Health inspection·July 3, 2025

F600 Federal Code Regulations §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. California Code of Regulations, Section 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. California Code of Regulations, Section 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. California Code of Regulations, Section 72527. Patient 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 5/22/25, the California Department of Public Health (CDPH) conducted an unannounced visit to investigate a Facility Reported Incident regarding resident abuse. As a result of the investigation, the CDPH determined the facility failed to protect Resident 2’s right to be free from physical abuse from Resident 1 when Resident 1 hit/punched Resident 2’s face. Resident 2 sustained a laceration on the left eyebrow that required examination and cleaning at the General Acute Care Hospital 1 (GACH 1). 1. A review of Resident 1's Admission Record (AR) indicated the facility admitted Resident 1, a 55-year-old male on 10/11/24 and readmitted on 2/1/25 with diagnoses including Huntington's disease, unspecified dementia with psychotic disturbance and schizophrenia. A review of Resident 1's History & Physical (H&P) dated 2/3/25 indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS) dated 2/7/25 indicated Resident 1's cognition was moderately impaired. The MDS indicated Resident 1 had no impairment in the upper or lower extremity range of motion and Resident 1 ambulated independently. A review of Resident 1's Psychosocial Care Plan (CP) dated 2/26/25 indicated Resident 1 had a habit of disliking anyone while preparing coffee, or drinking coffee, and Resident 1 had angry outburst due to psychiatric disturbance. The CP interventions indicated for staff to intervene as necessary to protect the rights and safety of others. A review of Resident 1's CP titled "Behavior" dated 3/6/25 indicated Resident 1 had an episode of hitting another resident. The CP interventions indicated to monitor the resident's whereabouts in the facility. A review of Resident 1's Psychiatric Note dated 3/11/25 indicated Resident 1 had significantly impaired coping skills. A review of Resident 1's CP titled, "Behavior” dated 3/24/25 indicated Resident 1 had alteration in behavior pattern related to psychosis manifested by refusing care and striking out. The CP interventions indicated to keep Resident 1 away from other residents when agitated. 2. A review of Resident 2's AR indicated the facility admitted Resident 2, a 60-year-old male on 7/31/24 with diagnoses including thrombocytopenia, hemiplegia/ hemiparesis and unspecified dementia. A review of Resident 2's MDS dated 4/30/25 indicated Resident 2 had severe cognition impairment. The MDS indicated Resident 2 had impairment in the upper or lower extremity range of motion on one side and Resident 2 used a wheelchair for ambulation. A review of Resident 2’s H&P dated 1/21/25 indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's Nurse Progress Notes (NPN) dated 5/16/25 indicated Resident 2 claimed Resident 2 was hit by Resident 1. Resident 2 had a laceration to the top of the left eyebrow with discoloration and redness to the left upper cheek. Resident 1 was observed standing in front of Resident 2 with a water pitcher and there was spilled water on the floor. A review of Resident 2's GACH 1 Emergency Department (ED) General Noted dated 5/16/25 indicated Resident 2 was punched in the face and sustained a left eyebrow laceration. The ED note indicated Resident 2 had a history of an intercranial bleed with no suspicion of intercranial injury or bone fracture. The ED note indicated the plan was to clean Resident 2’s wound and follow up with Resident 2’s primary physician within 2-3 days or return to ED with worsening symptoms or conditions. During an interview with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated Resident 1 was “possessive” with his belongings, such as coffee & cups and would respond with physical aggression if someone would get in Resident 1’s space. CNA 1 stated CNA 1 heard a loud "Hey" coming from Resident 1's room and Resident 2 was propelling his wheelchair down the hallway. CNA 1 stated Resident 1 was in the hallway, and CNA 1 saw Resident 1's cup and a puddle of water on the floor. CNA 1 stated CNA 1 noticed redness and a cut above Resident 2's eyebrow. CNA 1 stated, in the past, Resident 1 was aggressive to other residents. During an interview with CNA 2 on 5/22/25 at 3:23 p.m., CNA 2 stated Resident 1 always had behaviors of aggression. CNA 2 stated, in the past, Resident 1 threw coffee at CNA 2 when CNA 2 was standing in front of the coffee cart. During an interview with CNA 3 on 5/22/25 at 3:45 p.m., CNA 3 stated, in the past, other CNAs stated Resident 1 had hit them. The facility failed to protect Resident 2’s right to be free from physical abuse from Resident 1 when Resident 1 hit/punched Resident 2’s face and Resident 2 sustained a laceration on the left eyebrow that required examination and cleaning at the General Acute Care Hospital 1 (GACH 1). These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 2.