Health inspection·March 25, 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; 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 2/7/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility-reported-incident regarding staff-to-resident altercation. The facility failed to protect Resident 1's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) when on 1/29/2025 at 10:55 a.m., Student Nurse 1 (SN 1) and Student Nurse 2 (SN 2) witnessed Certified Nurse Assistant 1 (CNA 1) hit Resident 1 in the back of the head three times with an open hand (did not indicate which hand). As a result, Resident 1 was subjected to physical abuse by CNA 1 while under the care of the facility. Resident 1 stated he (Resident 1) felt humiliated (ashamed), sad, and complained of pain to the back of the head. A review of Resident 1's Admission Record indicated the facility admitted Resident 1, an 85-year-old male, on 11/16/2023, with diagnoses that included hemiplegia (paralysis [inability to move] that affects only one side of the body) and hemiparesis (muscle weakness that affects one side of the body) following a cerebral infarction (a condition where blood flow to the brain is interrupted causing brain tissue to die) affecting right dominant side, difficulty walking, heart failure (when the heart does not pump blood as well as it should), and history of falling. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/5/2024, indicated Resident 1 had moderate impairment of cognition (ability to think and make decisions). The MDS indicated Resident 1 required moderate assistance with activities of daily living (ADL - routine tasks and or activities such as bathing, dressing, and toileting a person performs daily to care for themselves). A review of Resident 1's document titled, "Interact Change in Condition (COC - when there is a sudden change in a resident's health condition or behavior) Evaluation," dated 1/29/2025, indicated that on 1/29/2025 at 10:55 a.m., SN 1 and SN 2 reported seeing CNA 1 in Resident 1's room, hitting the “top” of Resident 1's head three times. The COC further indicated that CNA 1 was immediately removed and a head-to-toe assessment (a comprehensive medical examination where a healthcare professional checks a resident's entire body from the top of their head to the tips of their toes, systematically evaluating each body system to assess their overall health and identify any potential problems) on Resident 1 was completed with no skin issues noted. The COC indicated that Resident 1 was interviewed and reported in Spanish that CNA 1 hit him (Resident 1) in the head three times. A review of CNA 1's Employee Counseling and or Disciplinary Notice, dated 1/29/2025, indicated CNA 1 was witnessed hitting Resident 1’s head. A review of Resident 1's Psychiatric Evaluation follow-up note dated 2/3/2025 indicated that Resident 1 was seen for a follow-up visit after Resident 1 reported an incident (abuse) to facility staff. The note indicated Resident 1 alleges that a nurse (referring to CNA 1) "tapped" Resident 1 on the back of Resident 1's head. During an interview on 2/7/2025 at 9 a.m., Resident 1 stated that CNA 1 hit him (Resident 1) three times on the back of his head. Resident 1 stated he (Resident 1) had asked the staff (referring to CNA 1) for assistance. Resident 1 stated that CNA 1 verbalized that CNA 1 did not want to help Resident 1, so CNA 1 then started hitting Resident 1. Resident 1 stated he (Resident 1) felt sad, ashamed, and had some pain to the back of the head because CNA 1 hit him (Resident 1) “very hard”. Resident 1 stated he (Resident 1) could not defend himself (referring to Resident 1) because he (Resident 1) was sick and felt very bad. A review of SN 2's written statement, dated 1/29/2025, indicated that SN 2 witnessed CNA 1 hit Resident 1 on the head (did not indicate which part) three times. The written statement indicated Resident 1, and CNA 1 were previously arguing in the bathroom. The written statement indicated when CNA 1 hit Resident 1, Resident 1 yelled in Spanish (a type of language), "The CNA (CNA 1) hit me, she hit me." SN 2's written statement indicated that CNA 1 verbalized hitting Resident 1 by stating "I hit him (Resident 1)." During an interview on 2/7/2025 at 10 a.m., SN 1 stated on 1/29/2025, she (SN 1) observed CNA 1 "slapped" the back of Resident 1's head. SN 1 stated CNA 1 had her palm (inner part of hand) open (did not indicate which palm) and slapped Resident 1 in the head three times “very hard”. SN 1 stated Resident 1 was yelling out that a CNA (referring to CNA 1) hit him. During an interview on 2/7/2025 at 11 a.m., the Clinical Instructor (CI) stated that on 1/29/2025 SN 1 and SN 2 came to her and reported witnessing CNA 1 hitting Resident 1 in the head. The CI stated they (SN 1, SN 2, and CI) went to report the incident (abuse) to the Director of Nurses (DON). During an interview on 2/7/2025 at 3:30 p.m., the DON stated the incident that occurred on 1/29/2025 with Resident 1 and CNA 1 was considered abuse. The DON stated the facility does not allow any type of abuse to occur because there is zero tolerance (a strict policy that prohibits violence, bullying, and other harmful behaviors in the workplace) for abuse. The DON stated CNA 1 was removed from the facility staffing schedule. During a review of the current facility-provided policy and procedure (P & P) titled, "Abuse, Neglect, Exploitation (the act of taking advantage of someone or something for personal gain) and Misappropriation (unauthorized, improper, or unlawful use) Prevention Program," dated 2021, the P & P indicated residents have the right to be free from abuse.... This includes ... physical abuse. The facility failed to protect Resident 1's right to be free from physical abuse when on 1/29/2025 at 10:55 a.m., SN 1 and SN 2 witnessed CNA 1 hit Resident 1 in the back of the head three times with an open hand. As a result, Resident 1 was subjected to physical abuse by CNA 1 while under the care of the facility. Resident 1 stated he (Resident 1) felt humiliated, sad, and complained of pain to the back of the head. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.