Health inspection·July 17, 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; California Code of Regulations, Title 22, 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. California Code of Regulations, Title 22, Section 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. California Code of Regulations, Title 22, Section 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 6/4/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility-reported-incident (FRI) regarding resident-to-resident physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another). The facility failed to protect the resident’s right to be free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) on 5/31/2025 at 9 p.m., when Resident 2 and Resident 3 had a verbal altercation (an angry argument or disagreement expressed through words) in the smoking patio that led to a physical altercation (a confrontation or fight involving physical contact or force) where Resident 3 grabbed Resident 2 by the neck to choke Resident 2. Resident 2 did not have any injury besides complaint of pain. Pain medication and x-ray (a procedure to create pictures of the inside of the body) were offered to Resident 2, but Resident 2 refused the pain medication and x-ray. As a result, Resident 2 was subjected to physical abuse by Resident 3 while under the care of the facility. Resident 2 stated when Resident 3 grabbed her (Resident 2) neck, Resident 2 ended up landing on the right side of her (Resident 2) body with her (Resident 2) chair on the ground. The incident made Resident 2 feel “shocked (emotionally or physically disturbed; upset),” scared, and experienced pain on her (Resident 2) right knee with a pain intensity of five out of 10 on the pain scale (a scale used to measure pain, typically from 0 to 10, where 0 represents no pain and 10 represents the worst possible pain). A review of Resident 2’s Admission Record indicated the facility initially admitted Resident 2, a 68-year-old female, on 4/27/2020 and readmitted on 10/28/2024 with diagnoses including osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time) and hypertension (high blood pressure, which is when the force of blood against the artery walls is too high). A review of Resident 2’s Minimum Data Set (MDS – a resident assessment tool), dated 3/31/2025, indicated Resident 2 had moderately impaired thought process (when individuals experience noticeable decline in cognitive abilities, such as memory, language, and problem-solving) and required moderate assistance from staff to complete activities of daily living (ADLs – activities such as bathing, dressing, and toileting a person performs daily). A review of Resident 2’s History and Physical Examination, dated 10/29/2024, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2’s Change in Condition (a noticeable alteration in a resident’s health or physical state) Evaluation, dated 5/31/2025, indicated Resident 2 claimed an allegation of abuse. The Change in Condition Evaluation indicated Resident 2 stated Resident 3 caused Resident 2 to fall at the smoking patio. A review of Resident 2’s Post Fall Evaluation, dated 5/31/2025, indicated Resident 2 alleged another resident (Resident 3) caused her (Resident 2) to fall at the smoking patio. A review of Resident 2’s Pain Assessment, dated 5/31/2025, indicated Resident 2 verbalized complaints of pain with a pain intensity of five out of 10 on the pain scale. The Pain Assessment indicated Resident 2 had mild pain in her right knee. A review of Resident 2’s Progress Notes, dated 5/31/2025, indicated offered pain medication to Resident 2 three times and Resident 2 refused. A review of Resident 2’s Progress Notes, dated 6/1/2025, indicated that Resident 2 stated “I do not need it I can move my legs”. Resident 2 refused an x-ray. A review of Resident 3’s Admission Record indicated the facility admitted Resident 3, a 46-year-old female, on 3/5/2025, with diagnoses including encephalopathy (brain is not working right due to some kind of injury or disease) and chronic obstructive pulmonary disease (airflow obstruction, making it difficult to breathe). A review of Resident 3’s History and Physical Examination, dated 5/26/2025, indicated Resident 3 had the capacity to make decisions for ADLs. A review of Resident 3’s MDS, dated 3/11/2025, indicated Resident 3 had moderately impaired thought processes and required moderate assistance from staff to complete ADLs. The MDS indicated Resident 3 required supervision during sit to lying, chair/bed to chair transfer, toilet transfer, shower transfer, walking 10 feet, and walking 50 feet with two turns. A review of Resident 3’s Change in Condition Evaluation, dated 5/31/2025, indicated Resident 2 stated Resident 3 caused her (Resident 2) to fall at the smoking patio. A review of Resident 4’s Admission Record indicated the facility initially admitted Resident 4 on 8/31/2016 