Health inspection·April 24, 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 3/10/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct its annual recertification survey and investigate two Facility-Reported Incidents (FRIs) regarding resident abuse. The facility failed to: 1. Protect Resident 50’s right to be free from verbal abuse (a type of abuse that uses language) when on 3/12/2025 Resident 15 yelled at Resident 50, "Shut up, you "fucking bitch." As a result, Resident 50 was subjected to verbal abuse while under the care of the facility. 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). 2. Protect Resident 61’s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) when on 3/3/2025, Resident 18 pushed Resident 61 causing Resident 61 to fall. As a result, Resident 61 was subjected to physical abuse by Resident 18 while under the care of the facility. 1. A review of Resident 50's Admission Record indicated the facility originally admitted the resident on 1/9/2020 and readmitted the resident on 12/16/2024 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 50's Minimum Data Set (MDS - a resident assessment tool), dated 1/7/2025, indicated Resident 50 had intact cognition (thought processes) and was dependent on staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). A review of Resident 50's Situation, Background, Assessment, and Recommendation Communication Form (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents), dated 3/12/2025 indicated that the resident was interacting with another resident. The SBAR indicated that Resident 50 stated, "He [Resident 15] was fixing the wall. I told him to stop. Then he called me a "bitch." A review of Resident 15's Admission Record indicated the facility originally admitted the resident on 1/24/2025 and readmitted the resident on 2/20/2025 with diagnoses including metabolic encephalopathy (a brain dysfunction resulting from a chemical imbalance in the blood, often caused by underlying systemic illnesses or organ dysfunction, rather than a primary brain injury), history of traumatic brain injury (TBI - a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality). A review of Resident 15's MDS, dated 2/24/2025 indicated the resident had severely impaired cognition and required maximal assistance from staff for most ADLs. On 3/12/2025 at 2:01 p.m., during an interview with Registered Nurse 2 (RN 2), RN 2 stated she was sitting at north nursing station when she heard a commotion. RN 2 stated she heard Resident 50 yelling but could not understand what Resident 50 was saying. RN 2 stated that, when she asked Resident 50 what happened, Resident 50 pointed at Resident 15 and stated that she was trying to tell Resident 15 to stop moving the personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) bin that was outside of his room. RN 2 stated that Resident 50 told her that Resident 15 then responded by saying, "Shut up, bitch!" On 3/12/2025 at 3:54 p.m., during an interview with the Director of Staff Development (DSD), the DSD stated that, between 7:15 a.m. and 7:30 a.m., he heard Resident 50 yelling, "Stop cleaning the walls, and stop moving the signs!" The DSD stated he observed Resident 15 outside his room removing signs that were outside his room. The DSD stated he then heard Resident 15 shout, "Shut up!" to Resident 50. On 3/13/2025 at 8:38 a.m., during an interview with Resident 50, Resident 50 stated she saw Resident 15 taking off the sign in front of his door, so she yelled for him to stop. Resident 50 stated that Resident 15 responded by yelling, "Fuck you, bitch! Shut up, bitch!" On 3/13/2025 at 9:09 a.m., during an interview with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated that, between 7 a.m. to 7:15 a.m., she heard Resident 50 speaking very loudly. CNA 1 stated that, when she got to Resident 50's room, she observed Resident 50 yelling profanities at Resident 15, and she tried to tell Resident 50 to stop. CNA 1 stated that Resident 15 responded to Resident 50 by stating, "Shut up, you "fucking bitch." On 3/13/2025 at 11:37 a.m., during an interview with the Administrator (ADM), the ADM stated that, at around 7:55 a.m., RN 2 notified her of the verbal resident-to-resident incident between Resident 50 and Resident 15. The ADM stated RN 2 told the ADM that Resident 50 was trying to tell Resident 15 to stop moving around the signs outside of his room. The ADM stated she was told that Resident 15 responded to Resident 50 by stating, "Shut up, you fucking bitch." On 3/13/2025 at 4:20 p.m., during an interview with the ADM, when asked if she (ADM) considered Resident 15 stating "Shut up, you fucking bitch," to Resident 50 to be verbal abuse, the ADM stated that she did consider the incident as verbal abuse. During a review of the facility's policy and procedure (P&P) titled, "Abuse Prevention/Prohibition," last reviewed on 2/26/2025, the policy and procedure indicated that the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment ...Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms directed to residents or their families or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. 2. A review of Resident 61's Admission Record indicated that the facility originally admitted the resident on 5/13/2022, and readmitted on 3/18/2024, with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia, schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and major depressive disorder. A review of Resident 61's MDS dated 1/31/2025 indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 61 required staff partial/moderate assistance (helper does less than half the effort) for toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 61`s SBAR dated 3/3/2025 indicated that on 3/3/2025, Resident 61 was allegedly pushed by Resident 18 in the hallway. The SBAR form indicated that this incident was witnessed by Resident 53. A review of Resident 61`s care plan (a document outlining a detailed approach to care customized to an individual resident's need) for risk for injury related to alleged resident to resident altercation initiated on 3/3/2025, the care plan indicated a goal that the resident will have no injuries. The care plan interventions were to monitor the resident for pain and discomfort, provide safety reassurance, redirect the resident to another area away from the group of residents, and approach the resident in a calm manner. A review of Resident 61`s Interdisciplinary Team (IDT- a group of professionals from different disciplines who collaborate to provide comprehensive care for a patient) Conference Record-Fall Management Follow up dated 3/4/2025 indicated that Resident 61 had a fall incident on 3/3/2025, because the resident was allegedly pushed by another resident for no apparent reason and was found on the floor. The