Health inspection·April 17, 2025

§483.12(a)(1) 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. (a)The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. §72315(b) 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. §72523(a) 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 2/26/2025, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) regarding verbal abuse from Licensed Vocational Nurse 2 (LVN 2) toward resident (Resident 2). On 3/5/2024, the CDPH conducted an unannounced visit to the facility to investigate the FRI. Upon investigation the CDPH determined LVN 2, and Resident 2 were involved in a verbal altercation in which LVN 2 cursed at Resident 2, calling Resident 2 a "B****." The facility failed to: 1. Ensure Resident 2 was free from verbal abuse, when LVN 2 and Resident were involved in a verbal altercation and LVN 2 cursed at Resident 2 by calling the resident a "b****." 2. Follow the facility Policy and Procedure (P/P) titled, "Residents Rights," which indicated residents had the right to be free from mental and physical abuse. These deficient practices resulted in Resident 2 feeling unsafe while LVN 2 was working in the facility and had the potential to cause Resident 2 psychosocial (mental, emotional, and social) harm. Findings: A review of Resident 2's Admission Record (Face Sheet), indicated Resident 2, a 53-year-old female, was admitted to the facility on 1/16/2025 with a diagnosis of anxiety disorder (a mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities). A review of Resident 2's Minimum Data Set ([MDS] resident assessment tool), dated 2/5/2025, indicated Resident 2 was mildly cognitively (ability to think and reason) impaired. A review of the facility's Investigation Report, dated 2/26/2025, indicated on 2/25/2025 Resident 2 requested to speak to LVN 2 regarding her (Resident 2's) medication. The Investigation Report indicated LVN 2 told Resident 2 that she had already given her, her medication. The Investigation Report indicated Resident 2 asked LVN 2 if her doctor had spoken to the psychiatrist regarding her medication. The Investigation Report indicated Resident 2 cursed at LVN 2 who cursed back at Resident 2. During an interview on 3/5/2025 at 12:26 p.m., Resident 2 stated on 2/25/2025, sometime around 8 p.m., LVN 2 came in her room angry because she (Resident 2) requested to speak with her. Resident 2 stated LVN 2 was yelling and stated she was on her break and had already given her, her medication. Resident 2 stated she expressed to LVN 2 that she did not feel right and wanted the dosage of her medication adjusted. Resident 2 stated LVN 2 reminded her again that she was on her break, so she (Resident 2) told her Family Member (FM) who was on the phone with her, that LVN 2 was a "f****ing b****" and LVN 2 responded "no you're a f****** b****." Resident 2 stated she was angry that LVN 2 responded to her that way, when all she wanted was for LVN 2 to contact her physician about her medication. Resident 2 stated LVN 2's response triggered her which was why she cursed at LVN 2. Resident 2 stated she did not feel safe the rest of the shift with LVN 2 as her nurse. During an interview on 3/5/2025 at 1:09 p.m., Resident 4, (Resident 2's roommate), stated she witnessed LVN 2 curse at Resident 2 on 2/25/2025. Resident 4 stated it was upsetting to see that LVN 2 had no patience or empathy when Resident 2 cursed at her, and she was disappointed how aggressive and brutal (yelling and curing) LVN 2's response was to Resident 2. During an interview on 3/5/2025 at 2:13 p.m., LVN 2 stated on 2/25/2025, while she was on break, CNA 1 informed her that Resident 2 wanted to speak to her about her medication. LVN 2 stated she was on break but went to see Resident 2 to make sure it was nothing urgent. LVN 2 stated she informed Resident 2 that she had given her all of her medications, but Resident 2 told her she did not feel right and believed there had been changes made to her medication and wanted to discuss it with her physician. LVN 2 stated, she asked Resident 2 if she had discussed this with any of the other nurses and began looking into her chart to see if there were any changes but was not able to find any. LVN 2 stated, Resident 2 told her next time do not come here on your break. LVN 2 stated Resident 2 called her a "b****" to which she (LVN 2) replied, "If I'm a b**** you are one too." LVN 2 stated she was shocked that she cursed back at Resident 2 and had not been able to sleep since it happened. LVN 2 stated she resigned from the facility after that. During an interview on 3/5/2025 at 3:19 p.m., the Director of Nursing (DON) stated LVN 2 was suspended for verbally abusing Resident 2. The DON stated verbal abuse by LVN 2 towards Resident 2 was inappropriate and could cause mental or emotional harm. The DON stated LVN 2 resigned after being suspended. A review of facility's P&P titled, "Residents Rights" dated 9/2017, indicated residents had the right to be free from mental and physical abuse. The facility failed to: 1. Ensure Resident 2 was free from verbal abuse, when LVN 2 and Resident were involved in a verbal altercation and LVN 2 cursed at Resident 2 by calling the resident a "b****." 2. Follow the facility P/P titled, "Residents Rights," which indicated residents had the right to be free from mental and physical abuse. These deficient practices resulted in Resident 2 feeling unsafe while LVN 2 was working in the facility and had the potential to cause Resident 2 psychosocial harm. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 2.