Health inspection·January 20, 2026

Code of Federal Regulations, Title 42, 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 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. Code of Federal Regulations, Title 42, Section 483.25. Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: California Code Regulations, Title 22, Section 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. 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, 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 12/09/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate one Facility Reported Incidents regarding abuse. The facility failed to protect a resident's right to be free from physical abuse for one of two sampled residents (Resident 1) when the facility did not address Resident 2's escalating behaviors and noncompliance of his medications which resulted in Resident 2 hitting Resident 1 multiple times in the face on 12/4/25. This failure resulted in Resident 1 sustaining multiple injuries to his face, scalp and his right ear lobe, and required him to be transferred to an acute care hospital on 12/4/25 for immediate treatment. This failure also resulted in psychosocial harm to Resident 1. A review of Resident 2's "ADMISSION RECORD," indicated Resident 2 was admitted to the facility with a diagnosis of, but not limited to dementia (a range of conditions involving a significant loss of mental abilities such as memory, thinking, and reasoning skills severe enough to interfere with a person's daily life and activities), schizophrenia (a serious brain condition that affects how a person thinks, feels, and behaves, making it difficult for them to tell what was real and what was not), noncompliance with other medical treatment and regimen, and history of traumatic brain injury (a brain injury that is caused by an outside force). A review of Resident 2's clinical record titled, "[Name of Hospital] Discharge Summary Final Report," dated 11/18/25, indicated, "...Final Diagnosis...History of traumatic brain injury with added progressive dementia...Personal history of noncompliance with medical treatment...Poor short-term memory...can be impulsive..." A review of Resident 2's clinical record titled, "Psychiatric Visit Progress Report," dated 11/20/25, indicated, "...Initial NP [nurse practitioner] Psychiatric Evaluation...History of schizophrenia, depression (a serious mood disorder causing persistent sadness and loss of interest in activities), insomnia (difficulty falling asleep), and angry outburst...[Resident 2] was in bed, disorganized, bizarre...Staff report that the [Resident 2] recently threw his breakfast, has difficulty following directions..." A review of Resident 1's "ADMISSION RECORD," indicated Resident 1 was admitted to the facility with a diagnosis of, but not limited to encephalopathy (a condition affecting the brain's function causing confusion, memory loss, personality changes, and trouble concentrating), major depressive disorder (a condition characterized by persistent feelings of sadness and loss of interest in activities which interfere with daily life), and psychosis (a mental health condition when a person experiences a significant break from reality). A review of Resident 1's clinical record titled, "[Name of facility] History and Physical," dated 2/12/25, indicated, "...ASSESSMENT AND PLAN...Agitation and violent behavior...Depression...consider mental health evaluation if needed..." A review of Resident 1's clinical record titled, "Psychiatric Visit Progress Report," dated 11/21/25, indicated, "...[Resident 1]...was seen and evaluated for a follow up assessment of psychiatric symptoms and to make recommendations to assist with person-centered treatment planning...Objective: [Resident 1] is seen in his bed, irritable, irritable, and poorly cooperative...Staff reported aggressive behavior toward others..." A review of Resident 1's Nurses Note, dated 12/4/25, indicated, "...Around 0450 [4:50 AM]...[Resident 1] walked out of room with a bloody face...Claiming roommate [Resident 2] punched him repeatedly in the face and chest 25 times...Has wounds to right head laceration [deep cut], Knott [sic] to right forehead, wound to right lip, bleeding from right ear, nd [and] skin tear to right hand. Victim [Resident 1] and assaulter [Resident 2] separated immediately, 911 called. Around 0510 [5:10 AM] Cops arrived and [paramedics] arrived...took [Resident 1] to [acute care hospital]..." A review of Resident 1's Nurses Note, dated 12/4/25, at 5:20 AM, indicated, "...