Health inspection·October 24, 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. 22 CFR § 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 CFR § 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. 22 CFR § 72527 Patients' 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. On 9/10/2025, the California Department of Public Health (CDPH) received a facility reported incident (FRI) regarding a resident-to-resident abuse allegation. On 9/11/2025, the CDPH conducted an unannounced visit at the facility to investigate the abuse. Based on observation, interview, and record review, the facility failed to protect Resident 1's right to be free from physical abuse by Resident 2 when, Resident 2 slapped Resident 1 on the right side of the face. a. Resident 1 was an 87-year-old female, admitted to the facility on 10/14/2022 and readmitted on 10/31/2024 with diagnoses including Alzheimer's disease and major depressive disorder. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/16/2025, indicated Resident 1 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 1 required supervision with eating and using a wheelchair. The MDS indicated Resident 1 required partial assistance with oral hygiene and personal hygiene. The MDS indicated Resident 1 required maximal assistance with toileting hygiene and showering/ bathing. The MDS indicated Resident 1 was dependent on staff for bed-to-chair transferring. A review of Resident 1's History and Physical (H&P), dated 11/1/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's care plan titled "Resident at risk for recurrent fall/injury," revised on 7/23/2025, indicated staff were to observe Resident 1 frequently and to place Resident 1 in a supervised area when out of bed. A review of Resident 1's nursing progress notes, dated 9/10/2025 at 9:33 a.m., indicated on 9/10/2025 at 9:05 a.m., Licensed Vocational Nurse (LVN) 1 reported to Registered Nurse (RN) 1 that Resident 2 slapped Resident 1. b. Resident 2 was an 82-year-old female, admitted to the facility on 12/22/2021 with diagnoses including dementia, anxiety, and major depressive disorder. A review of Resident 2's MDS, dated 8/29/2025, indicated Resident 2 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 2 required setup assistance with eating, oral hygiene, toileting hygiene, and bed-to-chair transferring. The MDS indicated Resident 2 required supervision with showering/ bathing, personal hygiene, and walking. A review of Resident 2's H&P, dated 8/18/2025, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's care plan titled "Chronic confusion related to dementia as evidenced by altered interpretation or response to stimuli," revised on 8/29/2025, indicated staff were to maintain a pleasant and quiet environment. A review of Resident 2's nursing progress notes, dated 9/10/2025 at 9:41 a.m., indicated on 9/10/2025 at 9:05 a.m., LVN 1 reported to RN 1 that Resident 2 slapped Resident 1. During an interview on 9/11/2025 at 11:14 a.m., CNA 1 stated on 9/10/2025 around 8:50 a.m., he entered Resident 1 and Resident 2's room and informed Resident 1 that it was time to shower. Resident 1 replied "No" which upset Resident 2. CNA 1 stated she left the room to get a Hoyer lift (a device that helped move people with limited mobility safely between surfaces) to transfer Resident 1 from a wheelchair to a shower chair. CNA 1 stated she left Resident 1 in the wheelchair by her bedside. CNA 1 stated within four seconds of leaving the room, she heard Resident 2 cursing at Resident 1. CNA 1 stated when she returned to the room Resident 1 was next to Resident 2's bed. CNA 1 stated Resident 2 got out of the bed, cursed at Resident 1, slapped Resident 1's right side of her face and punched Resident 1's stomach. CNA 1 stated she would not have left Resident 1 alone in the room with Resident 2, if she knew Resident 1 could unlock the wheelchair and wheel herself to Resident 2's bedside. CNA 1 stated she should have taken Resident 1 with her when she left the room to get the Hoyer lift to prevent Resident 2 from physically attacking Resident 1. During an interview on 9/11/2025 at 12:23 p.m., LVN 1 stated on 9/10/2025 at 9 a.m., she was passing medication outside Room A. LVN 1 stated CNA 1 walked to her quickly from Resident 1's room and informed her that Resident 2 slapped Resident 1 on the right side of her face. LVN 1 stated CNA 1 did not bring Resident 1 with her. LVN 1 stated she rushed to Resident 1's room and observed Resident 1 sitting in the wheelchair at her bedside, and Resident 2 sleeping in bed. LVN 1 stated she separated the residents and placed Resident 1 in another room. LVN 1 stated Residents 1 and 2 were not able to provide any details about what happened. LVN 1 stated it was not acceptable to leave Resident 1 alone with Resident 2 because of the risk of verbal, physical, or emotional abuse. LVN 1 stated the incident would have been prevented if CNA 1 removed Resident 1 from the room when Resident 2 became upset. During an interview on 9/12/2025 at 10:41 a.m., RN 1 stated on 9/10/2025 around 9 a.m., LVN 1 informed her that Resident 2 slapped Resident 1 on the right side of the face. RN 1 stated Resident 1 could self-propel in the wheelchair and go to Resident 2's side of the room. RN 1 stated it was not acceptable to leave Resident 1 in the room with Resident 2 after Resident 2 slapped Resident 1. RN 1 stated CNA 1 should have removed Resident 1 away from Resident 2 immediately when Resident 2 became verbally aggressive toward Resident 1. RN 1 stated Resident 1 was not protected. During an interview on 9/12/2025 at 12:25 p.m., the Administrator in Training (AIT) stated the facility should provide a safe environment for residents. The AIT stated it was not acceptable to leave Resident 1 in the same room as Resident 2 after the incident. The AIT stated Resident 1 was not protected. The AIT stated Resident 2 slapping Resident 1 was preventable. The AIT stated CNA 1 should not have left Resident 1 in bed or asked someone to bring the Hoyer lift to the room. A review of the facility's Certified Nursing Assistant Job Description, undated, the Job Description indicated the certified nursing assistant's responsibilities included implementing the individualized plan of care of the assigned residents. A review of the facility's Policy and Procedure (P&P) titled "Abuse Policy," dated 10/2024, the P&P indicated residents would be protected from abuse and harm while residing at the facility. The P&P indicated no abuse or harm of any type would be tolerated, and residents would be monitored for protection. The P&P indicated all staff should monitor residents and identify potential signs and symptoms of abuse. The P&P indicated residents would be protected from the alleged offenders. The P&P further indicated that staff witnessing abuse would immediately intervene to protect the resident. The facility failed to protect Resident 1's right to be free from physical abuse by Resident 2. As a result, Resident 2 slapped Resident 1 on the right side of the face. This violation had a direct or immediate relationship to the health, safety, or security of residents.