Health inspection·May 30, 2025

F600 42 CFR § 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. (a) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 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. (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. 42 CFR § 483.12(b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95. 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 § 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 CCR § 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. An unannounced visit was conducted by California Department of Public Health (CDPH) on 4/15/2025 at 11:36 AM to investigate a Facility Reported Incident regarding an allegation that a facility nurse “smacked” Resident 1’s back on 4/10/2025. The facility failed to (1) protect Resident 1’s right to be free from physical abuse and corporal punishment, (2) treat Resident 1 with respect and dignity, and (3) follow its policies and procedures when on 4/10/2025 at around 4:42 PM, Certified Nurse Assistant 1 (CNA 1) grabbed Resident 1’s shirt from the back causing the shirt to choke Resident 1’s neck area and slapped Resident 1’s back, which made a loud smacking noise. This resulted in Resident 1 experiencing physical abuse from CNA 1 and had the potential to affect Resident 1’s emotional, mental, and psychosocial (relating to social factors and individual thought and behavior) well-being. A review of Resident 1’s Admission Record, the Admission Record indicated the facility admitted Resident 1, a 78-year-old-female, on 3/11/2025 with diagnoses that included, but not limited to, delirium (a serious disturbance in a person’s mental abilities that results in a decreased awareness of one’s environment and confused thinking), depression (a common and serious mental health disorder that negatively affects how you feel, think, act, and perceive the world), dementia (a progressive state of decline in mental abilities), and mood disorder (a mental health condition characterized by persistent and significant changes in mood that interfere with daily functioning and well-being). A review of Resident 1’s Minimum Data Set (MDS-a resident assessment tool) dated 3/1/2025, the MDS indicated Resident 1 had severe impairment of cognitive skills for daily decision making. The MDS indicated Resident 1 required set up or clean up assistance (Helper sets up or cleans up, but resident completes the activity with eating, oral, and personal hygiene. The MDS indicated Resident 1 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with upper body dressing. The MDS indicated Resident 1 required partial/moderate assistance (Helper lift, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, lower body dressing and putting on/taking off footwear. The MDS also indicated Resident 1 required substantial/maximal assistance (Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathing self. During an interview on 4/15/2025 at 2:47 PM with CNA 2, CNA 2 stated she was at the nurses’ station 1 on 4/10/2025 around 4:42 PM when CNA 2 witnessed CNA 1, who was assigned one-to-one monitoring (1:1 monitoring involves a single staff member providing continuous supervision to a resident for a specific period, ensuring their safety and well-being) for Resident 1, held Resident 1’s shirt from the back causing the shirt to choke Resident 1 from the front neck area as Resident 1 got up from the chair. CNA 2 stated, CNA 1 later told CNA 2 that CNA 1 did it to stop Resident 1 from moving towards the nursing station desk and reaching for things from the nurse’s station. CNA 2 stated, as Resident 1 started to walk towards the nursing station desk, when Resident 1 suddenly turned towards CNA 1 and threw a cup of water at CNA 1’s face. CNA 2 stated that CNA 1 then slapped Resident 1’s back with CNA 1’s left hand which made a loud slapping sound. CNA 2 stated staff cannot hit residents when residents are aggressive to staff. CNA 2 stated the Administrator (ADM) also witnessed the incident. During an interview on 4/15/2025 at 2:55 PM with CNA 3, CNA 3 stated, CNA 3 was also at the nurses’ Station 1 on 4/10/2025 at 4:42 PM when Resident 1 stood up from the chair to grab something at the nursing station desk, CNA 1 grabbed Resident 1’s shirt from the back and caused the shirt to choke Resident 1 from the neck area to stop Resident 1 from getting to the nursing station desk and that was when Resident 1 threw a cup of water at CNA 1’s face. CNA 3 stated she saw CNA 1 and was startled that CNA 1’s reflex/ immediate response was to slap Resident 1’s back, which made a loud smacking noise. During a concurrent interview and record review on 4/15/2025 at 4 PM with ADM, the facility’s surveillance video recorded on 4/10/2025 at 4:42 PM was reviewed. The surveillance video showed Resident 1 was seated in a chair at the nurses’ station 1 then Resident 1 stood up and walked closer to the desk, while CNA 1 grabbed Resident 1’s shirt from the back to stop her from getting to the nursing station desk. Resident 1 turned to CNA 1 and threw a cup of water in CNA 1’s face. The video surveillance showed CNA 1 then hit Resident 1’s back with CNA 1’s left hand. ADM stated that according to the video surveillance, the facility staff who slapped Resident 1’s back was CNA 1. ADM stated he was standing at ADM’s office door facing nurses’ station 1 on 4/10/2025 at 4:42 PM and witnessed CNA 1’s physical abuse to Resident 1. ADM stated Resident 1 was seated in a chair at the nurses’ station 1, then Resident 1 stood up and walked towards the desk. ADM stated CNA 1 held Resident 1’s shirt from the back to stop Resident 1 from throwing a cup of water in CNA 1’s face. ADM stated CNA 1 did not follow the facility’s policy on abuse. A review of the facility’s Policy and Procedures (P&P) titled, “Abuse, Neglect, Exploitation and Misappropriation Prevention Program,” revised April 2021, indicated: • Residents have the right to be free from abuse, this includes physical abuse. • Protect residents from abuse by anyone including, but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, friends, visitors, and/or any other individual. • Develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents. • Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. • Implement measures to address factors that may lead to abusive situations, for example: adequately prepare staff for caregiving responsibilities; help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. The facility failed to (1) protect Resident 1’s right to be free from physical abuse and corporal punishment, (2) treat Resident 1 with respect and dignity, and (3) follow its policies and procedures when on 4/10/2025 at around 4:42 PM, Certified Nurse Assistant 1 (CNA 1) grabbed Resident 1’s shirt from the back causing the shirt to choke Resident 1’s neck area and slapped Resident 1’s back which made a loud smacking noise. This resulted in Resident 1 experiencing physical abuse from CNA 1 and had the potential to affect Resident 1’s emotional, mental, and psychosocial well-being. These 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.