Health inspection·October 9, 2025

F550 §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident’s individuality. The facility must protect and promote the rights of the residents. § 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. § 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. On 9/12/25 at 8:45 AM, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding employee to resident abuse. The facility failed to treat Resident 1 with respect and dignity when Houskeeper 1 (HK 1) yelled and used profanity towards Resident 1 on 9/12/25. This failure resulted in Resident 1 verbalizing feeling mad as a result of the verbal altercation between the resident and HK 1. A review of Resident 1’s Admission Record, indicated Resident 1 was readmitted to the facility on 4/9/2025 with diagnoses including schizoaffective disorder (a mental health condition including schizophrenia [a serious mental health condition that affects how people think, feel and behave] and mood disorder symptoms), extrapyramidal and movement disorder (involuntary movements or muscle stiffness that can occur as a side effect of certain medications, particularly antipsychotic [a class of drugs used to treat mental health conditions characterized by psychosis] drugs) and schizophrenia. A review of Resident 1’s Care Plan for Anxiety manifested by calm to agitated; verbal aggressive to others, revised on 3/27/25. The interventions indicated for staff to encourage residents to utilize coping skills when feeling angry. A review of Resident 1’s Minimum Data Set (MDS, an assessment and screen tool) dated 8/8/2025 indicated Resident 1 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding through thought, experience and the senses). The MDS indicated Resident 1’s potential indicators of psychosis were delusions (misconceptions or beliefs that are firmly held, contrary to reality). A review of Resident 1’s Nursing Progress Notes dated at 9/9/2025 at 2:05PM indicated Resident 1 was verbally aggressive and using profanity towards housekeeper (HK) 1 over the toilet paper being unwrapped and being touched with HK 1’s dirty gloves. The Note indicated Resident 1 became upset and yelled at HK 1 calling her a “bitch.” The Note indicated Housekeeping Supervisor (HS) 1 intervened to explain the protocol for unwrapped toilet paper to Resident 1. The note indicated Resident 1 remained verbally aggressive and both Resident 1 and HS 1 exchanged profanity towards each other. A review of Resident 1’s Program Counselor (PC) Progress Notes dated at 9/9/2025 at 8:19 PM indicated Resident 1 was asked if he felt safe with maintenance and housekeeping and Resident 1 replied “No their body language shows me that they want to kill people, and they don’t clean they just stand there.” A review of Resident 1’s PC’s Follow up Progress Note on 9/10/2025 at 5:27 PM, indicated Resident 1 received one to one counseling for verbal aggression with staff. The Note indicated Resident 1 stated “I wasn’t being aggressive; they were yelling at me.” A review of the investigation statement provided by the facility, dated 9/9/2025, and written by PC 1, indicated PC1 heard and observed Resident 1 and HS 1 exchange profanity toward each other in an escalating verbal confrontation. The statement indicated Resident 1 and HS 1 were going back and forth, raising concerns for further escalation. The statement indicated PC 1 and Mental Healthcare Worker (MHW) 1 intervened promptly to de-escalate and prevent situation from worsening. A review of the undated investigation statement provided by the facility, and written by MHW 2, indicated Resident 1 was in HS 1’s face regarding dirty toilet paper. The statement indicated Resident 1 was upset because HK 1 gave Resident 1’s toilet paper without putting on any gloves. The statement indicated Resident 1 and HS 1 were “cussing” at each other. A review of the facility’s provided investigation statement dated 9/9/2025, and written by HS 1, indicated Resident 1 yelled out “your housekeeping is a ‘bitch.’ The statement indicated HS 1 yelled out of anger “shut the fuck up,” and walked into the janitor closet. During a review of HS 1’s employee file, the file indicated the following: -?Patient’s Rights Policy dated 11/6/2018 and signed by HS 1, indicated staff may not verbally or physically abuse any patient for any reason. The policy indicated staff may not verbally or physically strike a patient intentionally because they are angry or for any other reason. The policy indicated staff must have a great deal of patience and not be influenced to react to a patient’s behavior by verbally or physically striking the patient. -Walk Away Policy dated 11/6/2018 and signed by HS 1, indicated that any staff member who becomes frustrated when assisting a resident must walk away from the situation. The policy indicated if at any time a staff member becomes frustrated with a resident, he or she must walk away from the situation immediately and seek assistance. During an interview on 9/12/2025 at 10:19 AM, the Administrator (ADM) stated Resident 1 was already verbally aggressive towards HK 1, and that HS 1 should not have responded to Resident 1 by returning the verbal abuse since it could escalate verbal abuse to physical abuse. The ADM stated HS 1 would be terminated During an interview on 9/12/2025 at 10:39 AM with PC 1, PC 1 stated he heard a commotion from nursing station 1 and observed Resident 1 being verbally aggressive towards HS 1. PC 1 stated both Resident 1 and HS 1 were yelling at each other. PC 1 stated he separated Resident 1 and HS 1 to prevent situation from escalating. During a telephone interview on 9/12/2025 at 10:52 AM with HS 1, HS 1 stated as he was coming out of the janitor’s closet, he heard Resident 1 yelling and was upset about the toilet paper. HS 1 stated Resident 1 was yelling at HK 1, and when HS 1 tried to talk to Resident 1 to deescalate the situation, Resident 1 came closer, and said “fuck you, you faggot, she’s (HK 1) a bitch.” HS 1 stated he tried to calm Resident 1 down and explained the protocols when housekeeping provides toilet paper to the residents. HS 1 stated Resident 1 continued yelling and HS 1 said to Resident 1 “man, shut the fuck up already,” and walked back to the janitor closet. During an interview on 9/12/2025 at 11:20 AM, infection prevention nurse (IPN) stated Resident 1 could get aggressive and had the tendency to antagonize others. IPN stated Resident 1 was verbally aggressive, and when witnessed, staff must try to deescalate the situation, but also walk away and call for someone to assist the resident to calm down. IPN to prevent further incidents, de-escalation of the situation must be done. During an interview on 9/12/2025 at 11:28 AM with Resident 1, Resident 1 stated he complained to HS 1 about toiled paper and HS 1 got mad and started shouting. Resident 1 stated because HS 1 started shouting “it got me mad, so I started shouting back at him.” Resident 1 stated he could not recall what was said, but stated staff separated Resident 1 and HS 1. Resident 1 stated the incident made him feel mad because he did not understand why HS 1 raised his voice. A review of facility’s policy and procedure (P&P) titled “Abuse, Neglect, Exploitation and Misappropriation Prevention Program,” dated 4/2021 indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, physical abuse, and physical or chemical restraint not required to treat resident’s symptoms. The facility failed to treat Resident 1 with respect and dignity when Houskeeper 1 (HK 1) yelled and used profanity towards Resident 1 on 9/12/25. This failure resulted in Resident 1 verbalizing feeling mad as a result of the verbal altercation between the resident and HK1. This violation had a direct relationship to health, safety, and security to Patient 1 and all patients residing in the facility.