Other·April 24, 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. 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. On 04/03/26, the department conducted an unannounced visit to the facility to investigate two Facility Report Incidents, regarding abuse. The facility failed to protect one of three sampled residents (Resident 2) from physical abuse by another resident when Resident 1 allegedly pushed his wheelchair into Resident 2's knees on 3/17/26 and punched her in the abdomen on 3/19/26. This failure resulted in Resident 2 being physically assaulted by Resident 1 on two occasions and had the potential to negatively affect her psychosocial well-being. A review of Resident 1's "ADMISSION RECORD," indicated Resident 1 was admitted to the facility with diagnoses which included dementia (a condition that causes a decline in cognitive abilities such as memory, thinking, reasoning, and problem solving) and psychosis (a mental disorder characterized by disconnection from reality). During a review of Resident 1's clinical document titled, "Brief Interview for Mental Status" (BIMS [a tool used to screen for cognitive impairment, with a range of scores from 0 to 15]), the document indicated a score of 4 which indicates severe cognitive impairment. During a review of Resident 1's clinical document titled, "Care Plan Report," dated 9/12/25, the document indicated, "...Focus...Risk for Violence r/t [related to] impaired impulse control...as evidenced by escalating agitation and irritability and physical restlessness...Goal...Resident will not harm self or others...Interventions/Tasks...Maintain safety: place resident in calm low stimulus environment. Remove objects that could be used as weapons to prevents [sic] harm to patient, staff and others..." A review of Resident 2's "ADMISSION RECORD," indicated she was admitted to the facility with diagnoses which included osteoarthritis (disease that causes joint pain and stiffness) and depression (mental health condition that causes a persistent feeling of sadness). During a review of Resident 2's clinical document titled, "Brief Interview for Mental Status (BIMS)," the document indicated a score of 15 which indicates intact cognition. During an interview on 4/3/26 at 8:59 AM with Resident 2, Resident 2 stated she woke up in her bed on 3/17/26 and Resident 1 was in her room. Resident 2 stated she told Resident 1 to leave and he did not move. Resident 2 further stated Resident 1 had a cart with blankets on it, and he hit her left knee with it. Resident 2 stated she told staff and they did nothing, so she called the police. Resident 2 further stated, "she should not be subjected to perverts like that". Resident 2 stated she and Resident 1 had an altercation in the past. During an interview on 4/3/26 at 9:55 AM, with Licensed Nurse (LN) 1, LN 1 stated Resident 1 went in and out of other patient rooms frequently and was redirected by staff. LN 1 stated Resident 1 could become angry and agitated at times. LN 1 stated she was not aware of the incident that occurred on 3/17/26 until the police showed up around 10 AM. During a review of Resident 1's progress notes titled, "Nurse Notes," dated 3/17/26 at 3:32 PM, the note indicated, "...At approximately 10:25am [AM]...Police department came into facility asking to speak to [Resident 1]...other resident reported that [Resident 1] allegedly, 'went into her room at approximately 4:00am and was looking through her closet. When she woke up and told him to get out, he then went over to her with his wheelchair and rammed her knees/legs 4 times and walked out'..." During a telephone interview on 4/6/26 at 7:56 AM with Certified Nurse Assistant (CNA) 3, CNA 3 stated Resident 1 frequently went into other residents' rooms, and the residents told him to get out. CNA 3 further stated during her shift on 3/17/26 she observed Resident 1 in the doorway of Resident 2's room. CNA 3 stated Resident 2 was awake and yelling at Resident 1 to leave the room. CNA 3 stated Resident 2 told her Resident 1 pushed something and hit her leg. CNA 3 stated she did not report it to her supervisor because she was not sure if it happened that day or on another day. During a review of Resident 2's progress notes titled "Nurse Notes," dated 3/19/26 at 11:19 PM, the note indicated, "...Resident -to- resident altercation occurred in the hallway near medication cart. [Resident 2] was seated in a wheelchair awaiting medication administration. [Resident 1] exited the dining room with an angry affect [sic] and visible agitation. [Resident 1] was moving to the medication area...Verbal redirection was attempted; however, resident remained escalated. [Resident 2] verbally engaged [Resident 1], stating, Don't come nearme! [sic] despite no prior direct interaction. Following [Resident 2's] statement, [Resident 1] redirected attention toward [Resident 2] and advanced in her direction [Resident 1] then made physical contact with [ Resident 2] striking her in the stomach with a closed fist..." A review of Resident 2's progress notes titled, "Social Services Progress Note," dated 3/20/26 at 5:31 PM, indicated "...Pt. [Resident 2] stated, "I just want him to stay away from me. I don't care if he doesn't realize what he is doing..." During an interview on 4/3/26 at 12:55 PM with the Director of Nurses (DON), the DON stated Resident 1 had been monitored every 30 minutes by staff after the incident on 3/17/26 and the monitoring increased to every 15 minutes after the incident on 3/19/26. The DON stated the facility was doing the best they could to continually monitor Resident 1's behaviors and adjust his medications to decrease his anxiety and agitation. During a review of a facility policy titled, "Abuse, Neglect and Exploitation," dated 2025, the policy indicated, "...It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property..."Physical Abuse" includes, but is not limited to hitting, slapping, punching, biting, and kicking ...The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation...Responding immediately to protect the alleged victim and the integrity of the investigation...Examining the alleged victim for any sign of injury...Increased supervision of alleged victim and residents..." Therefore, the facility failed to protect Resident 2 from physical abuse by another resident when Resident 1 allegedly pushed his wheelchair into Resident 2's knees on 3/17/26 and punched her in the abdomen on 3/19/26. This failure resulted in Resident 2 being physically assaulted by Resident 1 on two occasions and had the potential to negatively affect her psychosocial well-being. This violation had a direct or immediate relationship to the health, safety, or security of Resident 2 and is a B citation.