Health inspection·June 13, 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. On 5/2/2025, the California Department of Public Health (CDPH) made an unannounced visit to investigate a Facility-Reported Incident (FRI) regarding resident abuse. The facility failed to protect the Resident 1’s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) when on 4/19/2025, Resident 2 hit Resident 1’s face several times with a fist. As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 sustained hematoma (a change in skin color caused by bleeding under the skin) on the left dorsal (back side) hand, left eye and left nostril, and skin lacerations (deep cuts or tears in the skin) on the nasal septum (the thin wall that separates the right and left sides of the nose), left eye, left lower lip, and left lower chin requiring transfer to General Acute Care Hospital 1 (GACH 1) for further evaluation and suturing (the process of using stitches to close as wound). A review of Resident 1’s Admission Record indicated the facility admitted Resident 1 on 9/7/2023, with diagnoses that included cerebral infarction (often referred to as a stroke, death of brain tissue caused by a blockage or disruption of blood flow to the brain) with hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body) and hemiparesis (weakness or inability to move one side of the body), dementia (a progressive state of decline in mental abilities). A review of Resident 1’s Minimum Data Set (MDS - a resident assessment tool) dated 3/13/2025 indicated Resident 1 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS further indicated that Resident 1 was dependent on staff for toileting hygiene and lower body dressing, and required maximum assistance from staff for oral hygiene, upper body dressing, personal hygiene, and mobility. A review of Resident 1’s Situation- Background- Assessment- Recommendation (SBAR- a form that provides a framework for communication between members of the health care team about a resident’s condition) Communication Form dated 4/19/2025, timed at 6:00 p.m., indicated on 4/19/2025 Resident 1 was hit by his roommate (Resident 2) and as a result Resident 1 sustained facial cuts and a cut on his (Resident 1) nose. The SBAR further indicated Resident was observed with a bloody face. The SBAR indicated Resident 1’s physician was notified with a new order to transfer Resident 1 to a hospital for further evaluation and treatment. A review of Resident 1’s Physician Order dated 4/19/2025, timed at 11:30 p.m., indicated to transfer Resident 1 to GACH 1 for further evaluation due to cuts on the lip and nose. A review of Resident 1’s Discharge Skin and Body Assessment dated 4/19/2025 indicated the following skin conditions: 1. Skin cut on left eye area measuring 1.5 centimeters (cm) 2. Skin cut on nose area measuring 0.5 cm 3. Skin cut on left side of lip area measuring 0.5 cm 4. Skin cut on left lower chin area measuring 1.5 cm 5. Hematoma on Resident 1’s left dorsal hand A review of Resident 1’s Physician Order dated 4/20/2025, timed at 5:24 p.m., indicated to readmit the resident (Resident 1) to the facility. A review of Resident 1’s Skin Assessment dated 4/20/2025 (upon Resident 1’s return to the facility) indicated the following skin conditions: 1. Nasal Septum cut closed with two stitches, measuring 1.5 cm in length and zero cm in width. 2. Left eye cut closed with one stitch, measuring 0.6 cm in length and zero cm in width. 3. Left lower lip cut closed with four stitches, measuring two cm in length and zero cm in width 4. Left lower chin cut closed with two stitches, measuring one cm in length and zero cm in width 5. Left dorsal hand hematoma measuring two cm in length and two cm in width 6. Left eye hematoma measuring three cm in length and five cm in width 7. Left nostril hematoma measuring one cm in length and 0.5 cm in width 8. Left eye bruise with swelling A review of Resident 1’s Physician Orders dated 4/20/2025 indicated the following: 1. Nasal Septum cut with two stitches: Cleanse with normal saline (NS – a saltwater solution used to clean wounds). Pat dry and leave open to air every day shift for laceration for 14 days. 2. Left eye cut with one stitch: Cleanse with NS. Pat dry and leave open to air every day shift for laceration for 14 days. 3. Left lower lip cut with four stitches: Cleanse with NS. Pat dry and leave open to air every day shift for laceration for 14 