Health inspection·August 29, 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. §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property[.] 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. 22 CCR § 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. 22 CCR §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 7/14/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct its annual health recertification survey and to investigate a facility-reported incident (FRI) regarding a resident-to-resident altercation. The facility failed to protect Resident 224’s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by Resident 45 when on 6/28/2025 at 2:45 p.m., Certified Nursing Assistant 11 (CNA 11) witnessed Resident 45 approached Resident 224 and hit Resident 224 multiple times, on the head and right lower extremity (RLE – right side of the lower part of the human body) with a single point cane (a mobility aid with a single tip that provides basic support and balance assistance for individuals with minor mobility issues). As a result, Resident 224 was subjected to physical abuse by Resident 45 while under the care of the facility. On 6/28/2025, Resident 224 sustained bruising (discoloration of the skin caused by blood pooling beneath the surface) and swelling secondary to blunt force trauma on the RLE, redness on top of the head, and pain level of two (mild pain) out of 10 on the numeric pain rating scale (a pain assessment tool that uses a scale ranging from 0 [no pain] to 10 [worst pain imaginable], to quantify pain intensity). Resident 224 complained of mild headache on 6/28/2025 at 3:15 p.m. and Tylenol (a brand of medication used to treat mild to moderate aches and pains) 325 milligrams (mg) two tablets were administered to Resident 224. A review of Resident 224’s Admission Record indicated the facility originally admitted Resident 224, a 90-year-old male, on 3/23/2022 and readmitted in the facility on 5/12/2024 with diagnoses including Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). A review of Resident 224’s Order Summary Report dated 5/12/2024 indicated a physician’s order for Tylenol oral tablet 325 mg, give two tablets by mouth every four hours as needed for mild pain or general discomfort not to exceed three (3) grams (gm) per 24 hours. A review of Resident 224’s History and Physical (H&P – a comprehensive assessment of a resident’s medical condition), dated 5/1/2025 indicated Resident 224 did not have the capacity to understand and make decisions. A review of Resident 224’s Minimum Data Set (MDS – a resident assessment tool), dated 4/30/2025 indicated Resident 224 had severely impaired cognition (significant decline in a resident’s mental abilities that profoundly impacts their daily life and independence), and usually had the ability to make self understood and understand others. The MDS indicated Resident 224 required partial or moderate assistance (helper does less than half of the effort) with eating and was totally dependent (helper does all of the effort) on staff with all other activities of daily living (ADLs - routine tasks or activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 224’s Change of Condition (COC -major decline or improvement in a resident’s status that will not resolve without intervention) form, dated 6/28/2025, timed at 5 p.m. indicated that on 6/28/2025 at 2:45 p.m., Resident 224 was in the hallway (across Room A) sitting in the wheelchair and was yelling. The COC indicated that CNA 11 observed Resident 45 exiting Room A, approaching Resident 224 and hitting Resident 224 multiple times, on the head and RLE with a cane. A review of Resident 224’s Incident Note, dated 6/28/2025, timed at 5:15 p.m., indicated that on 6/28/2025 at 2:45 p.m., Resident 224 was in the hallway (across Room A) sitting in the wheelchair and was yelling. The Incident Note indicated that CNA 11 observed Resident 45 exiting Room A, approaching Resident 224 and hitting Resident 224 on the head and RLE with a cane and that upon further assessment, bruising and swelling were noted on Resident 224’s RLE and redness on top of Resident 224’s head. The Incident Note indicated Resident 224 complained of mild headache at 3:15 p.m. (on 6/28/2025) and Tylenol 325 mg two tablets were administered to Resident 224 as ordered. A review of Resident 224’s Progress Notes dated 6/29/2025 at 12:10 a.m., 6/29/2025 at 1:08 p.m., 6/30/2025 at 7:04 a.m., 6/30/2025 at 2:49 p.m., and 6/30/2025 at 9:05 p.m. indicated Resident 224 had bruising present on Resident 224’s RLE. A review of Resident 224’s Care Plan (CP) titled, “Resident has been involved in an incident on 6/28/2025 (struck by another resident),” initiated on 6/30/2025 indicated to provide appropriate pain relief measures, including pharmacological (the use of medications to treat prevent a medical condition) and non-pharmacological (not involving medication) interventions as one of the interventions to maintain resident’s safety and comfort. A review of Resident 224’s Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 6/2025 indicated Resident 224 received Tylenol 325 mg two tablets at 3:15 p.m. for a pain level of two out of 10 on the numeric pain rating scale. A review of Resident 45’s Admission Record indicated the facility originally admitted Resident 45, an 85-year-old male, on 6/27/2023 and readmitted in the facility on 5/8/2025 with diagnoses including Alzheimer’s disease, dementia, anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 45’s H&P, dated 5/14/2025 indicated Resident 45 had the capacity to understand and make decisions. A review of Resident 45’s MDS, dated 6/24/2025 indicated Resident 45 had moderately impaired cognition (slight decline in thinking and memory), and usually had the ability to make self understood and understand others. The MDS indicated Resident 45 