Other·May 7, 2026

F600 42 C.F.R. §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. (a) The facility must— (a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 22 CCR 72527. Patients' 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. 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 3/20/2026, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a Facility-Reported Incident (FRI) regarding resident abuse. The facility failed to protect the Resident 3’s right to be free from physical when on 3/19/2026 at 10:55 a.m., Resident 4 hit Resident 3 in the right eye with a “closed fist”. As a result, Resident 3 was subjected to physical abuse by Resident 4 while under the care of the facility. On 3/19/2026, Resident 3 sustained purplish discoloration (purple or darkened area on the skin, usually caused by bruising or bleeding under the skin), a cut above the right eye measuring 0.5 centimeters (cm) in length, 0.1 cm in width, 0.1 cm in depth and pain requiring first aid treatment (refers to initial assistance and care given to a resident who has been injured). A review of Resident 3’s Face Sheet (front page of the clinical record that contains a summary of basic information about the resident) indicated the facility originally admitted Resident 3 on 12/5/2024 and readmitted Resident 3 on 1/16/2026, with diagnoses including chronic obstructive pulmonary disease (COPD- a long term disease that makes it hard to breathe due to damaged, inflamed and narrowed airways), heart failure (a condition where the heart cannot pump blood throughout the body effectively enough to maintain the body's normal function) and type 2 diabetes (a condition where the body cannot control the level of sugar in the blood). A review of Resident 3’s Physician Progress Note, dated 1/17/2026, indicated Resident 3 has the capacity to understand and make decisions. A review of Resident 3's Minimum Data Set (MDS – a resident assessment tool) dated 2/2/2026, indicated Resident 3’s cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 3 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or light contact to ensure safety while a resident completes an activity) in most areas of activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). A review of Resident 3’s Situation-Background-Assessment-Recommendation (SBAR- a document used to communicate a resident's major decline or improvement in status that will not resolve without intervention) Communication Form, dated 3/19/2026, timed at 10:57 a.m., indicated that on 3/19/2026 at 10:55 a.m., Resident 3 was seated on a patio chair interacting with other residents, including Resident 4, who had been seated in a wheelchair in front of Resident 3, Resident 4 stood up and hit Resident 3 on the right upper eyebrow, causing a cut measuring 0.5 cm in length and 0.1 cm in width, with a small amount of bleeding. The SBAR Communication Form indicated first aid treatment was provided to Resident 3. A review Resident 3's Skin Supplemental Assessment, dated 3/19/2026, timed at 11:10 a.m., indicated a Registered Nurse (unidentified) assessed Resident 3 and observed Resident 3 with a linear cut to the right upper eye measuring 0.5 cm (in length), 0.1 cm (in width), and 0.1 cm (in depth) with reddish discoloration. A review of Resident 4's Face Sheet indicated the facility admitted Resident 4 on 7/1/2024 with diagnoses including acute kidney failure (a sudden, rapid loss of kidney function, often occurring within hours or days), dysphagia (difficulty swallowing), and anemia (a blood condition where a person lacks enough health red blood cells. A review Resident 4's Physician Progress Note, dated 4/9/2025, indicated Resident 4 had the capacity to understand and make decisions. A review of Resident 4’s MDS dated 2/2/2026, indicated Resident 4’s cognition was intact. The MDS indicated Resident 4 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) in most areas of ADLs. A review of Resident 4's SBAR Communication Form, dated 3/19/2026 timed at 10:58 a.m., indicated on 3/19/2026 at 10:55 a.m., Resident 4 was on the patio interacting with other residents (unidentified) including Resident 3, in the presence of Activity Staff 1 (ACS 1) when Resident 4 suddenly stood up and raised his (Resident 4’s) hand toward Resident 3. The SBAR Communication Form indicated that ACS 1 attempted to intervene; however, Resident 4 had already hit Resident 3 in the face. A review of Resident 4's Progress Note, dated 3/20/2026, indicated the facility transferred Resident 4 to another facility on 3/20/2026. During a concurrent observation and interview with Resident 3, in Resident 3’s room, on 3/20/26 at 3:45 p.m., Resident 3’s right eye was observed to have a cut on the right upper eye covered with clear steri-strips (a bandage used to help close a cut and support healing), with purplish discoloration present. Resident 3 stated that on 3/19/26, at 10:55 a.m., Resident 3 was on the patio with other residents, including Resident 4, having a discussion, when Resident 4 stood up and used Resident 4’s left “closed fist” to hit Resident 3's right eye area. Resident 3 stated Resident 3 was shocked because he considered Resident 4 to be a friend. Resident 3 stated his right eye ached and rated his pain to be two (2) out of 10 (on the numeric pain rating scale [0- no pain] to 10 [worst pain imaginable]). Resident 3 stated, "I wish it didn't happen." During a concurrent observation of Resident 3's right eye, in the presence of the Assistant Director of Nursing (ADON) and interview with the ADON in Resident 3’s room on 3/20/2026, at 3:47 p.m., Resident’s 3 right eye area had purplish discoloration and a cut covered with clear steri-strips. The ADON stated Resident 3 had an area of purplish discoloration approximately 1.0 cm x 1.0 cm in size next to Resident 3’s right eye and a laceration (a tear or cut in the skin or tissue, typically caused by blunt or sharp trauma, often with irregular or jagged edges) measuring approximately 1.0 cm in length, 0.1 cm in width, 0.1 cm in depth, covered with clear steri-strips. The ADON asked Resident 3 to rate Resident 3’s pain on the numeric pain rating scale and Resident 3 responded that Resident 3’s pain on the right eye area was 2 out of 10. During an interview on 3/20/2026, at 4:22 p.m., with ACS 1, ACS 1 stated he (ACS 1) witnessed Resident 4 use his (Resident 4’s) left hand to "slap" Resident 3 in the right eye area, resulting in a laceration above Resident 3's right eye area. During a concurrent interview and record review on 3/23/2026 at 4:56 p.m., with the Director of Nursing (DON), the facility's document titled, “CDPH (California Department of Public Health) 5-Day Report, dated 3/23/26 was reviewed. The 5-Day Report indicated that on 3/19/2026, Resident 4 stated he (Resident 4) felt his hand “made contact” with Resident 3's face. The DON stated Resident 4 used Resident 4’s hand to “strike” Resident 3 in the right eye area. During a concurrent interview and record review on 3/24/2026 at 4:30 p.m., with the Administrator (ADM), the facility's Policy and Procedure (P&P) titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," dated 11/5/2025 was reviewed. The P&P indicated, "Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation." The ADM stated that willful non-consensual contact between residents is abuse and abuse is never to be deemed unavoidable. The facility failed to protect the Resident 3’s right to be free from physical abuse when on 3/19/2026 at 10:55 a.m., Resident 4 hit Resident 3 in the right eye with a “closed fist”. As a result, Resident 3 was subjected to physical abuse by Resident 4 while under the care of the facility. On 3/19/2026, Resident 3 sustained purplish discoloration, a cut above the right eye measuring 0.5 cm in length, 0.1 cm in width, 0.1 cm in depth and pain requiring first aid treatment. The above violation had a direct relationship to the health, safety, or security of Resident 3.