days. 4. Left lower chin cut with two stitches: Cleanse with NS. Pat dry and leave open to air every day shift for laceration for 14 days. 5. Left dorsal hand hematoma: Monitor left dorsal hand hematoma for signs and symptoms (s/s) of skin breakdown every shift for 30 days. 6. Left eye hematoma: Monitor left eye hematoma for s/s of skin breakdown every shift for 30 days. 7. Left nostril hematoma: Monitor left nostril hematoma for s/s of skin breakdown every day shift for 30 days. A review of Resident 2’s Admission Record indicated the facility admitted Resident 2 on 4/24/2024 with diagnoses that included age-related cognitive decline (refers to the gradual decline in thinking abilities that can occur as people age) and alcohol dependence. A review of Resident 2’s MDS dated 1/29/2025 indicated Resident 2 had severely impaired cognition. The MDS further indicated that Resident 2 required moderate assistance from staff for personal hygiene and upper and lower body dressing, and supervision with toileting hygiene and mobility. A review of Resident 2’s SBAR dated 4/19/2025, timed at 6:00 p.m., indicated that on 4/19/2025, Resident 2 exhibited an aggressive behavior towards his (Resident 2’s) roommate and hit his (Resident 2’s) roommate (Resident 1) in the face causing skin cuts and bleeding from nose. A review of Resident 2’s Physician Order dated 4/19/2025, timed at 6:30 p.m., indicated to arrange Resident 2’s transfer to an inpatient psychiatric care due to sudden onset of aggressive behavior. A review of Resident 2’s Physician Order dated 4/20/2025, timed at 1:10 a.m., indicated to transfer Resident 2 to GACH 1 (same hospital where Resident 1 was transferred) instead for evaluation of sudden behavioral changes. During an interview on 5/2/2025 at 11:20 a.m. with Resident 1 and Admissions Coordinator 1 (AC 1), in Resident 1’s room, Resident 1 stated he does not remember the specific date but recalls his (Resident 1’s) former roommate (Resident 2) hit him (Resident 1) on the face (while pointing to Resident 1’s left eye, nose and left side of chin). Resident 1 stated that at the time of the incident, he (Resident 1) was calling the nurses to obtain assistance however Resident 2 did not like it and started hitting Resident 1 in the face several times with Resident 2’s fist. Resident 1 further stated he was very upset following the incident, during which Resident 1 was hit in the face multiple times by Resident 2 with a fist. Resident 1 stated he (Resident 1) could not express with the right words how he (Resident 1) feels but wanted to press charges against Resident 2. During an interview on 5/2/2025 at 4:42 p.m., with the Director of Nursing (DON), the DON stated that Resident 2 hitting Resident 1 in the face several times with a fist is physical abuse. The DON stated the incident on 4/19/2025 (involving Resident 1 and Resident 2) resulted in actual harm to Resident 1. During a phone interview on 5/5/2025 at 12:41 p.m., with Registered Nurse 2 (RN 2), RN 2 stated that he (RN 2) heard screaming and an agitated voice coming from the shared room of Resident 1 and Resident 2 while RN 2 was walking through the hallway. RN 2 stated he (RN 2) then entered the shared room of Resident 1 and Resident 2 and observed Resident 1 lying in his (Resident 1’s) bed with visible facial bleeding. RN 2 stated Resident 2 was unable to provide an explanation of the incident. A review of the facility’s policy and procedure (P&P) titled, “Abuse Prevention/Investigation/Reporting and Resolution”, last reviewed on 2/26/2025, indicated “This facility will protect the rights, safety and wellbeing of each resident (regardless of physical or mental condition), for whom we provide care and treatment against any and all forms of physical, verbal, mental abuse…………that are necessary to avoid physical harm, and to attain or maintain physical, mental, and psycho-social well-being of the residents.” The facility failed to protect the Resident 1’s right to be free from physical abuse when on 4/19/2025, Resident 2 hit Resident 1’s face several times with a fist. As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 sustained hematoma on the left dorsal hand, left eye and left nostril, and skin lacerations on the nasal septum, left eye, left lower lip, and left lower chin requiring transfer to GACH 1 for further evaluation and suturing. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.