Health inspection·March 27, 2026

42 C.F.R. § 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) (1): The facility must-Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; 42 C.F. R. §483.12 (b) The facility must develop and implement written policies and procedures that: (b)(1): Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, 42 C.F. R. §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2): Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3): Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4): Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. 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. 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. On 1/9/26, the Department received a report from the facility related to an allegation of staff aggressive behavior toward a resident. On 2/3/26 at 2:55 P.M., an unannounced onsite visit was conducted to investigate the incident. The facility failed to: 1. Ensure Resident 1 (who resided on Unit C) was protected from mental abuse and intimidation and 63 other residents on two units (Unit A and Unit B) were protected from potential abuse when: a. Certified Nursing Assistant (CNA) 1 responded to Resident 1's request for assistance with a raised voice, angry demeanor, and threatening and aggressive posturing on 1/6/26. b. Charge Nurse (CN) 1 and CNA 2 failed to report the incident between CNA 1 and Resident 1 as an allegation of abuse to the facility's administrator. c. Nurse Supervisor (NS) 1 failed to thoroughly investigate and collect evidence of the alleged abuse and report the results of all investigations to the Administrator (ADM). d. The facility did not thoroughly investigate the allegation of abuse at the time of its report and report the allegation of abuse to the state agency (California Department of Public Health, CDPH) for three days. e. The facility continued to assign CNA 1, with known behavioral issues, to provide care to 63 residents on Unit A and Unit B on 1/7/26 and 1/8/26 prior to beginning their investigation into the allegation of abuse on 1/9/26. f. ADON 1 failed to disclose CNA 1's behavioral issues and related disciplinary documentation to a CDPH representative during the investigation. 2. Implement its own written abuse policy in accordance with required procedures when: a. The facility did not identify, report, or investigate an allegation of abuse in a timely manner. b. The facility did not thoroughly investigate the allegation at the time of its report. c. The facility did not assess the risk to other residents when CNA 1 was assigned to provide resident care for two days after an abuse allegation was made. d. The facility did not identify Resident 1's increased fearfulness as a behavior which may indicate potential abuse. As a result, Resident 1 expressed feeling scared, worried, and withdrawn from socialization due to her emotional distress. In addition, this failure to identify Resident 1's allegation of abuse posed a risk to the safety and well-being of the 63 other residents on Unit A and Unit B where CNA 1 had been assigned during the facility's three-day investigation and reporting delay. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on 2/21/2007 with a diagnosis of quadriplegia (a form of paralysis that causes the loss of movement and feeling in all four limbs and the torso) due to motor vehicle accident. A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 12/30/25, indicated the resident's BIMS (Brief Interview for Mental Status) was 15 out of 15, indicating the resident was cognitively intact (no memory, focus, or judgment issues). On 2/3/26 at 3:19 P.M., an interview was conducted with Resident 1 while in the dining hall. Resident 2, who was a witness to the incident on 1/6/26, was also present. Resident 1 was asked about the incident that involved CNA 1 on 1/6/26. Resident 1 stated she asked CNA 1 to get a food item out of the fridge, but CNA 1 told her, "Are you gonna say hi to me if you want something from me?" Resident 1 stated it was her first encounter with CNA 1. Resident 1 stated she was confused by his reply. CNA 1 then repeated in an angry manner, "Are you gonna say hi to me if you want something from me?" Resident 1 stated she was still confused but also thought that maybe he was joking. Resident 1 then told CNA 1, "I don't have to say hi to you if I don't want to." Resident 1 stated CNA 1 was coming out of the nurse's station walking toward the refrigerator at which point he turned around and yelled, "If you don't say hi to me, you're not getting anything from me! Now you have to call your [assigned] CNA!" Resident 1 stated CNA 1 charged toward her with his chest out and aggressive arm movements. Resident 1 stated CNA 1 charged toward her in a manner that looked like he wanted to