident 1. The ADM stated CNA 1 was suspended on 2/19/2025 and was later terminated on 2/21/2025 because of her conduct. The ADM stated the residents should not be yelled and cursed at. The ADM stated the primary goal of the facility was for the residents to feel safe. b). Resident 2 was a 76-year-old male initially admitted to the facility on 2/22/2016 and readmitted on 1/3/2025. Resident 2's diagnoses included paraplegia (loss of movement and/or sensation, to some degree, of the legs), heart failure (a condition where the heart doesn't pump blood well), and DM. A review of Resident 2's "H&P," dated 1/6/2025, indicated, Resident 2 had the capacity to understand and make decisions. A review of Resident 2's MDS, dated 1/19/2025, indicated Resident 2's cognition was normally intact. During an interview on 2/26/2025 at 12:26 p.m., with Resident 2, Resident 2 stated on 2/19/2025, CNA 1 was upset about his (Resident 2) wheelchair being in her (CAN 1) way. Resident 2 stated CNA 1 moved the wheelchair in front of the bathroom door. Resident 2 stated he tried to explain to CNA 1 that Resident 1 was in the bathroom. Resident 2 stated CNA 1 was loud and yelled at Resident 1 about how the wheelchair was going to stay in front of the bathroom door. A review of facility policy and procedure (P&P) titled, "Abuse & Mistreatment of Residents," undated, indicated the facility will uphold (support) resident's right to be free from verbal abuse. The P&P indicated verbal abuse was any use of oral, written, or gestured language that willfully included disparaging (belittle) and derogatory (disrespectful) terms to residents with the hearing distance, regardless of their age, ability to comprehend, or disability. The facility failed to: 1. Ensure Resident 1 was free from verbal abuse when CNA 1 yelled and cursed at the resident. As a result, Resident 1 felt upset and had the potential to feel guarded, unsafe and cause psychosocial harm. This violation(s) caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to the resident.