Health inspection·June 18, 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; California Code of Regulations, Title 22, 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, Title 22, Section 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. (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. California Code of Regulations, Title 22, 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. On 5/6/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility-reported-incident (FRI) about resident-to-resident physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another). The facility failed to protect Resident 1’s right to be free from physical abuse when on 4/22/2025 at 8:40 p.m., Resident 1 and Resident 2, who were both inside Room A (Residents 1 and 2’s room), had a verbal altercation that led to a physical altercation in which Resident 2 punched Resident 1 on the left side of the face with a left closed fist. As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. On 4/22/2025, Resident 1 sustained left face swelling and pain level of seven (severe pain) out of ten on the numeric pain rating scale (a pain assessment tool that uses a scale ranging from zero [no pain] to ten [worst pain imaginable], to quantify pain intensity). Resident 1 was sent to General Acute Care Hospital 1 (GACH 1) on 4/23/2025 at 11:25 a.m. where Resident 1 was diagnosed with a displaced nasal bone fracture (occurs when the bone on the nose was broken into two or more parts allowing the bones to shift out of alignment). A review of Resident 1’s Admission Record indicated the facility admitted Resident 1, a 67-year-old male, on 12/20/2022 with diagnoses including monoplegia (a paralysis that affects a single limb) of lower limb following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side, hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction affecting the right dominant side, and chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow). A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 3/27/2025, indicated Resident 1’s cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. The MDS indicated Resident 1 required supervision (assistance may be provided throughout the activity or intermittently) on rolling left and right, sitting to lying, lying to sitting on the side of the bed, and sitting to standing. A review of Resident 1’s Progress Notes, dated 4/22/2025 at 11 p.m., indicated Resident 1’s skin was checked and documented that Resident 1 had left facial swelling related to the altercation with Resident 2. A review of Resident 1’s Neurological Flowsheet (used to assess, monitor, and record specific neurological [related to the nervous system] status following an injury resulting in suspected or actual head trauma), dated 4/22/2025 to 4/23/2025, indicated on 4/22/2025 at 10 p.m., Resident 1 had seven out of ten on the numeric pain rating scale. A review of Resident 1’s Change in Condition (COC – when there is a sudden change in a resident’s condition) Evaluation, dated 4/23/2025 at 12:30 a.m., indicated Resident 1 had a physical and verbal abuse altercation with Resident 2 on 4/22/2025 (time not indicated). The COC Evaluation indicated Resident 1 had swelling on the face. A review of Resident 1’s Physician Orders, dated 4/23/2025, indicated to transfer Resident 1 to GACH 1 due to facial swelling. A review of Resident 1’s Progress Notes, dated 4/23/2025 at 12:35 p.m., indicated an ambulance transported Resident 1 to GACH 1 on 4/23/2025 at 11:25 a.m. A review of Resident 1’s Physician History and Physical (H&P – comprehensive assessment conducted by a healthcare provider that includes gathering a thorough medical history from the resident and performing a physical examination to assess their overall health and identify any potential medical concern) from GACH 1, indicated on 4/23/2025, Resident 1 was admitted to GACH 1 after Resident 2 hit Resident 1 on the face. The Physician H&P indicated Resident 1 had left side nasal and facial pain and swelling. A review of Resident 1’s GACH 1 computed tomography (CT, a procedure that uses a computer to make a series of detailed pictures of areas inside the body) of the face, dated 4/23/2025, indicated Resident 1 had displaced nasal bone fracture. A review of Resident 2’s Admission Record indicated the facility admitted Resident 2, a 47-year-old male, on 12/3/2021 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), unspecified mood disorder (a person experiencing symptoms related to mood changes that were significant enough to cause distress in daily life but did not meet a mood disorder diagnoses), and schizophrenia (mental disorder in which people interpret reality abnormally). A review of Resident 2’s H&P (from the facility), dated 9/13/2024, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2’s MDS, dated 3/12/2025, indicated Resident 2’s cognition was intact. The MDS indicated under the section for behavioral symptom presence and frequency, Resident 2 had a history of verbal behavioral symptoms directed toward others such as threatening others, screaming at others, and cursing at others. A review of