Health inspection·September 16, 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. 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 8/1/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) regarding a resident-to-resident altercation. The facility failed to protect Resident 1’s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) when on 7/25/2025 at approximately 2:30 p.m., Resident 2 threw a cup filled with four ounces (oz – a unit of measurement) of thickened flavored water at Resident 1, inside Room A (Resident 1 and Resident 2's shared room), hitting Resident 1 on the left lower lip.   As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. On 7/25/2025, Resident 1 sustained a three (3) centimeter (cm – unit of measurement) scratch (a type of wound characterized by damage on the surface of the skin) to Resident 1’s left lower lip with bleeding that needed first aid (initial assistance and care given to a resident who has been injured). A review of Resident 1’s Admission Record indicated the facility admitted Resident 1, a 92-year-old male, on 8/19/2024 with diagnoses including cerebrovascular accident (CVA – stroke, loss of blood flow to a part of the brain), hemiplegia (total paralysis [loss of ability to move] of the arm, leg, and trunk on the same side of the body), and dysphagia (difficulty swallowing).   A review of Resident 1’s History and Physical (H&P - a comprehensive assessment of a resident’s medical condition), dated 8/20/2024, indicated Resident 1 did not have the capacity to understand and make decisions.   A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 5/6/2025, indicated Resident 1 had moderately impaired cognitive functioning (a decline in a resident’s mental abilities, impacting their ability to think, learn, remember, reason, and make decisions). The MDS further indicated Resident 1 required maximal assistance (helper does more than half of the effort) from staff with oral hygiene, upper body dressing, and was dependent (helper does all of the effort) on staff for toileting hygiene, showers, and personal hygiene.   A review of Resident 1’s Change of Condition (COC -major decline or improvement in a resident’s status that will not resolve without intervention) form, dated 7/25/2025, timed at 3:51 p.m., indicated that on 7/25/2025 (time not indicated), CNA 1 entered Room A after hearing shouting between two residents (Resident 1 and Resident 2). The COC form indicated that Resident 1 was observed with blood on the lower lip, resulting from a three cm scratch on Resident 1’s left side of the lip. The COC form further indicated that Resident 2 admitted to throwing a four-ounce thickened flavored water cup at Resident 1. The COC form indicated that the scratch on Resident 1’s lower lip was cleansed and left open to air (uncovered). The COC form indicated Resident 1 was placed on monitoring for discoloration (change in the skin’s natural color) of the affected area, monitoring for the condition of the scratch on the left lower lip, and for signs of emotional distress (a state of significant psychological discomfort or suffering, impacting a person's ability to function normally) related to receiving aggression (behaviors intended to cause harm) from Resident 2.   A review of Resident 1’s Care Plan (CP), initiated on 7/28/2025, indicated that Resident 1 sustained a skin tear (a type of wound where the outer layers of skin separate from each other due to friction, shear or blunt force) on the left side of the mouth due to roommate (Resident 2) throwing a cup of thickened liquid at Resident 1 on 7/25/2025. (Resident 1’s COC indicated the injury as scratch.) The CP interventions included cleansing the affected area (Resident 1’s left lower lip) with normal saline (a mixture of water and salt).   A review of Resident 2’s Admission Record indicated the facility admitted Resident 2, a 77-year-old male, on 2/10/2025 with diagnoses including CVA, hemiplegia, and diabetes mellitus (DM – a disorder characterized by difficulty in blood sugar control and poor wound healing).   A review of Resident 2’s H&P dated 2/12/2025 indicated Resident 2 had the capacity to understand and make decisions.   A review of Resident 2’s MDS, dated 5/20/2025, indicated Resident 2 had intact cognitive functioning (the state where a resident’s mental processes, including memory, attention, language, reasoning, and executive functions, are working at a normal or expected level for their age and background). The MDS further indicated Resident 2 required moderate assistance (helper does less than half of the effort) from staff with oral hygiene and upper body dressing. The MDS further indicated Resident 2 required maximal assistance from staff with toileting hygiene, showers, and lower body dressing.   