Health inspection·June 20, 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. §483.12(a) The facility must— §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 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 § 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. 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 § 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. An unannounced visit was conducted by California Department of Public Health (CDPH) on 5/5/2025 to conduct an annual recertification survey and investigate a facility reported incident (FRI) regarding an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) that a resident (Resident 312) flipped over another resident’s (Resident 30) wheelchair while Resident 30 was sitting on the wheelchair on 5/3/2025 at around 6:30 PM. The facility failed to protect Resident 30’s right to be free from abuse by another resident in accordance with the facility’s policies and procedures (P&P) titled Abuse Prevention and Prohibition Program. This resulted in Resident 30 hitting her head on a doorway after Resident 312 tipped over the wheelchair that Resident 30 was sitting on. 1. A review of Resident 312’s Admission Record, the Admission Record indicated Resident 312, a 59-year-old-male, was admitted to the facility on 3/24/2025 with diagnoses that included early onset Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities), major depressive disorder (a common mental health condition characterized by a persistent low mood, loss of interest or pleasure in activities, and other symptoms that can significantly interfere with daily life), hallucinations (false sensory perceptions), and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 312’s Minimum Data Set (MDS, resident assessment screening tool), dated 3/28/2025, the MDS indicated the resident had severe impairment of cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 312 experienced hallucinations. Resident 312 required partial/moderate assistance (helper does less than half the effort) for toileting hygiene, showering, lower body dressing and putting on/taking off footwear. Resident 312 required supervision (helper provides verbal cues or touching assistance) for upper body dressing. Resident 312 required set up or clean up assistance (helper sets up or cleans up) for eating, oral hygiene, and personal hygiene. A review of Resident 312’s Progress Notes, dated 5/3/2025 at 11:19 PM, the Progress Notes indicated that at 6:30 PM Resident 312 tipped over Resident 30 who was sitting on a wheelchair causing Resident 30 to fall on the ground and hit her right temporal (side of the head) area. 2. A review of Resident 30’s Admission Record, the Admission Record indicated Resident 30, a 94-year-old-female, was admitted to the facility on 3/15/2024 with diagnoses that included Parkinson’s Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Type 2 Diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). A review of Resident 30’s MDS, dated 3/22/2025, the MDS indicated the resident had severe impairment of cognitive skills for daily decision making and short term/long term memory problems. The MDS indicated Resident 30 used a wheelchair. Resident 30 required partial/moderate assistance for toileting hygiene, showering, lower body dressing, personal hygiene and putting on/taking off footwear. Resident 30 required supervision for oral hygiene, and upper body dressing. Resident 312 required set up or clean up assistance for eating. A review of Resident 30’s Progress Notes, dated 5/3/25 at 6:50 PM, the Progress Notes indicated Resident 312 flipped Resident 30 while Resident 30 was sitting on a wheelchair causing Resident 30 to hit her head on the doorway. The Progress Notes indicated Resident 30 sustained a minor skin tear on the right side of her scalp with minor bleeding. During an interview on 5/7/2025 at 10:37 AM with Certified Nurse Assistant 7 (CNA 7), CNA 7 stated that she saw Resident 312 flip over the wheelchair where Resident 30 was sitting on. CNA7 stated Resident 30 hit her head on the doorframe. Resident 30 was bleeding from the right side of her head behind her temple. A review of Resident 312’s Care Plan (CP) titled, “The resident has a behavior problem, flipped the chair of another resident while wheeling towards the dining room causing the other resident to fall.” Dated 5/3/2025, the CP indicated that interventions included: 1. Anticipate the needs of the resident. 2. Intervene as necessary to protect the rights and safety of others. 3. Monitor behavior episodes and attempt to determine underlying cause. During a concurrent interview and record review on 5/8/2025 at 4:05 PM with the Director of Nursing (DON), the facility’s policy and procedure (P&P) titled, “Abuse Prevention and Prohibition Program”, dated 8/1/2023 was reviewed. The P&P indicated: 1. Each resident has the right to be free from abuse. 2. The facility is committed to protecting residents from abuse by anyone. DON stated, residents have the right to be free from abuse but Resident 30 was abused by Resident 312. DON stated that Resident 312 was not monitored enough to prevent the abuse incident. The facility failed to protect Resident 30’s right to be free from abuse by another resident in accordance with the facility’s policies and procedures (P&P) titled Abuse Prevention and Prohibition Program. This resulted in Resident 30 hitting her head on a doorway after Resident 312 tipped over the wheelchair that Resident 30 was sitting on. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 30.