Resident 2’s care plan on aggression, last revised on 3/18/2025, indicated Resident 2 had the potential for verbal aggression (any communication intended to harm someone through words, tone, or manner, such as threats, insults, or harsh criticism). The care plan interventions indicated to document Resident 2’s observed behavior and attempted interventions. A review of Resident 2’s COC Evaluation, dated 4/22/2025, indicated Resident 2 had a change of behavior that led to physical aggression (actions that involve inflicting physical harm or damage) and verbal aggression towards Resident 1. During an interview on 5/6/2025 at 9:33 a.m., Resident 1 stated Resident 2 yelled at Resident 1 to turn the television off. Resident 1 stated he (Resident 1) refused to turn the television off. Resident 1 stated Resident 2 stood up on the right side of Resident 1’s bed and punched Resident 1 on the left side of the face twice with a left closed fist. Resident 1 stated he (Resident 1) required assistance on moving and was not able to defend himself from Resident 2’s punches. Resident 1 stated the left side of his (Resident 1) face became swollen and painful. Resident 1 stated he (Resident 1) was anxious (feeling fear, dread, and uneasiness) and did not feel safe in the facility knowing Resident 2 was in the facility. Resident 1 stated he (Resident 1) was hesitant to go to the activity room knowing Resident 2 also attended activities. During a telephone interview on 5/6/2025 at 11:19 a.m., Licensed Vocational Nurse (LVN) 1 stated she (LVN 1) heard someone yelling with an angry tone. LVN 1 stated she (LVN 1) went inside Room A and found Resident 1 lying in his (Resident 1) bed, while Resident 2 was standing on the right side of Resident 1’s bed. LVN 1 stated she (LVN 1) witnessed Resident 2 punching Resident 1’s face with his (Resident 2) left closed fist twice. LVN 1 stated Resident 1 and Resident 2 were separated by transferring Resident 1 to Room B. LVN 1 stated “maybe one to two hours” after Resident 2 punched Resident 1, Resident 1’s left side of the face (around the cheekbone) and nose were observed swollen that required an ice pack and pain medication. LVN 1 stated Resident 1 refused the pain medication. LVN 1 stated Resident 2 punching Resident 1 was physical abuse. During an interview on 5/6/2025 at 12:39 p.m., Certified Nursing Assistant (CNA) 1 stated she (CNA 1) heard Resident 2 yelling with an angry tone. CNA 1 stated she (CNA 1) ran to Room A and found Resident 2 standing on the right side of Resident 1’s bed. CNA 1 stated Resident 1’s face “looked shocked” and Resident 2’s face was “mad.” CNA 1 stated after Resident 1 was transferred to Room B, Resident 1’s left side of the face was observed swollen. CNA 1 stated Resident 2 punching Resident 1 was physical abuse. During an interview on 5/6/2025 at 4:30 p.m., the Director of Nursing (DON) stated residents should be free from abuse. The DON stated a person intentionally punching another person was considered physical abuse. The DON stated Resident 2 punching Resident 1 was considered abuse. The DON stated Resident 1 sustained injury from Resident 2’s punch. The DON stated Resident 1 had the potential for negative psychosocial effects (the interrelation of social factors and individual thoughts and behavior). The DON stated the facility failed to ensure Resident 1 was not subjected to any abuse and to ensure the safety and overall well-being of the residents. A review of the current facility-provided policy and procedure (PnP) titled, “Abuse Prevention, Screening, and Training Program,” last reviewed on 4/4/2025, indicated the purpose is “To address the health, safety, welfare, dignity, and respect of residents by preventing abuse…. The Facility does not condone any form of resident abuse … and develops Facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse…. Definitions: ‘Abuse’ is defined as the willful, deliberate infliction of injury…. It includes verbal abuse, … physical abuse…. ‘Verbal abuse’ is defined as any use of oral, written, gestured communication, or sounds that willfully includes disparaging and derogatory terms directed to residents within their hearing distance, regardless of age, ability to comprehend, or disability (physical or mental condition that limits a resident’s movements, senses, or activities)…. ‘Physical abuse’ is defined as, but not limited to, hitting, slapping, punching, and/or kicking….” The facility failed to protect Resident 1’s right to be free from physical abuse when on 4/22/2025 at 8:40 p.m., Resident 1 and Resident 2, who were both inside Room A, had a verbal altercation that led to a physical altercation in which Resident 2 punched Resident 1 on the left side of the face with a left closed fist. As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. On 4/22/2025, Resident 1 sustained left face swelling and pain level of seven out of ten on the numeric pain rating scale. Resident 1 was sent to GACH 1 on 4/23/2025 at 11:25 a.m. where Resident 1 was diagnosed with a displaced nasal bone fracture. The above 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 to Resident 1.