Health inspection·July 3, 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. §483.40 Behavioral health services. Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident’s whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. §483.40(a) The facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with § 483.71. §483.40(b) Based on the comprehensive assessment of a resident, the facility must ensure that— §483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. On 5/21/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate facility-reported-incidents (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 and verbal abuse (the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability) when on 5/9/2025 at 1:30 p.m., Resident 1 and Resident 2, who were both inside Room A (Resident 1 and Resident 2’s shared room), were observed by Certified Nursing Assistant (CNA) 1 and Resident 2 made a fist with his left hand and punched Resident 1 on Resident 1’s lower right abdomen, then Resident 2 used verbal profanity (offensive or vulgar language, often considered impolite, rude, or disrespectful) towards Resident 1. As a result, Resident 1 was subjected to physical and verbal abuse. A review of Resident 1’s Admission Record, indicated the facility admitted Resident 1, an 85-year-old female, on 4/10/2025 with diagnoses including major depressive disorder, unspecified psychosis (when someone experiences a loss of contact with reality, often marked by hallucinations [seeing or hearing things that aren't there] and delusions [false beliefs]), and unspecified dementia (a progressive state of decline in mental abilities). A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 4/17/2025, indicated Resident 1’s cognition was moderately impaired (decisions poor, cues/supervision required). The MDS indicated Resident 1 required substantial to maximal assistance with showering and required partial to moderate assistance with toileting, upper and lower body dressing and putting on and taking off footwear. A review of a facility-provided record titled, "Abuse Investigation Reporting Form," dated 5/14/2025, indicated based on eyewitness accounts from CNA 1, the facility substantiated that Resident 2 made contact with Resident 1 after Resident 1 attempted to wake Resident 2 up with Resident 2 hitting Resident 1 in the stomach. A review of Resident 2’s Admission Record, indicated the facility admitted Resident 2, a 96-year-old male, on 4/15/2025 with diagnoses of atrial fibrillation (a condition where the upper chambers of the heart [atria] beat irregularly and rapidly, sometimes faster than normal), type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle weakness (generalized). A review of Resident 2’s MDS, dated 4/22/2025, indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 required substantial to maximal assistance with toileting, showering, upper and lower body dressing, and putting on and taking off footwear and required partial to moderate assistance with oral hygiene and personal hygiene. A review of Resident 2’s Incident Note, dated 5/9/2025 at 2:41 p.m., indicated at 1:30 p.m. CNA 1 reported that Resident 1 told CNA 1 Resident 1 wanted to see her husband (Resident 2) and CNA 1 told Resident 1 “Okay, but come back.” CNA 1 stated she decided to follow Resident 1 and that was how CNA 1 saw Resident 2 hit Resident 1 for waking up Resident 2, then Resident 2 called Resident 1 names. During an interview on 5/21/2025 at 10:36 a.m. with Resident 2, Resident 2 stated he cannot recall the date of incident, but it must have occurred more than a week ago. Resident 2 stated he shared a room with wife (Resident 1) and Resident 1 kept waking Resident 2 up and around 1 p.m. Resident 1 woke Resident 2 up again and Resident 2 stated with his left-hand he (Resident 2) shoved or pushed Resident 1 back telling Resident 1 to go away. Resident 2 stated he said some bad words to Resident 1 like "you stupid women" and may have used profanity. During an interview on 5/21/2025 at 1:07 p.m. with CNA 1, CNA 1 stated she recalls the incident with Resident 1 and Resident 2 but does not recall the exact date and said it was around 1:30 p.m. after lunch. CNA 1 stated she was doing her charting (documentation) right outside of Room A, Resident 1 and Resident 2’s shared room, with Resident 1 by her (CNA 1) side asking about Resident 2. CNA 1 stated she told Resident 1 that Resident 2 was sleeping but Resident 1 wanted to see Resident 2. CNA 1 stated she told Resident 1 she could take a look at Resident 2 but to leave Resident 2 alone. CNA 1 stated she followed Resident 1 into Room A. CNA 1 stated Resident 1 walked into Room A and walked in front of Resident 2 and shrugged Resident 2’s shoulder and whispered to Resident 2 trying to wake Resident 2 up. CNA 1 stated Resident 2 was lying on his right side facing away from the door. CNA 1 stated she saw Resident 2 make a fist with his left hand and with the back of his hand Resident 2 punched Resident 1 on her lower abdomen and Resident 1 scooted back and Resident 2 was yelling at Resident 1 in their own language. CNA 1 stated she rushed to Resident 1 and Resident 2’s side and told Resident 2 that was not okay, and Resident 2 said profanities toward Resident 1. CNA 1 stated based on what she witnessed it was physical and verbal abuse. A review of the facility’s Policy and Procedure (P&P) titled, “Abuse Prevention and Prohibition Program,” last revised on 1/2025, indicated the purpose is “To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to … protect residents … in accordance with federal and state requirements. Each resident had the right to be free from … abuse…. The facility has zero-tolerance for abuse…. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse…. The facility is committed to protecting residents from abuse by anyone, including but not limited to … other residents….” A review of the facility’s P&P titled, “Definitions: Operational Manual- Abuse & Neglect,” last revised on 1/2025, indicated, “‘Abuse’ means the willful infliction of injury … with resulting physical harm, pain, or mental anguish…. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, … physical abuse, and mental abuse…. ‘Physical Abuse’ means assault, battery, assault with … force likely to produce great bodily injury…. ‘Verbal Abuse’ means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents…, or within their hearing distance, regardless of their age, ability to comprehend, or disability.” The facility failed to protect Resident 1’s right to be free from physical and verbal abuse on 5/9/2025 at 1:30 p.m., when Resident 2 made a fist with his left hand and punched Resident 1 on Resident 1’s lower right abdomen, then Resident 2 used verbal profanity towards Resident 1. As a result, Resident 1 was subjected to physical and verbal abuse while under the care of the facility. The above violations had direct or immediate relationship to the health, safety, or security of Resident 1.