Health inspection·May 6, 2025

F600 §483.12 Freedom from Abuse, Neglect, and Exploitation The patient has the right to be free from abuse, neglect, misappropriation of patient 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 patient’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.

F609 §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. On 3/28/2025 at 8:50AM, an unannounced visit was made by the California Department of Public Health (CDPH) to the facility to investigate a facility reported incident regarding Abuse, Neglect, and Exploitation. The facility failed to ensure one of three sampled residents (Residents 1) were free from physical abuse by Certified Nurse Assistant (CNA) 1 by failing to:    1. Protect Resident 1 when Responsible Party (RP) 1 observed CNA 1 being rough during Resident 1’s peri care (also known as perineal care, refers to the cleaning and maintenance of the genital and anal areas), on 3/14/2025 and informed CNA 1 to be gentler. RP 1 reported to the facility’s Infection Preventionist (IP) Nurse witnessing CNA 1 was rough during Resident 1’s peri care and complained of vaginal pain on 3/14/2025.  2. Protect Resident 1 from further abuse by CNA 1 when IP Nurse and Licensed Vocational Nurse (LVN) 1 allowed CNA 1 to continue caring for Resident 1 on 3/14/2025 and the next day, 3/15/2025. On 3/15/2025, RP 1 found Resident 1 in distress as reported by Resident 1’s roommate (Resident 2), who witnessed Resident 1 screaming, in distress and verbalized pain, while CNA 1 performed peri care towards Resident 1. CNA 1 continued to ignore Resident 1's screams and verbalization of pain on 3/15/2025 during peri care.  3. Report the allegation of physical abuse to California Department of Public Health (CDPH), the Ombudsman, and Law Enforcement within two (2) hours of an allegation of abuse by Certified Nurse Assistant (CNA) 1 towards Resident 1 when Responsible Party (RP) 1 observed CNA 1 being rough during Resident 1’s peri care (also known as perineal care, refers to the cleaning and maintenance of the genital and anal areas), on 3/14/2025 and informed CNA 1 to be gentler. RP 1 reported to the facility’s Infection Preventionist (IP) Nurse around 11:00 AM witnessing CNA 1 was rough during Resident 1’s peri care and complained of vaginal pain on 3/14/2025.   4. Suspend the CNA on 3/14/2025 in accordance with the facility's P&P. CNA 1 was assigned back to Resident 1 on 3/15/2025 after allegation of abuse was reported by RP 1 to IP nurse on 3/14/2025.  5. Investigate the allegation of abuse when RP 1 reported the incident to the IP Nurse on 3/14/2025.    These failures resulted in Resident 1’s rights violated when Resident 1 screamed and cried in tears and verbalized pain in the vaginal area during peri care and feeling scared towards CNA 1. Resident 2 verbalized being scared and uncomfortable on 3/15/2025. These failures also resulted in facility staff under reporting all allegations of abuse and delaying the investigation and placing Resident 1 at risk for further abuse.   Findings:  During a review of Resident 1’s Admission Records (AR), the AR indicated Resident 1 was an 87 year old female, admitted to the facility on 3/13/2025 with diagnoses that included traumatic subdural hemorrhage (a collection of blood between the brain and its outer covering due to a head injury, leading to a temporary or prolonged loss of awareness), Type 2 Diabetes( high blood sugar), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1’s “History and Physical” (H&P, a comprehensive physician’s note regarding the assessment of the resident’s health status), dated 3/13/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1’s “Minimum Data Set” (MDS, a federally mandated resident assessment tool), dated 3/20/2025, the MDS indicated the resident was severely impaired in cognition (problems with a person’s ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) with rolling to left and right, sit to lying, toilet transfer, tub/shower transfer. 2. During a review of Resident 2’s AR, the AR indicated Resident 1 was a 96-year-old female, admitted to the facility on 3/6/2025 with diagnoses that included joint replacement surgery (a surgical procedure that replaces a damaged joint with an artificial implant), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). During a review of Resident 2’s MDS dated 3/15/2025, the MDS indicated the resident cognition is intact. During a review of Resident 2’s “History and Physical” (H&P, a comprehensive physician’s note regarding the assessment of the resident’s health status), dated 3/7/2025, indicated Resident 1 is alert oriented, thought process, thought content without any abnormal thoughts, delusions, or hallucinations, normal cognition including orientation, attention, and memory, normal insight and judgment. During review of facility document titled “Nursing Staffing Assignment and Sign in Sheet” dated 3/14/2025 indicated CNA 1 was assigned to care for Resident 1 from 7 AM to 3 PM. During review of facility document titled “Nursing Staffing Assignment and Sign in Sheet” dated 3/15/2025 indicated CNA 1 was assigned to care for Resident 1 from 7 AM to 3 PM. During review of facility document titled “Transition Verification Report” dated 3/15/2025 and timed 8:06 PM, the document indicated 9 pages was faxed and indicates a result as “ok”.  During your review of the CDPD faxed document, which was received from facility on 3/15/2025 and timed at 8:07 PM, it was noted that the document contained 9 pages.  