Health inspection·December 4, 2025

Title 42, F600, Freedom from Abuse and Neglect Section 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 sub part. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat their resident's medical symptoms. Section 482.12(a) The facility must- Section 482.12(a)(1) Not use verbal, mental, sexual or physical abuse, corporal punishment, or involuntary seclusion. California Code of Regulations, Title 22, Section 72311, Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, 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, Title 22, 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 9/26/25 at 12:05 p.m., an announced visit was conducted at the facility to investigate a facility reported incident regarding injuries of unknown origin to Resident 1's face. As a result of the investigation, the Department determined that the facility failed to protect Resident 1 from abuse, when Resident 2 who had a history of verbal aggression struck Resident 1 in the face, which resulted in Resident 1 sustaining lacerations (a type of wound that occurs when skin is forcefully torn) to his nose, eyebrow, and face, caused pain to Resident 1, and had the potential to experience emotional distress. Findings: Resident 1 was admitted to the facility on 5/8/25 with multiple diagnoses which included dementia (a progressive state of decline in mental abilities) and cognitive communication deficit (difficulty with communication). A review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 8/11/25 indicated the resident had severe cognitive impairment. A review of Resident 1's care plan addressing cognitive impairment dated 9/25/25 indicated that resident had decreased ability to communicate with others, understand others and impaired decision making. The nursing measures directed staff to anticipate Resident 1's needs and meet them promptly. A review of Resident 1's care plan titled "Injury," dated 9/10/25 indicated the resident had injury to his face "as evidenced by lacerations to right eyebrow, abrasion [a skin scrape] with swelling on nose bridge area and discoloration on right periorbital area [the area around the eye, from the eyebrows down to cheekbones] with swelling d/t [due to] alleged abuse." During an observation in the presence of Licensed Nurse (LN ) 1 on 9/25/25, at 12:15 p.m., Resident 1 was sitting in wheelchair in the dining room getting ready to eat his lunch. Resident 1 was observed with a swollen nose, dry scab on the bridge of the nose and on his right eyebrow. Resident 1's nose area and right periorbital area had large fading yellow-purplish bruises. Resident 1 was asked what happened to his face and the resident was not able provide any details. Resident 1 was asked if he had a fall and injured himself or he obtained the injury when someone hit him, and the resident was not able to explain what happened. A review of Resident 1's clinical records contained a document titled, "SBAR Summary for Providers [Situation, Background, Assessment, and Recommendation] a Communication Form" dated 9/10/25, at 9:47 a.m., informing resident's physician that the resident experienced a change of condition (COC). The COC document indicated, "At approximately 09:30, resident reported to staff that another male individual allegedly struck him. Resident stated, "he hit me because he said I was making noise, but I wasn't." The document indicated that Resident 1 had laceration on his right eyebrow measuring 2 cm (centimeters, unit of measurement) in width, 3 cm in length, and 0.5 cm deep, laceration to his nose 2 cm wide and 3 cm long, and laceration to cheek 1 cm wide and 2 cm long. The note indicated, "Resident c/o [complained of] pain [sic] the bridge nose." The COC note indicated that the resident was sent to emergency department. Resident 2's admission record indicated the resident was admitted to the facility on 3/4/25 with multiple diagnoses including dementia, anxiety (intense, excessive and persistent worry and fear about everyday situation) and depression (a mental health condition characterized by persistent feelings of sadness and loss of interest). A review of Resident 2's MDS dated 8/8/25 indicated the resident was cognitively impaired. The MDS indicated that resident had behaviors of verbally threatening, screaming, and/or cursing at others, and had physical behaviors pushing and hitting others. A review of Resident 2's care plan dated 3/4/25 indicated that resident had "potential to demonstrate physical behaviors (can strike or hit) and verbal behaviors (by stating "I will punch you)" r/t [related to] anger, dementia, depression, history of harm to others, poor impulse control..." The care plan goal indicated, "Will not harm self or others." The interventions included, "Monitor/document/report to MD [Medical Doctor] of danger to self and others...When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress." A review of the nursing progress notes (NPN) indicated that Resident 2 had multiple episodes of aggressive behaviors toward other residents, especially his roommates. The NPN dated 8/3/25 at 12:36 p.m., indicated, "Patient [Resident 2] is being really aggressive towards the roommates [sic]. He [Resident 2] told him [his roommate] to "get out of my property otherwise you will be responsible for consciences [sic]." The NPN dated 8/4/25 at 8:42 a.m., indicated, "Patient [Resident 2] exhibiting aggressive behavior with staff and roommates." The NPN dated 8/11/25 at 4 a.m., indicated, "...resident was agitated and stated get him [roommate] out or I will hurt him." The NPN dated 8/20/25 at 7:59 a.m., and 1:48 p.m., contained communication notes to physician indicating that Resident 2 was 'Verbally aggressive and attempting to be physically aggressive towards roommate...pt [Patient, Resident 2] attempting to kick our [sic] roommate from room and cussing at him...Attempted to push roommate out of room and said "Get that [expletives] out of here." On 9/6/25 at 1:36 p.m., LN 1 documented that Resident 2 "went to bathroom. After...finished...had dirty toilet tissue and attempted to smear it on...roommate [Resident 1] stating, "I'm going to brown face you." A review