Health inspection·October 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. § 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. § 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. 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 08/12/2025, the California Department of Public Health (CDPH) received a facility-reported incident (FRI) alleging that Resident 2 physically abused Resident 1. On 08/20/2025, CDPH conducted an unannounced visit to the facility. Based on observation, interview, and record review, the investigation determined the facility failed to protect Resident 1's right to be free from physical abuse. The facility failed to: 1. Ensure Resident 2 was prevented from physically abusing Resident 1 in accordance with the policy and procedure (P&P) titled, "Abuse, Neglect, and Exploitation," undated As a result, Resident 1 sustained discoloration and redness to the left eye after being punched on 8/10/2025. A review of Admission Record indicated Resident 1 was 91-years old male, admitted to the facility on 02/02/2023 and readmitted on 10/02/2023 with diagnoses including schizophrenia and anxiety disorder. A review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 05/22/2025, indicated Resident 1's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 1 needed set up or clean up assistance with eating and supervision with oral hygiene, toileting, showering and dressing. A review of Admission Record indicated Resident 2 was 33 years old male, admitted to the facility on 11/18/2024 with diagnoses including schizoaffective disorder and unspecified psychosis. A review of Resident 2's MDS, dated 05/30/2025, indicated Resident 1's cognitive skills for daily decision making were intact. The MDS indicated Resident 2 required supervision or touching assistance with oral hygiene, toileting and dressing. The MDS indicated Resident 2 needed supervision or touching assistance with transfer and ambulation. A review of the facility's final investigation report indicated that Resident 2 claimed he hit Resident 1 on the head with his fist after Resident 1 refused to return a pair of shoes he (Resident 1) had taken. During a concurrent observation and interview on 08/20/2025 at 10:36 a.m. with Resident 1, Resident 1 was observed with left eye discoloration. Resident 1 appeared confused and could not recall what happened to his left eye. Resident 1 stated there were no issues with his left eye and refused to answer further questions. During a telephone interview on 08/20/2025 at 11:59 a.m., Resident 2's family members (FM) 1 stated Resident 2 informed FM 1 that Resident 1 was wearing Resident 2's shoes and he asked Resident 1 to remove them. FM 1 stated Resident 2 got upset and punched Resident 1 because he refused to remove Resident 2's shoes. FM1 stated staff did not intervene when Resident 2 was asking for his shoes from Resident 1. During a telephone interview on 08/21/2025 at 08:37 a.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 1 was assigned to her on 8/10/2025. CNA 1 stated she made her rounds during the night of 8/10/2025. but Resident 1 was asleep with his head covered up with a blanket. CNA 1 stated she did not like to bother residents at night when they sleep so she does not wake them up and look at their faces. CNA 1 stated she should have ensure to take a closer look at the residents when she makes rounds, especially at night. CNA 1 stated moving forward she would make sure she assessed residents when she makes her rounds to ensure they were okay. CNA 1 stated for safety she should not go through the shift without seeing the residents' face, because all staff are supposed to protect and keep residents safe. During a phone interview on 08/21/2025 at 10:10 a.m., with Licensed Vocational Nurse 1 (LVN 1), she was not aware Resident 1 was punched by Resident 2 in the face as no one reported it to her during her shift. LVN 1 stated she cannot recall seeing Resident 1's face during the change of shift reports (11 p.m.-7 a.m. shift). LVN 1 stated she makes rounds every hour but did not see any incident that happened on 8/10/2025. LVN 1 stated she should have seen all residents faces when she makes rounds to assess residents as it is part of resident assessment regardless of whether it was the night shift or not. LVN 1 stated she should look at residents' faces to see if any abnormality can be addressed in a timely manner. During an interview on 08/21/2025 at 12:31 p.m., with the Director of Nursing (DON), the DON stated all staff were supposed to check on all residents to make sure they were safe. The DON stated staff should see each resident face to face when they do the rounding. The DON stated regardless of any situation, all residents have the right to be free from any type of abuse. During a review of the facility's P&P titled, "Abuse, Neglect, and Exploitation," undated, indicated "Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The P&P indicated Resident must not be subject to abuse by anyone, including, but not limited to other residents." The facility failed to: 1. Ensure Resident 2 was prevented from physically abusing Resident 1 in accordance with the policy and procedure (P&P) titled, "Abuse, Neglect, and Exploitation," undated As a result, Resident 1 sustained discoloration and redness to the left eye after being punched on 8/10/2025. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.