and readmitted on 4/2/2024 with a diagnosis of hypertension and chronic obstructive pulmonary disease. A review of Resident 4’s MDS, dated 2/14/2025, indicated Resident 4 had intact thought process (a person's thinking is logical, sequential, and goal-directed, without excessive or disorganized rambling or shifting between topics) and was able to perform ADLs independently. A review of Resident 4’s History and Physical Examination, dated 10/25/2024, indicated Resident 4 had the capacity to understand and make decisions. During an interview on 6/2/2025 at 3:57 p.m. with Resident 2, Resident 2 stated in the smoking patio Resident 3 sat on a wheelchair across her (Resident 2) table and kept asking Resident 2 for a cigarette. Resident 2 stated she (Resident 2) did not have any cigarettes to give and refused to share her (Resident 2) cigarettes. Resident 2 stated Resident 3 grabbed her (Resident 2) by the neck choking her (Resident 2) while sitting and she (Resident 2) fell on her (Resident 2) right side and ended up breaking her headphones. Resident 2 stated that she was shocked and scared at what happened. Resident 2 stated facility staff was not present during the incident. Resident 2 stated Resident 4 witnessed the incident (Resident 3 grabbing Resident 2’s neck). During an interview on 6/2/2025 at 4 p.m. with Resident 4, Resident 4 stated on 5/31/2025 around 8 p.m. to 9 p.m., he (Resident 4) saw Resident 3 called Resident 2 a derogatory term and told Resident 2 to give her (Resident 3) a cigarette. Resident 4 stated he observed Resident 3 got up from her wheelchair, jumped on Resident 2, grabbed Resident 2’s neck, and Resident 2 fell. Resident 4 stated he observed Resident 3 left the smoking patio after the incident. Resident 4 further stated after witnessing the incident, he (Resident 4) went to the nurses’ station to ask for help, but no staff was found. During an interview on 6/3/2025 at 3:20 p.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Certified Nursing Assistant (CNA) 4 reported that Resident 2 was on the floor in the smoking patio. LVN 5 stated that he went to the smoking patio right away and assessed Resident 2. LVN 5 stated Resident 2 complained of five out of 10 pain intensity on the pain scale on her right knee. LVN 5 stated Resident 2 mentioned that Resident 3 pushed her to the floor. LVN 5 stated Resident 2 was upset because her headphones broke and wanted them to be replaced. During an interview on 6/3/2025 at 4:10 p.m. with CNA 4, CNA 4 stated she (CNA 4) was in the hallway pushing another resident (name not indicated) in the wheelchair and heard a noise. CNA 4 stated she (CNA 4) saw Resident 3 rushing back into her room by pushing her (Resident 3) wheelchair. CNA 4 stated she (CNA 4) thought something happened and went right away to the smoking patio. CNA 4 stated she (CNA 4) found Resident 2 lying on the floor in the smoking patio. CNA 4 stated she left the smoking patio and reported the incident to LVN 5. During an interview on 6/4/2025 at 2:17 p.m. with the Administrator, the Administrator stated Resident 3 caused physical harm to Resident 2 and was considered as physical abuse. The Administrator stated if there was a staff present in the smoking patio, the staff could have made a difference to prevent the incident. During an interview on 6/4/2025 at 2:55 p.m. with the Director of Nursing (DON), the DON stated staff should be present for resident safety if there are residents in the smoking patio. A review of the facility’s policy and procedure titled, “Abuse Prevention Program,” last reviewed on 1/2025, indicated, “Our residents have the right to be free from abuse.... This includes but is not limited to ... verbal, ... physical abuse.... As part of the resident abuse prevention, the administration will protect our residents from abuse by anyone including, but not necessarily limited to ... other residents....” The facility failed to protect the resident’s right to be free from physical abuse on 5/31/2025 at 9 p.m., when Resident 2 and Resident 3 had a verbal altercation in the smoking patio that led to a physical altercation where Resident 3 grabbed Resident 2 by the neck to choke Resident 2. Pain medication and x-ray were offered to Resident 2, but Resident 2 refused the pain medication and x-ray. As a result, Resident 2 was subjected to physical abuse by Resident 3 while under the care of the facility. Resident 2 stated when Resident 3 grabbed her (Resident 2) neck, Resident 2 ended up landing on the right side of her (Resident 2) body with her (Resident 2) chair on the ground. The incident made Resident 2 feel “shocked (emotionally or physically disturbed; upset),” scared, and experienced pain on her (Resident 2) right knee with a pain intensity of five out of 10 on the pain scale. The above violations had a direct or immediate relationship to the health, safety, or security of Resident 2.