physically fight her. Resident 1 stated she was scared when CNA 1 was verbally and physically aggressive and charging toward her with his threatening posture because her electric wheelchair moved slowly. Resident 1 stated she was worried she could not get away from him fast enough. CNA 1 then walked back into the nurse's station without getting what she requested out of the refrigerator. Resident 1 called for help and told CNA 2 and CN 1 what had happened. Resident 1 stated that she told CNA 2 and CN 1 that she was scared and did not feel safe with the way CNA 1 behaved toward her. Resident 2 stated that she witnessed the incident on 1/6/26 and that was what happened. A review of Resident 1's Interdisciplinary Progress Notes after the incident on 1/6/26 indicated: 1/6/26 at 11:15 P.M., "...Resident appeared to be in emotional distress at the time of incident...." 1/7/26 at 10:03 P.M., "...Resident just verbalized that she still couldn't believe the incident from yesterday occurred." 1/8/26 at 1:45 P.M., "Therapist made two attempts before lunch and after lunch to speak with resident and assess psychosocial wellbeing, however both times resident was sleeping and did not respond to knock at door or calling out of name...." 1/8/26 at 7 P.M., "...Resident was upset regarding the [facility's] action and verbalized that she will be reporting to Police and Ombudsman tomorrow. Resident stated that she's not safe with alleged PM CNA staff [CNA1]." 1/8/26 at 11:03 P.M., "Resident still verbalized feeling upset r/t [related to] incident with staff...." 1/9/26 at 1:33 P.M. "Resident refused to get OOB [out of bed]. Resident told CNA that she doesn't want to talk to anyone today...." 1/9/26 at 1:38 P.M. "Attempted multiple times to talk with resident regarding grievances reported on PM shift, she declines to talk." 1/9/26 at 10:40 P.M. "Tried to talk to resident to follow up on alleged abuse but resident declined...." 1/9/26 at 11:05 P.M. "...resident declined to talk about it anymore when asked...." 1/10/26 at 10:27 P.M. "...Resident stayed in her room all shift and did not get up." A review of Social Work Progress Note dated 1/12/26, indicated, "...The resident states she does not feel safe with the staff [CNA 1] from the SOC 341 being around her. The resident states she feels unsafe as she feel [sic] the alleged individual could lose their temper at any time not only with herself but other residents...." A review of Resident 1's psychotherapy (a process where you work with a trained expert to understand your feelings, change unhelpful habits, and learn better ways to handle life's challenges) note dated 1/14/26, indicated, "...The resident appeared disheveled... reported a recent interaction with a male CNA that elicited feelings of unsafety and a sense of being "frozen" during the incident. Subsequently, the resident endorsed spending three consecutive days in bed, primarily sleeping, citing significant fatigue...stating avoidance of social interaction to prevent retraumatization...The resident...agreed to continue working on reducing immobilization responses associated with fear...." A review of facility's staff assignment for 1/6/26 through 1/13/26, indicated CNA 1 provided resident care on 1/7/26 on Unit A and on 1/8/26 on Unit B during the PM shift (3 P.M. to 11:30 P.M.). A review of facility's census for Unit A and B combined on 1/7/26 and 1/8/26 indicated a total census of 63 residents. On 2/3/26 at 3:42 P.M., an interview with CNA 2 was conducted. CNA 2 stated she had witnessed CNA 1 being rude and sarcastic with other staff. CNA 2 stated she responded to Resident 1's call for help after the incident on 1/6/26. CNA 2 stated Resident 1 looked scared, and Resident 2 was sitting nearby having witnessed the incident. On 2/3/26 at 3:55 P.M., an interview was conducted with CNA 4. CNA 4 stated she was familiar with Resident 1. CNA 4 stated she noticed Resident 1 was emotionally distressed for a few days after the incident on 1/6/26. On 2/4/26 at 2:15 P.M., an interview and record review were conducted with the Director of Staff Development (DSD) 1 and DSD 2. The DSDs stated they had already identified "red flags" at the beginning of CNA 1's onboarding orientation (on 10/31/25) at the facility. The DSDs described CNA 1's behavior as "arrogant" and he would give them "lots of push backs" against their instructions. DSD 1 and DSD 2 both stated CNA 1 often would not follow directions. The DSDs stated CNA 1 would make statements such as, "I know that; I've been a CNA for nine years." The DSDs stated CNA 1 was late on the first day of orientation and had a bad attitude about it. The DSDs stated CNA 1 violated facility policy by taking food from residents' finished trays and stealing other staff's food and eating it. The DSDs stated they