Health inspection·June 18, 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 2’s right to be free from physical abuse when Resident 1 used his (Resident 1) right hand to graze (a skin injury to the outer layers of the skin) Resident 2’s left cheek on 4/23/2025. As a result, Resident 2 was subjected to physical abuse by Resident 1 while under the care of the facility. Based on the reasonable person concept (used to determine how an average, rational individual would act or respond in a given situation) due to Resident 2’s impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), an individual subjected to physical abuse can have lifetime physical and psychological (mental or emotional) effects including feelings of embarrassment and humiliation (the feeling of being ashamed or losing respect for yourself). A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 4/17/2025 with diagnoses that included neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body), arrhythmia (a problem with the rate or rhythm of your heartbeat), major depressive disorder (a mental health condition characterized by persistent feelings of sadness, hopelessness, and a loss of interest in activities that were once enjoyable), bipolar disorder (a mental health condition that causes extreme mood swings) and encephalopathy (damage or diseases that affects the brain). A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool) dated 4/21/2025, indicated Resident 1 had intact cognition. A review of Resident 1's Change in Condition (COC- when there is a sudden change in a resident’s health) Evaluation Form, dated 4/23/2025, timed at 4:31 p.m., indicated that on 4/23/2025 Resident 1 exhibited behavioral symptoms, including physical aggression (refers to acts that cause or threaten physical harm) and verbal aggression (involves the use of words to cause psychological harm such as insults, threats, or name-calling). The COC indicated Resident 1 was observed screaming, yelling and using profane language (refers to language that is considered offensive). The COC indicated that during the incident on 4/23/2025 Resident 1 made physical contact with another Resident (Resident 2), grazing Resident 2’s left cheek. A review of Resident 1’s Physician’s Order dated 4/23/2025, timed at 5:34 p.m., indicated to transfer (Resident 1) to General Acute Care Hospital 1 (GACH 1) for a psychological evaluation (a comprehensive assessment conducted by mental health professionals to understand an individual's mental health status, identify potential issues, and develop appropriate treatment plans) due to aggressive behavior and angry outburst. A review of Resident 1’s Post Event Interdisciplinary Team Review form dated 4/25/2025, timed at 3:58 p.m., indicated the resident (Resident 1) exhibited aggressive behavior and angry outburst behavior towards another resident (Resident 2). The Post Event Interdisciplinary Team Review form indicated the resident (Resident 1) grazed another resident (Resident 2) on the left cheek requiring staff to intervene and separate both residents. A review of Resident 2's Admission Record indicated the facility originally admitted Resident 2 on 10/21/2024 and readmitted on 3/4/2025 with diagnoses that included dementia (a progressive state of decline in mental abilities) and epilepsy (a chronic [long-term] disease that causes repeated seizures [a sudden, uncontrolled electrical disturbance in the brain that causes temporary changes in muscle tone or movement, behavior, sensation, or awareness]). A review of Resident 2's History and Physical (H&P- a formal assessment of a resident's health, encompassing both a thorough medical history and a physical examination), dated 3/7/2025, indicated Resident 2 does not have the capacity to make decisions. A review of Resident 2’s MDS dated 3/9/2025, indicated Resident 2 had impaired cognition. A review of Resident 2's COC Evaluation Form, dated 4/23/24, timed at 5:08 p.m., indicated that on 4/23/2025 Resident 2 was seated outside another resident’s room (Resident 1), when Resident 1 began yelling at Resident 2, in response Resident 2 told Resident 1 to “shut up”. The COC indicated the resident (Resident 2) sustained a skin injury to the left cheek after being grazed by another resident (Resident 1). A review of Resident 1’s Post Event Interdisciplinary Team Review form dated 4/25/2025, timed at 3:55 p.m., indicated the resident (Resident 2) was seated outside Resident 1’s room when Resident 1 began yelling at Resident 2. The Post Event Interdisciplinary Team Review form indicated Resident 2 told Resident 1 to “shut up” subsequently, Resident 1’s hand grazed Resident 2 on the left cheek. The Post Event Interdisciplinary Team Review form indicated Resident 2 was then escorted to a safe area. During an interview on 5/5/2025 at 1:52 p.m., with the Director of Staff Development 1 (DSD 1), DSD 1 stated that she (DSD 1) completed a written statement regarding the incident on 4/23/2025 involving Resident 1 and Resident 2. DSD 1 stated on 4/23/2025, at approximately 3:30 p.m., DSD 1 witnessed an altercation between Resident 1 and Resident 2 in the hallway near Resident 1’s room. DSD 1 stated she (DSD 1) stood approximately one (1) foot away from the residents (left side of Resident 1 and right side of Resident 2), with her arms extended between them to intervene and separate the residents. DSD 1 stated that on 4/23/2025 Resident 2 was seated outside Resident 1’s room when Resident 1 approached Resident 2 and began shouting and behaving aggressively. DSD 1 stated Resident 2 responded by shouting “shut up” at Resident 1. DSD 1 stated Resident 1 used his (Resident 1) right hand to make physical contact with Resident 2’s face, with the intent to cause injury. During a concurrent interview and record review on 5/6/2025 at 3:50 p.m., with the Director of Nursing (DON), the COC form dated 4/23/2025 for Resident 1 and Resident 2 were reviewed. The DON stated the incident between Resident 1 and Resident 2 documented in the COC form is consistent with the definition of abuse. The DON stated that the facility must prevent all forms of abuse without exception. During a concurrent interview and record review on 5/6/2025 at 3:55 p.m., with the Administrator (ADM), the ADM reviewed DSD 1’s written statement dated 5/5/2025 regarding the incident on 4/23/2025 involving Resident 1 and Resident 2 and the Post Event Interdisciplinary Team Review form dated 4/25/2025 regarding the incident on 4/23/2025 involving Resident 1 and Resident 2. The ADM stated she (ADM) is the facility’s abuse coordinator (the person that investigates allegations of abuse in the facility). The ADM stated the abuse incident that occurred on 4/23/2025 cannot be deemed unavoidable and thus must be prevented without exception, which the facility failed to do in this case. During a concurrent interview and record review on 5/6/2025 at 4:07 p.m., with the DON, the DON reviewed the facility's policy and procedure (P&P) titled “Abuse: Prevention of and Prohibition Against”, with a revised date of 3/2025. The P&P indicated, “It is the policy of this facility that each resident has the right to be free from abuse…” The DON stated that the facility failed to ensure that Resident 2 was free from abuse when on 4/23/2025, Resident 1 used his (Resident 1) right hand to willfully make contact with the left cheek of Resident 2 with the intent to inflict injury. The DON stated that the facility did not follow the facility’s P&P for the prevention of abuse. A review of the facility's P&P titled “Abuse: Prevention of and Prohibition Against”, with a revised date of 3/2025, indicated, “It is the policy of this facility that each resident has the right to be free from abuse…” The facility failed to protect the Resident 2’s right to be free from physical abuse when Resident 1 used his (Resident 1) right hand to graze Resident 2’s left cheek on 4/23/2025. As a result, Resident 2 was subjected to physical abuse by Resident 1 while under the care of the facility. Based on the reasonable person concept due to Resident 2’s impaired cognition, an individual subjected to physical abuse can have lifetime physical and psychological effects including feelings of embarrassment and humiliation. The above violation had direct or immediate relationship to the health, safety, or security of Resident 2.