IDT follow up record indicated that Resident 61 did not sustain any injuries and X-Ray results (images of internal tissues, bones, and organs on film or digital media) were negative for any fracture. A review of Resident 18's Admission Record indicated that the facility admitted the resident on 2/12/2025, with diagnoses including type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paranoid (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly) schizophrenia (a mental illness that is characterized by disturbances in thought), and encephalopathy (a general condition characterized by impaired brain function). A review of Resident 18`s History and Physical (H&P) dated 2/13/2025, the H&P indicated that the resident had the capacity to understand and make decisions. A review of Resident 18's MDS dated 2/19/2025 indicated that the resident`s cognitive skills for daily decision making was moderately impaired. The MDS indicated that Resident 18 required staff partial/moderate assistance for oral hygiene, toileting hygiene, lower body dressing, showering and bathing, putting on/talking off footwear, and personal hygiene. The MDS further indicated that Resident 18 exhibited behavioral symptoms not directed towards others. A review of Resident 61`s SBAR Communication Form dated 2/17/2025 indicated that on 2/17/2025, Resident 18 had behavioral symptoms such as throwing things and banging doors. A review of Resident 61`s SBAR Communication Form dated 3/3/2025 indicated that on 3/3/2025 at around 10:05 a.m., Resident 18 allegedly pushed another resident (Resident 61) without any provocation (an action or statement that is intended to make someone angry) that was witnessed by another resident (Resident 53). The SBAR form indicated that Resident 18 was immediately redirected back to his room and was placed on one-on-one supervision. The SBAR form indicated that when staff asked Resident 18 why he pushed Resident 61, Resident 18 stated that Resident 61 was making him uncomfortable and nervous. However, he (Resident 18) did not mean to hurt Resident 61, and he apologized. The SBAR form further indicated that Resident 18`s physician ordered to transfer the resident to hospital for psychological evaluation. A review of Resident 18`s care plan for alleged physical altercation with another resident, initiated on 3/3/2025 indicated that Resident 18 was the aggressor (the person who starts the attach first). The care plan indicated a goal that the resident`s behavior will be managed without complications and the resident will have minimized altercations with other residents. The care plan interventions were to provide one on one supervision, administer medications as ordered by the physician, assess for signs and symptoms that may trigger behaviors, redirect the resident to another area away from the group of residents, and approach the resident in a calm manner. A review of Resident 53's Admission Record indicated that the facility admitted the resident on 7/31/2024, with diagnoses including paranoid schizophrenia, and anxiety disorder. A review of Resident 53's MDS dated 1/27/2025 indicated that the resident`s cognitive skills for daily decision making was moderately impaired. The MDS indicated that Resident 53 was independent (resident completes the activity by herself) for eating, oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. During an observation on 3/10/2025 at 9:50 a.m., Resident 61 was observed walking in the hallways. Resident 61 appeared confused and was not able to answer any questions. During an interview on 3/10/2025 at 9:00 a.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated that on 3/3/2025 at around 10:00 a.m., she was assisting a resident inside a room when she heard a noise and commotion (a sudden, noisy, and confused activity or excitement). CNA 2 stated when she came out, she (CNA 2) Observed Resident 61 sitting on the floor in the hallway and the nurses were taking care of her. CNA 2 stated Resident 61 is confused and likes to walk in the hallways back and forth all the time. During an Interview on 3/12/2025 at 9:30 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated on 3/3/2025, he was inside a resident`s room when he (LVN 3) heard commotion outside in the hallway. LVN 3 stated he (LVN 3) ran outside, and observed Resident 18 standing in the hallway and Resident 61 was sitting on the floor next to him. LVN 3 stated Resident 53 was present in the hallway as well and stated she (Resident 53) witnessed Resident 18 pushed Resident 61 causing her to fall. The LVN 3 stated when he (LVN 3) interviewed Resident 18 about the reason he (Resident 18) pushed Resident 61, Resident 18 stated that Resident 61 was making him uncomfortable and nervous, and he (Resident 18) did not mean to hurt Resident 61. During an interview on 3/12/2025 at 10:14 a.m., Resident 53 stated that she remembers the day Resident 18 pushed Resident 61. Resident 53 stated that Resident 61 is always walking in the hallway. Resident 53 stated on 3/3/3024 in the morning in the hallway next to her room, she witnessed that Resident 61 walked towards Resident 18 and told him something. Resident 53 stated that Resident 61 always starts talking to others, but nobody understands her. Resident 53 further stated that Resident 18 pushed Resident 61 causing her to fall on the floor and hit her head against the wall. Resident 53 stated she (Resident 53) got very angry, screamed "Why did you do that", and then reported this incident to the nurses. During an interview on 3/13/2025 at 2:40 p.m., with the Director of Nursing (DON), the DON stated that the physical altercation between Resident 18 and Resident 61 was substantiated (to show something to be true, or to support a claim with facts) because it was witnessed by Resident 53. The DON stated Resident 53 reported that she witnessed Resident 18 pushed Resident 61 causing her to fall. The DON stated Resident 18 stated that he thought Resident 61 was following him, so he (Resident 18) pushed Resident 61. However, he (Resident 18) was sorry for his actions. During an interview on 3/13/2025 at 4:17 p.m., with the Administrator (ADM), The ADM stated that the abuse allegation was substantiated because Resident 53 witnessed that Resident 18 pushed Resident 61 causing her to fall. The ADM stated this altercation is considered physical abuse. The ADM stated it is important to protect the residents by keeping the residents safe from abuse and injury. During a review of the facility`s P&P titled "Abuse Prevention/prohibition," last reviewed on 2/26/2025, the P&P indicated that that facility does not condone any form of resident abuse, neglect (fail to care properly), misappropriation of resident property, mistreatment, and develops facility policies, training programs, and system