could "totally' imagine CNA 1 acting aggressively toward Resident 1. The DSDs stated CNA 1 should not have acted aggressively toward any residents regardless of the reason. DSD 1 further stated that Resident 1 was not the type of resident who would report abuse allegations indiscriminately. DSD 1 stated, "I can see it's pretty serious if she reports abuse." DSD 1 stated CNA 1's behavioral concerns were reported to the leadership. On 2/4/26 at 3:09 P.M., an interview was conducted with Nursing Supervisor (NS) 2, day shift supervisor. NS 2 stated Resident 1 was given the choice to report the incident that occurred on 1/6/26 as a facility internal complaint/grievance or report to CDPH as a formal complaint. NS 2 stated when Resident 1 told another staff on 1/9/26 that she was scared of CNA 1, that was when the facility reported the incident as an allegation of abuse to CDPH on 1/9/26. NS 2 was asked about CNA 1's job performance and behavior toward residents and she refused to answer. On 2/4/26 at 3:41 P.M., an interview with CN 1 was conducted. CN 1 stated CNA 1 would interrupt staff conversation and say, "You need to tell me what you guys are talking about. Are you talking about me?" CN 1 stated other staff members would report to her that they had concerns about CNA 1's behaviors which included false accusations. CN 1 stated CNA 1 was floated to Resident 1's unit around 7:30 P.M. on the day the incident happened (1/6/26). CN 1 stated CNA 1 was assigned to answer call lights while other CNAs and staff were making rounds. CN 1 stated this resulted in no other staff being present in the dining hall and nurse's station at the time of the incident which happened around 8:20 P.M. When the incident happened, CN 1 stated, she was called to the dining room where she saw Resident 1 and Resident 2 sitting close to each other. CN 1 stated Resident 1 was, "very shaken about it, shaking and visibly in distress." CN 1 stated Resident 1 told her she was "scared." CN 1 stated Resident 1 told her, "Don't leave me here with him [CNA 1], he's there." On 2/4/26 at 4:20 P.M., a follow up interview was conducted with Resident 1 inside the resident's room. Resident 1 stated a few minutes after the incident on 1/6/26, three nursing supervisors approached her and asked her if she would be willing to meet with CNA 1 to discuss the incident. Resident 1 stated she refused and told the nursing supervisors that she was too scared of CNA 1 to meet and talk with him. Resident 1 further stated she was worried about other residents, especially the more vulnerable ones, those who could not speak for themselves, and those who could become agitated through interactions with CNA 1 because of their psychiatric conditions. Resident 1 stated she stayed in bed for the next few days after the incident because she felt "closed off" and "put shells around" herself due to the incident. Resident 1 stated she refused to keep talking about the incident with staff because she did not want to be re-traumatized by thinking of or talking about it. On 2/10/26 at 12:14 P.M., a follow up interview was conducted with DSD 1 and DSD 2 regarding CNA 1's misconduct and behavior during his new hire orientation. The DSDs stated they informed ADON 1 and possibly ADON 2 within the first seven to 10 days of noticing his behavior. The conversation included reporting CNA 1's tardiness on the first day of orientation, multiple instances of resistance, and his unprofessional attitude. DSD 1 and DSD 2 stated the incident between Resident 1 and CNA 1 on 1/6/26 was emotional abuse and should have been addressed immediately. DSD 1 stated when Resident 1 told CNA 2 and CN 1 about the incident with CNA 1 on 1/6/26, they should have filled out the SOC 341 immediately and reported this incident to CDPH. DSD 1 stated the facility's investigation should have started immediately and should not have been delayed. On 2/10/26 at 1 P.M., an interview was conducted with ADON 1. ADON 1 stated CNA 1's behavior and misconduct were not documented in an employee file because he was a probationary employee. ADON 1 was asked if there were more issues with CNA 1's behavior toward residents or allegations of abuse made against him. ADON 1 stated the issues with CNA 1's behavior was discussed with leadership in an email thread. ADON 1 stated he would not elaborate on CNA 1's behavioral issues and he would not disclose any information related to any of CNA 1's disciplinary action. On 2/10/26 at 3:59 P.M., an interview was conducted with CNA 5. CNA 5 stated working with CNA 1 was very difficult because CNA 1 was rude and would give him push backs when anything was explained to him. CNA 5 stated he worked with CNA 1 and witnessed CNA 1 raising his voice and shouting to redirect residents. CNA 5 stated this behavio