Health inspection·October 10, 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. §483.12(a) The facility must— §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual’s obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. §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. California Code of Regulations, Title 22, 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. California Code of Regulations, Title 22, Section 72527 Patient’s 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. (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. California Code of Regulations, Title 22, Section 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. H&S § 1418.91 (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 8/28/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) regarding employee-to-resident verbal abuse (the use of harmful words or language to control, intimidate, threaten, humiliate or cause mental anguish [a state of severe emotional distress and suffering] to a resident). The facility failed to protect Resident 1’s right to be free from verbal abuse and failed to report an allegation of verbal abuse within two hours to the State Survey Agency (SSA) when on 8/23/2025 at around 6:30 a.m., Certified Nursing Assistant 1 (CNA 1) made an inappropriate gesture (“flipped off” [describes the act of extending the middle finger as a rude and offensive gesture to express anger, contempt, or annoyance toward someone, particularly in a non-verbal way]) by raising the middle fingers of both hands towards Resident 1, yelled obscenities (words or expressions that are offensive), and called Resident 1 a derogatory and racial insult (language that is intended to demean, belittle or harm someone based on their race or ethnicity). The facility reported the verbal abuse incident to the SSA on 8/26/2025, three days after the incident. As a result, Resident 1 was subjected to verbal abuse by CNA 1 while under the care of the facility and there was a delay for an onsite inspection by CDPH to ensure the safety of Resident 1 and other residents which had the potential to result in unidentified abuse. This delay placed Resident 1 at increased risk for further distress, including emotional pain and additional trauma related to the allegation of verbal abuse. A review of Resident 1’s Admission Record indicated the facility admitted Resident 1, a 53-year-old male, on 12/27/2023 with diagnoses including type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), polyneuropathy (nerve damage), hypertension (high blood pressure), and muscle weakness.   A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 7/3/2025, indicated Resident 1’s cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. The MDS indicated Resident 1 required substantial to maximal assistance (helper does more than half the effort) from staff with showering, toileting, and lower body dressing.   A review of Resident 1’s Care Plan, dated 8/27/2025, indicated that Resident 1 had a potential psychosocial (relating to the interrelation of social factors and individual thought and behavior) well-being problem due to a verbal incident with a staff member (CNA 1).   A review of Resident 1's Progress Notes, dated 8/28/2025, indicated that on 8/23/2025, at around 5 p.m., Resident 1 reported to the Staff Developer (DSD) and the Administrator (ADMIN) that on 8/23/2025, at around 6:30 a.m., CNA 1 called him (Resident 1) a derogatory and racial insult.   A review of Resident 2’s Admission Record indicated the facility admitted Resident 2, a 66-year-old male, on 1/15/2025 with diagnoses including history of falling, acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), and hypertension.   A review of Resident 2’s MDS, dated 7/3/2025, indicated Resident 2’s cognition was intact. The MDS indicated Resident 2 required substantial to maximal assistance from staff with showering, toileting, and lower body dressing.   During an interview on 8/28/2025 at 10:10 a.m., with Resident 1, Resident 1 stated that on 8/23/2025, at around 6:30 a.m., Resident 1 pressed the call light because he (Resident 1) wanted to be changed. Resident 1 stated CNA 1 answered his (Resident 1) call light, and he (Resident 1) told CNA 1 he wanted a different CNA to change him (Resident 1). Resident 1 stated CNA 1 made an inappropriate gesture (“flipped off”) at him (Resident 1) by raising the middle fingers of both hands towards him (Resident 1). Resident 1 stated CNA 1 called him (Resident 1) a derogatory and racial insult. Resident 1 stated CNA 1 continued to yell obscenities at him (Resident 1). Resident 1 stated that he (Resident 1) called Registered Nurse Supervisor 1 (RN 1) from his (Resident 1) cell phone to come to his (Resident 1) room for assistance. Resident 1 stated he (Resident 1) told RN 1 that CNA 1 was yelling obscenities at him (Resident 1).   During an interview on 8/28/2025 at 12:10 p.m., with Resident 2, Resident 2 stated that on 8/23/2025 at 6:30 a.m., his roommate (Resident 1) pressed the call light and CNA 1 came inside the room to answer the call light. Resident 2 stated he (Resident 2) heard Resident 1 tell CNA 1 that Resident 1 wanted a different CNA to change Resident 1. Resident 2 stated he (Resident 2) heard CNA 1 yell out obscenities and a derogatory and racial insult at Resident 1. Resident 2 stated CNA 1 should have walked away and called RN 1, instead of staying in the room and yelling out obscenities at Resident 1.     During an interview on 8/28/2025 at 12:30 p.m., with RN 1, RN 1 stated that on 8/23/2025 at 6:30 a.m., Resident 1 called her (RN 1) because he (Resident 1) did not want CNA 1 to change him (Resident 1). RN 1 stated that Resident 1 reported to her (RN 1) that CNA 1 called him (Resident 1) a derogatory and racial insult. RN 1 stated that she (RN 1) did not report this verbal abuse allegation to anyone because she (RN 1) did not think anything of it. RN 1 stated she (RN 1) then realized on 8/23/2025, when she went home, that the incident was verbal abuse and that she (RN 1) should have reported the verbal abuse allegation to the abuse coordinator (referring to ADMIN) within two hours.   During an interview on 8/28/2025 at 3:30 p.m., with the ADMIN and the Director of Nurses (DON), the ADMIN stated that on 8/26/2025, at around 5:00 p.m., Resident 1 reported to her (ADMIN) and the DSD that on 8/23/2025 at 6:30 a.m., CNA 1 responded to his (Resident 1) call light and he (Resident 1) requested a different CNA. The ADMIN stated Resident 1 reported that CNA 1 yelled a derogatory and racial insult at him (Resident 1). The ADMIN stated that she (ADMIN) was not aware that Resident 1 had reported the incident to RN 1 on 8/23/2025, after the incident occurred. The ADMIN and the DON stated that the facility has zero tolerance for any form of abuse and that RN 1 should have reported the incident immediately. The ADMIN stated the facility reported the incident to the State Survey Agency (SSA) on 8/26/2025.   A review of the facility’s policy and procedure (P&P) titled, “Abuse, Neglect, Exploitation, and Misappropriation Prevention Program,” dated 4/2021, indicated residents have the right to be free from abuse. This includes but is not limited to verbal abuse. A review of the facility’s P&P titled, “Abuse Investigation and Reporting,” last revised on 7/2017, indicated, “All reports of resident abuse … shall be promptly reported to local, state and federal agencies (as defined by current regulations) …. Reporting 1. All alleged violations involving abuse … will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/\certification agency responsible for surveying/licensing the facility …. 2. An alleged violation of abuse … will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse….” The facility failed to protect Resident 1’s right to be free from verbal abuse and failed to report an allegation of verbal abuse within two hours to the SSA when on 8/23/2025 at around 6:30 a.m., CNA 1 made an inappropriate gesture by raising the middle fingers of both hands towards Resident 1, yelled obscenities and called Resident 1 a derogatory and racial insult. The facility reported the verbal abuse incident to the SSA on 8/26/2025, three days after the incident. As a result, Resident 1 was subjected to verbal abuse by CNA 1 while under the care of the facility and there was a delay for an onsite inspection by CDPH to ensure the safety of Resident 1 and other residents which had the potential to result in unidentified abuse. This delay placed Resident 1 at increased risk for further distress, including emotional pain and additional trauma related to the allegation of verbal abuse. The above violations had a direct or immediate relationship to the health, safety, or security of Resident 1.