[Resident 1] face covered in blood, resident stated "my roommate attacked me, he punched me 25 times, all over in my face," bump noted to right eyebrow with laceration, skin tear to left brow, bleeding from his mouth, bleeding from his right ear, and a skin tear to his right hand...[Resident 1] stated, "look at what he did to my ear", while pointing at his ear with his right hand..." A review of Resident 1's clinical record titled, "Emergency Documentation," dated 12/4/25, indicated, "...[Resident 1] is a 78 year old male presenting from nursing home for assault...[Resident 1] per report was assaulted in his sleep by another nursing home resident. He was hit multiple times in the face with a fist...[Resident 1] has lacerations to the face and scalp as well as bleeding from the right ear lobe. [Resident 1] is complaining of generalized pain mostly across the head...Presentation is consistent with a closed head injury and soft tissue trauma..." A review of Resident 1's Nurses Note, dated 12/4/25, at 12:45 PM, indicated, "...[Resident 1] back in facility...[Resident 1] noted with stitches to middle left eyebrow, laceration to right earlobe and scattered bruising to the face..." A review of Resident 1's Nurses Note, dated 12/4/25, at 9:36 PM, indicated, "...[Resident 1] is on day 1 s/p [status post] hospitalization d/t [due to] resident [Resident 1] to resident [Resident 2] altercation...Noted resident [Resident 1] with laceration to forehead with stitches and some dry blood of resident (Resident 1) face..." A review of Resident 1's Social Services Progress Note, dated 12/5/25, indicated, "...SSD [Social Services Director] asked pt [patient] how he was doing. [Resident 1] stated, "I feel like I got hit by a truck."...SSD asked pt if recalls incident from yesterday...[Resident 1] replied, "Yes, a man that I thought was trustworthy hit me with his fist at least 12 times."..." During a concurrent observation and interview on 12/4/25, at 2:54 PM, with Resident 1, in his room (a resident room with 3 beds), Resident 1 was observed to be seated on the bed farthest from the door. Resident 1 was noted to have dark purple discolorations on both eyebrows, stitches were noted on the left eyebrow, stitches were noted on the forehead between the brows, and a dark bluish-purple discoloration noted on the right earlobe. Resident 1 stated that he was hurt badly and Resident 2 smashed his face and beat him up. Resident 1 further stated he was lying in bed but was awake in the morning of the incident. Resident 1 stated he saw his roommate (Resident 2) who stood up from his bed (the middle bed in the room next to Resident 1's bed) and started hitting him. Resident 1 further stated there was no curtain between them, and they were the only two persons in the room. Resident 1 stated he did not fight back. Resident 1 further stated when he realized he was hurt; he walked out of the room and asked the staff for help. During an interview on 12/4/25, at 3:07 PM, with Resident 1's Family Member (FM) 1, FM 1 stated she had visited him the day before on 12/3/25, and had not seen any injuries on his face. FM 1 further stated she was worried that the physical aggressiveness episode would likely have a possible negative impact on Resident 1's personality, especially given his dementia. FM 1 stated she felt terrible about what had happened to Resident 1. During an interview on 12/4/25, at 3:34 PM, with licensed nurse (LN) 1, LN 1 stated the AM (morning) shift told her about the altercation between Resident 1 and Resident 2. LN 1 further stated the fight happened during the (latter part) of night shift on 12/4/25, and Resident 1 came out of the room (in the early morning) with a bloody face. LN 1 stated Resident 1 was sent to the hospital and returned the same day around 12:45 PM during the AM shift. LN 1 further stated that Resident 2 was admitted to the facility in mid- November and was observed with a "bad mouth" as Resident 2 was heard yelling expletives (swear words) to others. LN 1 stated she witnessed Resident 2 throwing food, medicines, and trays if Resident 2 was unhappy. LN 1 stated Resident 1 had dementia and sometimes showed behaviors like increased agitation and restlessness. LN 1 further stated that it was not a good idea to have Resident 1 and Resident 2 in the same room because both had known behavioral issues. LN 1 explained with the history of Resident 1 and Resident 2, they