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating and bed mobility and partial or moderate assistance to substantial/maximal assistance from staff with all other ADLs. A review of Resident 45’s COC form, dated 6/28/2025, timed at 4:56 p.m., indicated that on 6/28/2025 at 2:45 p.m., CNA 11 observed Resident 45 becoming agitated and annoyed at Resident 224 who was yelling from across the hall near his (Resident 45) room (Room A). The COC indicated that CNA 11 observed Resident 45 exiting Room A, approaching Resident 224 and hitting Resident 224 on the head and RLE with a cane. A review of Resident 45’s CP (untitled), initiated on 6/28/2025 indicated Resident 45 was observed manifesting impulsive behavior, physical aggression towards another resident (Resident 224), and being aggressive during afternoon breaks. During an interview on 7/17/2025 at 2:58 p.m. with CNA 11, CNA 11 stated that on 6/28/2025 at 2:45 p.m., as he (CNA 11) was walking past Room C, in the hallway, he (CNA 11) observed Resident 224 sitting in the wheelchair outside Room B, yelling. CNA 11 stated that he (CNA 11) saw Resident 45 exit Room A, which is directly across from Room B, approach Resident 224, and hit Resident 224 on the head and RLE with a single point cane. CNA 11 further stated that Resident 45 was speaking in a foreign language (did not state specific language) with an angry tone and appeared agitated prior to hitting Resident 224. Resident 224 and Resident 45 were separated immediately by the staff (CNA 11 and Licensed Vocational Nurse [LVN] 16). The incident between Resident 45 and 224 is physical abuse as he (CNA 11) witnessed Resident 45 physically hit Resident 224 and he (CNA 11) observed redness on Resident 224’s right lower leg after being hit by Resident 45. During an interview on 7/18/2025 at 9:15 a.m. with Registered Nurse (RN) 4, RN 4 stated she was notified by the Charge Nurse (CN) that on 6/28/2025 at 2:45 p.m., CNA 11 observed Resident 45 became agitated and annoyed due to Resident 224 yelling from across the hall from his (Resident 45) room (Room A). Resident 45 exited Room A approached Resident 224 and hit Resident 224. RN 4 stated that during an interview (on 6/28/2025) with Resident 45, Resident 45 stated that he (Resident 45) wanted Resident 224 to stop yelling. The incident between Resident 224 and Resident 45 was a resident-to-resident physical abuse. All residents in the facility should be free from any type of abuse. During an interview on 7/18/2025 at 12:28 p.m. with Social Services Designee (SS Designee), the SS Designee stated the SS Department follows up with the residents involved after an allegation of abuse for psychosocial support and to ensure the residents their safety while in the facility. During her (SS Designee) visit with Resident 45 on 6/30/2025, Resident 45 stated that Resident 224 was making too much noise, so he (Resident 45) hit Resident 224. The incident between Resident 224 and Resident 45 was physical abuse and the facility should ensure that all residents are free from any type of abuse. During a concurrent interview and record review on 7/18/2025 at 10:05 a.m., with the Risk Management Nurse (RMN), Resident 224’s COC, Incident Note, Progress Notes, and MAR were reviewed. The RMN stated the facility was able to substantiate that physical abuse happened between Residents 224 and 45 and that Resident 224 suffered bruising on the RLE and redness on the head. All residents in the facility have the right to be free from any form of abuse, in order to ensure their safety and well-being at all times. During an interview on 7/18/2025 at 2:30 p.m. with the Director of Nursing (DON), the DON stated that all residents should be free from abuse. The provoking behavior was Resident 224 yelling and making noise in the hallway. Resident 45 became agitated by Resident 224’s yelling and, in response, hit Resident 224 on the head and RLE, resulting in bruising and swelling on Resident 224’s RLE. The incident is considered physical abuse and may have a negative psychosocial impact (refers to the negative effects that an incident has on a person’s mental health, psychological well-being and social interactions) on Resident 224. The DON further stated that the facility failed to prevent the physical abuse between Residents 224 and Resident 45, as CNA 11 was unable to intervene in a timely manner to prevent the incident. During a review of the current facility-provided policy and procedure (P&P) titled, “Abuse Prevention and Prohibition Program,” last reviewed by the facility on 4/28/2025, the P&P indicated, “To ensure the facility established, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to … protect residents, and to ensure a standardized methodology for the prevention … of abuse … in accordance with federal and state requirements. Each resident has the right to be free from abuse…. The Facility has zero-tolerance for abuse…. The staff must not permit anyone to engage in … physical abuse…. The facility is committed to protecting residents from abuse by anyone, including but not limited to … other residents….” The facility failed to protect Resident 224’s right to be free from physical abuse by Resident 45 when on 6/28/2025 at 2:45 p.m., CNA 11 witnessed Resident 45 approached Resident 224 and hit Resident 224 multiple times, on the head and RLE with a single point cane. As a result, Resident 224 was subjected to physical abuse by Resident 45 while under the care of the facility. On 6/28/2025, Resident 224 sustained bruising and swelling secondary to blunt force trauma on the RLE, redness on top of the head, and pain level of two out of 10 on the numeric pain rating scale. Resident 224 complained of mild headache on 6/28/2025 at 3:15 p.m. and Tylenol 325 mg 2 tablets were administered to Resident 224. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 224.