A review of Resident 2’s COC form, dated 7/25/2025, timed at 2:48 p.m., indicated that on 7/25/2025 (time not indicated), CNA 1 entered Room A after shouting was heard between two residents (Resident 1 and Resident 2). The COC form indicated Resident 1 was observed with blood on the lip, resulting from a three cm scratch on the left side of Resident 1’s lower lip. The COC form further indicated that Resident 2 admitted to throwing a four-ounce thickened flavored water cup at Resident 1.   A review of Resident 2’s CP (untitled), initiated on 7/28/2025, indicated that on 7/25/2025, Resident 2 was involved in an incident in which he (Resident 2) threw an object at his roommate (Resident 1).   A review the facility’s five-day conclusion report titled, “Abuse Investigation Reporting Form,” dated 7/28/2025, indicated Resident 2 threw a four-ounce thickened flavored cup at Resident 1 on 7/25 2025 at 2:30 p.m. The report indicated Resident 1 had blood on his lip from a three-centimeter scratch on the left side of the lower lip. The report indicated Resident 1’s left lower lip scratch was cleaned and left open to air.   During an interview on 8/1/2025 at 10:18 a.m., with Resident 2, Resident 2 stated that during an argument (cannot remember the date and time) with his roommate (Resident 1), in Room A, Resident 1 used profanity (offensive language) towards him (Resident 2) after which Resident 2 threw a cup at Resident 1, hitting Resident 1 on the left lower lip. Resident 2 was unable to recall the exact date and time of the incident.   During an interview on 8/1/2025 at 1:18 p.m., with LVN 1, LVN 1 stated the incident (Resident 2 threw a cup at Resident 1) happened at approximately 2:30 p.m., (unable to recall the exact date of the incident). LVN 1 stated LVN 2 requested assistance from her (LVN 1) to provide translation in Room A. LVN 1 stated that during the interview with Resident 1, Resident 1 stated that he (Resident 1) had asked Resident 2 to lower the television volume, at which point Resident 2 threw a cup at Resident 1. LVN  1 further stated that during a separate interview (on 7/25/2025) with Resident 2, Resident 2 admitted to throwing an “object” from his (Resident 2’s) meal tray at Resident 1 to scare him (Resident 1). LVN 1 further stated Resident 1 was observed to have a scratch on the lower lip. LVN 1 stated that the incident between Resident 1 and Resident 2 was physical abuse. LVN 1 further stated that Resident 2 could potentially hit Resident 1 in the head, which could result in a hematoma (a localized collection of blood outside of blood vessels, often resulting in a swollen, painful lump or bruise [an injury where blood vessels under the skin break, causing blood to leak into surrounding tissues]), or other serious injuries.    During an interview on 8/1/2025 at 1:28 p.m., with LVN 2, LVN 2 stated that on 7/25/2025 (unable to recall the exact time of the incident), he (LVN 2) observed CNA 1 exiting Room A and requesting assistance. LVN 2 stated upon entering Room A, LVN 2 observed Resident 1 with bleeding from a scratch on the mouth. LVN 2 stated that during an interview (on 7/25/2025), with LVN 1 providing translation services, Resident 2 admitted to throwing a cup at Resident 1. LVN 2 further stated that the incident between Resident 1 and Resident 2 was resident-to-resident physical abuse (refers to situations where one resident intentionally inflicts physical harm on another resident).   During an interview on 8/4/2025 at 12:05 p.m., with the Director of Nursing (DON), the DON stated that the incident between Resident 1 and Resident 2 was a resident-to-resident physical abuse resulting in Resident 1 sustaining a scratch on his (Resident 1) mouth (left lower lip). The DON further stated that the incident had the potential to negatively affect Resident 1’s psychosocial (refers to the interplay between psychological factors [thoughts, feelings, behaviors] and social factors [relationships, environment, culture]) well-being.   During an interview on 8/4/2025 at 12:40 p.m., with the Administrator, the Administrator stated that the incident between Resident 1 and Resident 2 was a physical abuse that resulted in Resident 1 sustaining a scratch on his mouth (left lower lip).   A review of the current facility-provided policy and procedure (P&P) titled, “Abuse Prevention and Prohibition Program,” last reviewed on 7/28/2025, indicated, “To ensure the facility establishes, 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 …. 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 1’s right to be free from physical abuse when on 7/25/2025 at approximately 2:30 p.m., Resident 2 threw a cup filled with four oz of thickened flavored water at Resident 1, inside Room A (Resident 1 and Resident 2's shared room), hitting Resident 1 on the left lower lip.   As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. On 7/25/2025, Resident 1 sustained a three (3) cm scratch to Resident 1’s left lower lip with bleeding that needed first aid. 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 1.