Health inspection·July 16, 2025

F609 42 CFR §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. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. On 6/2/2025, the California Department of Public Health (CDPH) made an unannounced visit to conduct the annual recertification survey and investigate two Facility-Reported Incidents (FRIs) regarding resident abuse. The facility failed to: 1. Protect Resident 46’s and Resident 577’s right to be free from verbal abuse (a type of abuse that uses language) when: a. Resident 96 shouted offensive and discriminatory (treating someone unfairly or differently because of who they are - for example because of their race, gender, age, religion, or disability) language towards Resident 46. b. Certified Nursing Assistant 5 (CNA 5) used offensive language in response to Resident 577's remarks. 2. Implement its policy and procedure (P&P) titled, "Abuse, Neglect and Exploitation," by not reporting to CDPH, the local Ombudsman (an advocate who supports residents by resolving issues related to their health, safety and well-being), the Local Law Enforcement (LLE), and the facility administrator (ADM), an allegation of verbal abuse by Resident 96 to Resident 46, immediately but no later than two hours after the allegation was made. As a result, Resident 46 and Resident 577 were subjected to verbal abuse while under the care of the facility and there was a delay for an onsite inspection by CDPH to ensure the safety of Resident 46 and other residents. 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 46’s and Resident 577’s impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), residents who are subjected to verbal abuse are at increased risk for low self-esteem (when someone lacks confidence in themselves and their abilities), anxiety (a feeling of fear, dread, and uneasiness), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities for long periods of time) and social isolation (when someone has few or no social connections or support, and lacks relationships with others). 1.a. A review of Resident 46's Admission Record indicated the facility originally admitted the resident on 1/11/2017 and readmitted the resident on 1/29/2025 with diagnoses including but not limited to hemiplegia (total paralysis [loss of the ability to move] of the arm, leg, and trunk on the same side of the body) following unspecified cerebral vascular disease (multiple conditions that affect the blood vessels and blood supply to the brain) and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 46's History and Physical (H&P), dated 8/14/2024 indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 46's Minimum Data Set (MDS- a resident assessment tool), dated 5/5/2025 indicated the resident had impaired cognition. The MDS further indicated Resident 46 was dependent on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). A review of Resident 96's Admission Record indicated the facility admitted the resident on 9/17/2022 with diagnoses including but not limited to legal blindness and major depressive disorder. A review of Resident 96's H&P dated 12/14/2024 indicated the resident could make his needs known but could not make medical decisions. During a review of Resident 96's MDS, dated 3/6/2025 indicated the resident had severe cognitive impairment. The MDS further indicated Resident 46 was dependent on staff for most ADLs. During an interview on 6/2/2025 at 9:30 a.m., with Resident 46 and Certified Nursing Assistant 7 (CNA 7) in Resident 46's room, Resident 46 stated his roommate (Resident 96) has yelled at him many times. Resident 46 stated Resident 96 used offensive language and made discriminatory remarks regarding Resident 46's race. CNA 7 stated that about a month ago when Resident 46 was watching television, she (CNA 7) heard Resident 96 stated profanities to Resident 46 including discriminatory remarks about Resident 46's race while Resident 96 was asking Resident 46 to change the television channel. CNA 7 stated she (CNA 7) has heard Resident 96 used profanities directed at Resident 46 many other times before that incident as well. During an interview on 6/4/2025 at 4:40 p.m., with Certified Nursing Assistant 9 (CNA 9), CNA 9 stated he heard Resident 96 say profanities towards Resident 46 when Resident 46 was watching a non-English language channel on the television on multiple occasions. During an interview on 6/4/2025 at 4:55 p.m., with Certified Nursing Assistant 10 (CNA 10), CNA 10 stated he heard Resident 96 say profanities towards Resident 46 after Resident 46 turned on his television. CNA 10 stated Resident 96 does not like listening to Resident 46's non-English language channel on the television and he has heard Resident 96 tell Resident 46 to turn it off on multiple occasions. During an interview on 6/5/2025 at 11:50 a.m., with the Social Services Director (SSD), the SSD stated a resident saying profanity is verbal abuse if it was directed to another resident. The SSD stated there is a risk of psychosocial distress (refers to unpleasant emotions or psychological symptoms an individual experiences) if a resident hears profanities directed at them. During an interview on 6/5/2025 at 1:53 p.m., with the Director of Nursing (DON) and the ADM, the DON stated hearing profanities could have a negative effect emotionally or psychologically. The ADM stated verbal abuse includes communicating something to someone that could have a negative effect emotionally or psychologically like yelling, profanities, or discriminatory language with the intent to make someone feel bad. During a concurrent interview and record review on 6/4/2025 at 4:15 p.m., with the ADM, the facility's P&P titled, "Abuse, Neglect and Exploitation," last reviewed on 4/24/2025, indicated verbal abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging (expressing the opinion that something is of little worth) and derogatory (to express a low opinion of someone or something) terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The ADM stated the words Resident 96 said to Resident 46 meets this definition of verbal abuse. The ADM stated staff should have reported this to a supervisor and it should have been reported to external entities. A review of the facility's P&P titled, "Abuse, Neglect and Exploitation," last reviewed on 4/24/2025 indicated it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The P&P further indicated verbal abuse includes communication that willfully includes disparaging and derogatory terms to residents or within their hearing distance regardless of their age, ability to comprehend, or disability. The P&P further