of Resident 2's clinical record contained a COC communication note dated 9/10/25 at 10 a.m. The COC note indicated, "Therapy staff reported that [Resident 2] stated coming out of room "Get that [expletives] out of my room" ...Entered both residents room...Assessed the roommate [Resident 1]...Resident [2] was not present in the room...Resident [2] was located and assessed...Resident [2] is wearing ring on right hand." During an interview on 9/26/25 at 12:30 p.m., LN 1 described Resident 1 as non-ambulatory and requiring staff's assistance with transferring to and from wheelchair. LN 1 stated Resident 1 had yelling and screaming behaviors directed at staff during personal care, but no verbal or physical behaviors toward Resident 2 or other residents. LN 1 stated Resident 2 was ambulating independently. LN 1 stated Resident 2 had frequent behaviors of verbal aggression toward Resident 1 and other residents and required frequent staff's observation and redirection. LN 1 added, "Apparently he did not like his roommate [Resident 1]." During a continued interview on 9/26/25, commencing at 12:30 p.m., LN 1 stated Resident 1 and Resident 2 were assigned to him on 9/10/25 when the alleged abuse happened. LN 1 stated he was alerted by a Certified Nursing Assistant (CNA) 1 that Resident 1 "had bloody face, his nose and right eye were swollen" and that the resident pointed towards his roommate's bed. LN 1 stated after he attended to Resident 1's facial lacerations, he went to talk to Resident 2 who was in the dining room. LN 1 stated Resident 2 could not provide any details what happened and denied hitting Resident 1. LN 1 mentioned that Resident 2 had a large ring on his right hand, but there was no blood or other markings on the resident's hands. LN 1 acknowledged that the sharp edges of the ring could have caused lacerations to Resident 1's face when Resident 2 struck him. LN 1 agreed that Resident 2 could have walked to the bathroom and washed his hands, which could explain why there were no blood on his hands. During an interview on 9/26/25, at 1 p.m., CNA 2 stated Resident 2 was observed being angry and yelling at the residents in the dining room on many occasions. During an observation on 9/26/25, at 1:13 p.m., Resident 2 was observed leaving the dining room and walking in the hall. Resident 2 was unstable and was holding onto the wall when he ambulated and a large bulky ring was observed on his right hand. Resident 2 stated he had trouble finding his room. When the resident was asked if he was getting along with other residents, Resident 2 replied, "Not always...some of them are too noisy." When Resident 2 was asked about incident with his roommate, Resident 1, he did not provide any details. After a moment Resident 2 added, "This is my home and I live alone. I don't need anyone in my room." During an interview on 9/26/25, at 1:17 p.m., Physical Therapy Staff (PTS) stated he worked with Resident 2 frequently and in order for the resident to participate in the therapy the resident had to be in good mood. The PTS added, "I have not seen anything physical, but he is verbally aggressive to other residents; I've seen on multiple occasions." The PTS stated that he was working with another resident in the morning on 9/10/25 when he met Resident 2 near nursing station 2. The PTS added, "He seemed on the verge of being very angry, was loudly talking to himself. I heard him saying something like "hurting my roommate." During an interview on 9/26/25, at 1:45 p.m., CNA 1 stated that when she went to check on Resident 1 on 9/10/25, the resident was in bed. CNA 1 stated when she entered the resident's room, Resident 1 "pointed to his face and said, "look at my face." CNA 1 added that Resident 1's "face was bloody, the face and nose were red and right side of the face was swollen...He pointed to his roommate's bed, closer to the door but did not say what happened." CNA 1 described Resident 1 as "Noisy, moody, and lots of verbal aggression." During a concurrent interview and record review of Resident 2's clinical record conducted with Administrator (ADM) on 9/30/25, at 3:05 p.m., the ADM stated he was aware of Resident 2's multiple verbal aggressive behaviors toward residents. The ADM added, "[Resident 2's name] had history of threatening his roommate, but never done anything physical." The ADM agreed that Resident 2's verbal aggression and threatening placed Resident 1's safety at risk. The ADM confirmed that on 9/10/25 Resident 1 was found in his room with swollen bloody face and multiple facial lacerations. The ADM added, "The incident happened, but we can't say for sure that it was [Resident 2] that hit [Resident 1], he might have injured himself." The ADM acknowledged that the facility was responsible for keeping all residents safe. When asked about interventions to keep Resident 1 safe, the ADM stated the staff were to provide snacks, redirect, and engage Resident 2 in activities. When asked if the interventions were effective, the ADM did not respond. A review of the facility's Policy and Procedure (P & P) titled, "Abuse Prevention Program," with revision date of 8/2006 indicated, "Our residents have the rights to be free from abuse...Our facility is committed to protecting our residents from abuse by anyone including...other residents." A review of the facility's P & P titled, "Safety and Supervision of Residents," revised 7/2017, indicated, "Resident safety and supervision...are facility-wide priorities...Safety risks...are identified on an ongoing basis...Resident supervision is a core component of the system approach to safety...The type and frequency of resident supervision may vary...Resident supervision may need to be increased when...there is a change in the resident's condition." In violation of the above stated standards, the facility failed to protect Resident 1 from abuse when Resident 2 struck Resident 1 in the face, which resulted in Resident 1 sustaining lacerations to his nose, eyebrow, and face, caused pain to Resident 1, and had the potential to experience emotional distress. This violation had a direct relationship to the health, safety, or security of long-term care facility residents.