should not have been placed together. LN 1 stated the incident (12/4/25) could have been prevented if Resident 2 had been admitted to a different room that suited him better. During an interview on 12/4/25, at 3:49 PM, with certified nurse assistant (CNA) 1, CNA 1 stated Resident 1 had been in his current room for a while. CNA 1 further stated Resident 1 got anxious easily and needed to be handled with patience. CNA 1 further stated she needed to adjust her tone of voice because Resident 1 could become agitated quickly. CNA 1 stated Resident 1's dementia sometimes made him act out, and he had the potential to hurt others. CNA 1 further stated Resident 2 had been observed displaying aggressive behavior since his admission, such as throwing things and breaking the hand sanitizer attached by the room door. CNA 1 stated if the facility had reviewed Resident 1 and Resident 2's behavior history before placing them in the same room, the incident might have been prevented. CNA 1 further stated the room assignment should have been carefully considered to avoid conflicts between Resident 1 and Resident 2. During a concurrent interview and record review on 12/5/25, at 9:50 AM, with LN 2, Resident 2's electronic health record (EHR) was reviewed. LN 2 stated she had heard about the altercation between Resident 1 and Resident 2. LN 2 further stated Resident 2 often behaved aggressively, like throwing plates and yelling. LN 2 stated Resident 2 refused to take his morning psychotropic (any substance that primarily affects the mind, emotions, and behavior) medication even after being told about the risks and benefits. LN 2 further stated Resident 2's behavior was very unpredictable, being calm one moment and suddenly aggressive the next. LN 2 stated she had noticed a change in Resident 2's behavior on 11/28/25, when Resident 2's aggressive actions escalated from verbal outbursts to physical actions, such as breaking things like the hand sanitizer dispenser on the wall, the sliding window, and trying to confront other residents. LN 2 further stated Resident 2 showing both verbal and physical aggression was becoming a danger to himself and others. LN 2 stated she called the Medical Doctor (MD) at that time (11/28/25), who ordered that Resident 2 be sent out for further care. LN 2 further stated the MD agreed with LN 2 that Resident 2 was becoming a danger to himself and others. LN 2 checked the Medication Administration Record (MAR - used to record all medications given to a patient) for November and December 2025 and confirmed that Resident 2 did not get his morning psychotropic medication since he was admitted. LN 2 stated she informed the MD about Resident 2's refusal to take his psychotropic medication. LN 2 further stated Resident 2's refusal to take his psychotropic medication caused his behavior to get worse. LN 2 stated Resident 2's noncompliance put him at increased risk of becoming more aggressive. LN 2 further stated Resident 2's compliance in taking his medication was very important for managing his behavior. During an interview on 12/5/25, at 10:59 AM, with LN 4, LN 4 stated she conducted the Nursing Clinical Admission Evaluation for Resident 2 on 11/18/25. LN 4 confirmed that when Resident 2 was admitted, Resident 2 was disoriented and confused. LN 4 stated Resident 2 showed signs of agitation and Resident 2 cursed at the staff (on 11/18/25). LN 4 further stated Resident 2 refused the skin assessment and cursed at her when LN 4 tried to explain why it was necessary. LN 4 stated Resident 2 reported multiple hallucinations during the assessments. LN 4 confirmed that she documented a change in condition on 11/19/25 because Resident 2 had refused a new admission blood draw. LN 4 explained to Resident 2 the importance of blood draw, but Resident 2 replied, "No one is putting any [expletive] needles in me." During an interview on 12/5/25, at 11:26 AM, with LN 5, LN 5 stated Resident 2 had behaved very aggressively towards the staff on 12/4/25, making threats and using curse words. LN 5 further stated Resident 2 was very agitated when the police arrived to check on him. LN 5 stated Resident 2 was offered assistance on the day of the incident, but Resident 2 became more agitated. LN 5 further stated when the ambulance arrived to take Resident 2 to the hospital as ordered by the MD, Resident 2 continued to threaten the staff aggressively. LN 5 stated it was a bad idea to have Resident 1 and Resident 2 in the same room