indicated willful means the individual acted deliberately, not that the individual must have intended to inflict injury or harm. 1.b. A review of Resident 577's Admission Record indicated the facility admitted the resident on 5/22/2025 with diagnoses that included confirmed case of adult physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) and injury of the head. A review of Resident 577' s MDS dated 5/28/2025 indicated Resident 577 had moderately impaired in cognition. The MDS indicated Resident 577 required moderate/partial assistance with mobility (movement) including walking 50 feet (ft- unit of length). A review of Resident 577's Change in Condition (COC- when there is a sudden change in a resident’s cognition) Report, dated 6/03/2025 at 8 p.m., indicated that on 6/3/2025 at 7:25 p.m., Resident 577 reported to Registered Nurse 2 (RN 2) a verbal altercation with CNA 5 after the dinner tray was picked up without his (Resident 577) consent. A review of Resident 577's Nursing Progress Note, dated 6/3/2025, at 9:02 p.m., indicated that at 7:25 p.m., Resident 577 reported to RN 2 a verbal altercation Resident 577 had with a staff member (CNA 5) after the dinner tray was picked up without his consent. The note indicated the assigned staff member was sent home and CDPH, the local Ombudsman, LLE, and Resident 577's Nurse Practitioner (NP - a nurse who has advanced clinical education and training) and Psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) were notified. During a phone interview on 6/5/2025 at 8:05 a.m., with CNA 5, CNA 5 stated that on 6/3/2025 at approximately between 6:30 p.m. and 6:45 p.m. she (CNA 5) picked up Resident 577's dinner tray from his room. CNA 5 stated Resident 577 was in the bathroom when CNA 5 asked him if she could pick up his tray, and he (Resident 577) said yes. CNA 5 stated at approximately 7 p.m., Resident 577 came out into the hallway and asked where his tray was. CNA 5 stated Resident 577 directed profanities to her and she (CNA 5) responded by using profanity toward Resident 577 as well. During an interview on 6/5/2025 at 8:21 a.m., with Resident 577, Resident 577 stated that CNA 5 came to take his tray when he was in the bathroom. Resident 577 stated he replied he was not done with dinner, but CNA 5 took the tray anyway. Resident 577 stated he said profanities to CNA 5, and CNA 5 responded by using profanity towards him. During an interview on 6/5/2025 at 8:30 a.m., with the DON, the DON stated CNA 5 should not have used profane language towards Resident 577. The DON stated that when residents say inappropriate things, the staff should walk away from the situation. The DON stated this was important for staff to maintain a professional relationship with residents. The DON stated this is for resident safety and to promote the residents' mental well-being. During an interview on 6/5/2025 at 3:45 p.m., with the DON, when asked if the altercation between Resident 577 and CNA 5 was considered verbal abuse, the DON stated it would not be willful, but what CNA 5 said was not an accident. During a concurrent interview and record review on 6/5/2025 at 4:17 p.m., with the ADM, the facility's P&P titled, "Abuse, Neglect and Exploitation," last reviewed on 4/24/2025 was reviewed. The ADM stated that the abuse policy indicated the word willful means:" the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm." The ADM stated what CNA 5 said to Resident 577, according to the definition, would be verbal abuse. A review of the facility's P&P titled, "Abuse, Neglect and Exploitation," last reviewed on 4/24/2025 indicated it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The P&P further indicated verbal abuse includes communication that willfully includes disparaging and derogatory terms to residents or within their hearing distance regardless of their age, ability to comprehend, or disability. The P&P further indicated willful means the individual acted deliberately, not that the individual must have intended to inflict injury or harm. 2. A review of Resident 46's Admission Record indicated the facility originally admitted the resident on 1/11/2017 and readmitted the resident on 1/29/2025 with diagnoses including but not limited to hemiplegia following unspecified cerebral vascular disease and DM. A review of Resident 46's H&P dated 8/14/2024 indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 46's MDS dated 5/5/2025 indicated the resident had impaired cognition. The MDS further indicated Resident 46 was dependent on staff for all ADLs. A review of Resident 96's Admission Record indicated the facility admitted the resident on 9/17/2022 with diagnoses including but not limited to legal blindness and major depressive disorder. A review of Resident 96's H&P dated 12/14/2024 indicated the resident could make his needs known but could not make medical decisions. During a review of Resident 96's MDS, dated 3/6/2025 indicated the resident had severe cognitive impairment. The MDS further indicated Resident 46 was dependent on staff for most ADLs. During an interview on 6/2/2025 at 9:30 a.m., with Resident 46 and CNA 7 in Resident 46's room, Resident 46 stated his roommate (Resident 96) has yelled at him many times. Resident 46 stated Resident 96 used offensive language and made discriminatory remarks regarding Resident 46's race. CNA 7 stated that about a month ago when Resident 46 was watching television, she (CNA 7) heard Resident 96 stated profanities to Resident 46 including discriminatory remarks about Resident 46's race while Resident 96 was asking Resident 46 to change the television channel. CNA 7 stated she (CNA 7) has heard Resident 96 used profanities directed at Resident 46 many other times before that incident as well. During an interview on 6/2/2025 at 3:40 p.m., with the SSD, the SSD stated he was unaware of any altercation or concern between Residents 46 and 96. The SSD stated no staff had ever talked to him about it. During an interview on 6/4/2025 at 9:53 a.m., with CNA 7, CNA 7 stated she did not report Resident 96's language to Resident 46 to anyone else because everyone already knew about it. During an interview on 6/4/2025 at 4:40 p.m., with CNA 9, CNA 9 stated he heard Resident 96 say profanities to Resident 46 when Resident 46 was watching a non-English language channel on the television on multiple occasions. CNA 9 stated he never reported this to anyone else because everyone on staff already knew Resident 96 says these things to Resident 46. CNA 9 stated everyone hears Resident 96 say these things regularly. During an interview on 6/4/2025 at 4:55 p.m., with CNA 10, CNA 10 stat