Health inspection·October 24, 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; 22 CCR § 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. 22 CCR § 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. 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 9/15/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) regarding a resident-to-resident altercation. The facility failed to protect Resident 1's right to be free from physical abuse (willful infliction of injury and willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm) when on 8/29/2025 at approximately 4:15 p.m., while Resident 1 and Resident 2 were both in Room A (Resident 1 and Resident 2's shared room), Resident 2, using his (Resident 2) "three fingers" (did not specify which hand), pushed Resident 1's back, between the shoulder blades (a large, triangular-shaped bone located on the back of the upper rib cage, one on each side of the body). As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 fell on the floor in a semi-sitting position (a partially upright body position) leaning on his (Resident 1) right side. a. A review of Resident 1's Admission Record indicated the facility admitted Resident 1, a 67-year-old male, on 2/28/2025 with diagnoses including schizoaffective disorder bipolar type (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder (mental health illness causing a persistent feeling of sadness, loss of interest, and can interfere with daily life), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). A review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 2/20/2025, 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 5/27/2025, indicated Resident 1 had moderately impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) from the facility staff with toileting hygiene, showers, and lower body dressing. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching assistance) with toilet transfer, chair to bed transfers, and walking 150 feet (ft-unit of measurement). A review of Resident 1's Care Plan, initiated on 5/5/2025, indicated Resident 1 was at risk for falls due to requiring assistance with activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily) care, use of psychotropic medication, preferring to use his wheelchair as assistive device during ambulation. A review of Resident 1's Care Plan, initiated on 8/29/2025, indicated Resident 1 was pushed by roommate (Resident 2) and landed on his (Resident 1) right side. The Care Plan indicated Resident 1 was at risk for physical injury, pain, and emotional distress. b. A review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 9/12/2024 with diagnoses including type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder, chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing). A review of Resident 2's H&P, dated 1/13/2025, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's MDS, dated 8/15/2025, indicated Resident 2's cognitive functioning was intact. The MDS indicated Resident 2 required moderate assistance from the facility staff with showers and lower body dressing. The MDS indicated Resident 2 was independent with ambulating 50 ft and required supervision with ambulating 150 ft. A review of Resident 2's Care Plan (not titled), initiated on 8/27/2024, indicated Resident 2 had a history of behavioral and emotional challenges such as verbal disagreements with his (Resident 2) roommate (name not indicated). A review of Resident 2's Care Plan (not titled), initiated on 8/29/2025, indicated Resident 2 was involved in a physical altercation (confrontation or argument that escalates to physical aggression, involving physical force or contact between individuals) with another resident (Resident 1), resulting in the resident (Resident 1) being pushed and found on the floor. A review of Resident 2's change of condition (COC - when there is a sudden significant change in a resident's health status) form, dated 8/29/2025, indicated on 8/29/2025 (time not indicated), Resident 2 had an episode of physical altercation with another resident (Resident 1). The COC form indicated that Resident 2 admitted to pushing another resident (Resident 1) that resulted in the other resident (Resident 1) to be found sitting down on the floor on his (Resident 1) right side. c. A review of Resident 3's Admission Record, indicated the facility originally admitted Resident 3 on 1/18/2025 and readmitted on 3/2/2025 with diagnoses including type 2 DM, muscle weakness, and personal history of other (healed) physical injury and trauma. A review of Resident 3's MDS, dated 7/25/2025, indicated Resident 3's cognitive functioning was intact. The MDS indicated Resident 3 was independent and was using a wheelchair. During an interview on 9/15/2025, at 10:40 a.m. with Resident 3, Resident 3 stated on the day of the incident between Resident 1 and Resident 2 (Resident 3 could not recall the exact date but stated it was during the afternoon), Resident 3 was resting in bed in Room B (Resident 3's room that is in front of Room A), when he (Resident 3) heard Resident 2 screamed saying that he (Resident 2) had told him (Resident 1) not to make a mess. Resident 3 stated he (Resident 3) could not recall if Resident 1 replied to Resident 2. Approximately two to three minutes after he (Resident 3) heard Resident 2's voice, he (Resident 3) heard a loud noise. He (Resident 3) immediately went outside (in a wheelchair) into the hallway in front of Room A and saw Resident 1 lying on the floor, on the side of Resident 1's bed facing the window. Resident 1's legs were visible on the floor from the hallway. Resident 3 stated Resident 2 was standing in the middle of the room. Resident 2 came out of the room and told Resident 3 that he (Resident 2) pushed Resident 1 to the floor and that he (Resident 2) was worried that he (Resident 2) would get in trouble. During an interview on 9/15/2025 at 11:09 a.m. with Resident 2, Resident 2 stated that on 8/29/2025, at approximately 4:15 p.m., he (Resident 2) pushed Resident 1's back with his "three fingers" (did not indicate which hand) and Resident 1 fell and sat on the floor. Resident 2 stated that Resident 1 had a bowel movement on his (Resident 1) bed and told Resident 2 that he (Resident 1) would defecate on Resident 2's bed as well. Resident 1 was walking towards Resident 2's bed when he (Resident 2) approached and pushed Resident 1's back between his (Resident 1) shoulder blades. During a concurrent interview and record review on 9/15/2025 at 12:17 p.m. with the Acting Director of Nursing (DON), Resident 1's COC form, initiated on 8/29/2025, at 16:20 p.m., was reviewed. The COC form indicated that on 8/29/2025 (time not indicated) Resident 1's roommate (Resident 2) pushed Resident 1 and Resident 1 fell on his (Resident 1) right side. The Acting DON stated that on 8/29/2025, at approximately 4:30 p.m., the Director of Staff Development asked her (Acting DON) to go to Room A. The Acting DON stated she (Acting DON) immediately went to Room A and saw Resident 1 on the floor next to Resident 1's bed. Resident 2 admitted to pushing Resident 1 because he (Resident 2) was bothered by the smell of Resident 1's bowel movement. During an interview on 9/15/2025 at 1:47 p.m. with the Acting DON, the Acting DON stated that the facility failed to keep Resident 1 free from physical abuse. The incident of physical altercation on 8/29/2025 between Resident 1 and Resident 2 was an incident of physical abuse and had the potential for Resident 1 to sustain fractures, contusion (an injury that occurs when tissue is damaged by a blunt force causing bleeding under the skin and discoloration), and negatively affect Resident 1's emotional well-being. During an interview on 9/15/2025 at 1:55 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 8/29/2025, at approximately 4: 10 p.m., Resident 2 approached him (LVN 1) and informed that Resident 1 had a bowel movement and needed assistance. Approximately two to three minutes after (approximately 4:15 p.m.) talking to Resident 2, he (LVN 1) went to Room A and found Resident 1 on the floor near the foot of Resident 1's bed, leaning towards his (Resident 1) right side, in a semi-sitting position. LVN 1 stated that he immediately got in between Resident 1 and Resident 2 since Resident 2 was standing too close to Resident 1. Resident 2 said that he (Resident 2) pushed Resident 1. The incident of Resident 2 pushing Resident 1 on 8/29/2025 was an incident of physical abuse and had the potential for Resident 1 to sustain injuries such as fractures, head injury, and bleeding. During an interview on 9/15/2025 at 2:26 p.m. with Registered Nurse (RN) 1, RN 1 stated that on 8/29/2025 she (RN 1) was informed by LVN 1 that Resident 2 pushed Resident 1. She (RN 1) could not recall the exact time of the incident but when she (RN 1) entered Room A, Resident 1 was on the floor next to Resident 1's bed, lying towards his (Resident 1) right hip. RN 1 stated Resident 2 told her (RN 1) that he (Resident 2) pushed Resident 1. RN 1 stated that the incident of Resident 2 pushing Resident 1 on 8/29/2025 was an incident of physical abuse and had the potential for Resident 1 to sustain injuries, such as fractures. A record review of the facility-provided policy and procedure titled, "Abuse Prevention and Reporting Policy," last reviewed on 4/2025, indicated, "It is the policy of this facility to maintain a zero tolerance for abuse .... All residents have the right to be free from abuse and mistreatment.... Purpose - Ensure residents are protected from all forms of abuse (physical ...).... Definitions - Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment causing physical harm, pain, or mental anguish." The facility failed to protect Resident 1's right to be free from physical abuse when on 8/29/2025 at approximately 4:15 p.m., while Resident 1 and Resident 2 were both in Room A, Resident 2, using his (Resident 2) "three fingers", pushed Resident 1's back, between the shoulder blades. As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 fell on the floor in a semi-sitting position leaning on his (Resident 1) right side. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.