During review of a facility document titled “Alleged abuse” dated 3/15/2025 timed at 4 PM, the document indicated the Director of Nurses (DON) spoke to [RP 1] who “claimed” she saw [CNA 1] performing peri care with Resident 1. The document indicated [RP 1] “claimed” that [CNA 1] wiped Resident 1 with the washcloth repeatedly in a rough manner. The document indicated [RP 1] “claimed” she told [CNA 1] to be gentle, but “[CNA 1] ordered her [RP 1] out of the room, closed the curtain and continued with the care.” The document indicated [RP 1] “claimed” [CNA 1] later came out of Resident 1’s room with the dirty briefs. The document indicated [RP 1] stated she did not like how CNA 1 responded so RP 1 called the police. During a review of Resident 1’s Care Plan (CP) dated 3/13/2025, the CP indicated Resident 1’s “ADL (activities of daily living) function rehabilitation potential altered manifested by requires cues, reminders, and supervision ADL assistance needed: personal hygiene, toileting, bathing.” The interventions included, “Do not rush resident, allow enough time to complete task at own pace, explain all necessary procedure prior to rendering care and treatment plan.” During a review of Resident 1’s Care Plan (CP) dated 3/15/2025, the CP indicated Resident 1 was “At risk for psychosocial distress (a set of painful mental and physical symptoms that are associated with normal fluctuations of mood in most people) related to allegations by [RP 1] that staff [CNA1] was rough during care” with interventions that included, “Change caregiver to ensure immediate safety, monitor for psychosocial distress manifested by tearfulness, fearfulness related allegation of roughness.” During a review of the “Police Report” dated 3/15/2025 timed at 5:48 PM, the Report indicated on Saturday, 3/15/2025 at approximately 6 PM, Police Officer responded at the facility regarding an abuse investigation concerning Resident 1. The Report indicated Resident 1 speaks a foreign language. On Friday 03/14/2025 at approximately 9 AM, [RP 1] visited Resident 1 at the facility. [RP 1] entered the room and noticed [Resident 1] was in distress and grasping for air attempting to say something. Resident 1 was in pain, stressed out, and agitated. [Resident 1] said CNA 1 was mistreating her. [RP 1] added that she witnessed CNA 1 “aggressively" grabbed her [Resident 1] by the arm, attempting to move her on her side to clean the resident’s vaginal area. [RP 1] stated [Resident 1] was recovering from a dislocated shoulder and had fragile muscle. [RP 1] stated [CNA 1] was rough when cleaning [Resident 1] and ultimately causing pain. [RP 1] stated [CNA 1] showed no interest in treating [Resident 1] in a fair manner. [RP 1] asked [CNA 1] about what was going on, when [CNA 1] quickly closed the curtains on [RP 1]. [RP 1] reported the incident. The next day, Saturday 3/15/2025 at approximately 9 AM, [RP 1] went back to the facility. [CNA 1] was in the room changing [Resident 1] before she arrived. When [RP 1] arrived, she observed Resident 1 in distress again about to cry and took RP 1 some time to calm Resident 1 down. Resident 2 (Resident 1’s roommate) stated she heard Resident 1 screaming in pain before [RP 1] had arrived. [Resident 2] stated [CNA 1] continued to ignore [Resident 1] screams, closed the curtain and walked out of the room. During a review of an electronic (e-mail) mail sent by the DON on 3/28/2025 timed at 5:03 PM, the e-mail indicated the DON had just completed Resident 1’s roommate’s interview with the help of a translator and would need to further investigate. The e-mail indicated the DON called CNA 1 and placed CNA 1 on administrative leave (a temporary, paid or unpaid, suspension of an employee's duties, typically initiated by an employer for specific reasons) pending further investigation. During an interview on 3/28/2025 at 9:40 AM with Resident 1, Resident 1 stated, CNA 1 hurt her many times. Resident 1 stated CNA 1 “hold her body very hard and rough, and clean her vaginal area very rough.” Resident 1 nodded her head and stated “Yes” in Resident 1’s primary language, when asked if she was scared with CNA 1. During an interview on 3/28/2025 at 9:50 AM with RP 1, RP 1 stated that on 3/14/2025, on a Friday at around 9 AM, RP 1 came to the facility to visit Resident 1. RP 1 stated when she entered Resident 1’s room, the privacy curtains were pulled back. RP 1 stated she heard Resident 1 moaning, so RP 1 opened the privacy curtain and saw CNA 1 was cleaning Resident 1. RP 1 stated CNA 1 asked her to get out and close the curtain, so RP 1 introduced herself and informed CNA 1 that she is Resident 1’s responsible party. RP 1 stated CNA 1 did not listen to her and still informed RP 1 to close the curtain and get out. RP 1 stated she closed back the privacy curtain but stayed inside the room. RP 1 stated that after a few minutes, RP 1 heard Resident 1 saying in her primary language “You hurting me, it hurts.” RP 1 stated she opened the privacy curtain and asked CNA 1 to be gentle, but CNA 1 continued wiping Resident 1’s peri area with the towel (wash cloth) repeatedly in a rough manner. RP 1 stated CNA 1 did not stop even after RP 1 had approached her. RP 1 stated that when CNA 1 finished Resident 1’s peri care, CNA 1 just left the room with no explanation. During the same interview on 3/28/2025 at 9:50 AM, RP 1 stated that on that same day (3/14/2025) at around 11 AM, the Infection Preventionist (IP) nurse came in and RP 1 reported witnessing CNA 1 was rough during Resident 1’s peri care and Resident 1 complained that her vagina hurts. RP 1 stated that IP nurse informed her that she would inform Licensed Vocational Nurse (LVN) 1. RP 1 stated that CNA 1 continued to be assigned to Resident 1 on 3/14/2025 until the end of the AM shift, up to the afternoon (7 AM to 3 PM). RP 1 stated CNA 1 was still the assigned CNA who assisted Resident 1 with incontinence care (refers to cleaning and drying of the perineal area after involuntary leakage of urine) in the afternoon. During the same interview on 3/28/2025 at 9:50 AM, RP 1 stated the next day, 3/15/2025, RP 1 stated she came back to the facility to visit Resident 1 at around 9 AM. RP 1 stated she found Resident 1 in tears, crying, and gasping for words. RP 1 stated Resident 1 informed RP 1 that CNA 1 was very rough during peri care and turned her from side to side forcefully. RP