Health inspection·February 20, 2026

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident (FRI) 2701263. Survey event ID: 1E07EB-H1 State Citation A was written. 42 CFR §483.12(a) (1) 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. 42 CFR §483.40 (b) (1) Behavioral health services. Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. (b) Based on the comprehensive assessment of a resident, the facility must ensure that- (1) A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. 22 CCR § 72315 (b) 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 § 72311 (a) (1) (B) 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: (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. 22 CCR § 72523 (a) 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 1/8/26 at 8:30 A.M., an onsite visit was conducted to investigate a facility reported incident of alleged abuse between Resident 5 and Resident 3 that occurred in the facility's dining room on 12/25/25. The facility failed to: 1. Assess Resident 5's post-traumatic stress disorder (PTSD- a mental health condition resulting from trauma experiences) upon admission and develop an individualized care plan to manage potential behavioral triggers. 2. Develop a care plan and implement preventative measures to protect residents from Resident 5's physical aggression when residents were perceived to be stealing from him around the meal carts and/or in his room. 3. Intervene and address when Resident 5 designated himself as a licensed vocational nurse on the unit. 4. Protect Resident 3 from Resident 5's triggered aggressive behavior after Resident 5 had a physical altercation with another resident. 5. Implement facility policies titled: "Abuse, Neglect, Exploitation or Misappropriation Prevention Program" revised April 2021," "Resident-to-Resident Altercations" dated September 2022, "Behavioral Assessment, Intervention, and Monitoring" revised February 2025, and "Trauma Informed Care and Culturally Competent Care" undated. These failures resulted in or had a substantial probability in resulting in: Resident 5 initiating an altercation with Resident 3 and escalating to Resident 5 punching Resident 3 in the mouth causing a laceration to Resident 3's inner upper lip, bleeding, and pain. A review of Resident 3's Admission Record indicated the resident was readmitted to the facility on 4/28/25 with diagnoses to include anxiety. A review of Resident 3's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 10/22/25, indicated the resident scored 15 out of 15 on the brief interview of mental status (which meant the resident was cognitively intact). A review of Resident 5's Admission Record indicated the resident was admitted to the facility on 8/4/25 with diagnoses to include traumatic brain injury, post-traumatic stress disorder, bipolar disorder (a mood disorder that alternates between depression and mania), and Alzheimer's dementia (a progressive brain disorder that affects memory, thinking, and behavior). A review of Resident 5's Summary of Physician Discharge Instructions (hospital documentation provided to the facility upon the resident's admission) dated 8/4/25, indicated, "...Safety Plan...Triggers, Risk Factors, and Warning Signs...How will you know when you are in crisis and that the safety plan should be used? What are your personal red flags... 2. I get angry or aggravated when people are [stealing] from me...." Resident 5 was involved in physical altercations with other residents when triggered on: A review of Resident 5's nursing note dated 11/14/25, indicated, "...[Resident 4] was standing near the food cart when [Resident 5] ...pushed him aside. This caused the other resident [Resident 4] to loss [sic] his balance and fall to the ground...." A review of Resident 5's IDT [interdisciplinary team] Behavior Note dated 12/26/25, indicated, "...Writer was notified of an incident in the dinning [sic] room [on 12/25/25]. Another resident [Resident 3] was seated in her wheelchair in the dinning [sic] room when this resident [Resident 5] approached her and attempted to pull her wheelchair backwards. The other resident [Resident 3] turned towards this resident and instructed him to stop. This resident [Resident 5] then struck the other resident [Resident 3] in the face without apparent provocation...." A review of Resident 5's IDT Behavior Note dated 12/31/25, indicated, "...Writer was notified that this resident [Resident 5] was noted to be ambulating down the hallway when he approached another resident [Resident 6] and began yelling and grabbed his arm. Before staff could intervene, the other resident [Resident 6] swung at this resident [Resident 5] striking him in the face causing this resident [Resident 5] to fall to the ground...." A review of Resident 3's IDT note dated 12/26/25, indicated, "... [Resident 3] was seated in her wheelchair in the dining room [on 12/25/25] when another resident [Resident 5] approached her and attempted to pull her wheelchair backwards. [Resident 3] turned towards the other resident [Resident 5] and instructed him to stop. The other resident [Resident 5] then struck this resident [Resident 3] in the face... This resident [Resident 3] was noted with laceration to the upper inner lip. First aid administered. Resident medicated for pain...." A review of Resident 3's Alert Charting notes dated 12/26/25 and 12/27/25, indicated, "Resident is on alert charting for being subject of aggression, neuro-check [an assessment] on progress, pain being treated with Tylenol as order [sic]...." On 1/8/26 at 9:41 A.M., an observation and interview were conducted with Resident 3 while inside her room. Resident 3 stated the incident with Resident 5 occurred on Christmas during lunchtime. Resident 3 stated Resident 5 got a hold of her wheelchair and would not let go. Resident 3 stated she told Resident 5 to let go of her wheelchair and "he punched me in the mouth." Resident 3 pointed to one of her front teeth and stated being punched in the mouth had loosened one of her teeth. Resident 3 was asked if she experienced any pain from the incident and the resident stated, "Oh, God yes." Resident 3 stated she got hurt and the pain lasted a long time. Resident 3 stated staff were not close enough to intervene until she got punched. Resident 3 stated staff told her Resident 5 was no longer in the facility and was gone. Resident 3 stated she would feel afraid if Resident 5 was on the unit and would not feel safe because of "his violent nature." Resident 3 stated she was aware Resident 5 had hit other residents before. On 1/8/26 at 9:57 A.M., an observation was conducted in the hallway. Resident 5 approached and asked, "Are you theft investigators? Here to investigate the thefts?" On 1/8/26 at 10:12 A.M., an observation and interview were conducted with Resident 5 in front of the nurses' station. Resident 5 was asked about the altercations he was involved in with other residents. Resident 5 stated, "Which one do you want to know about first?" Resident 5 alleged Resident 3 had put her feet on the table to irritate him. Resident 5 stated he threw Resident 3's feet on the floor. Resident 5 stated he also had an altercation with Resident 6 because he saw Resident 6 wearing his shoes and he wanted them back. Resident 5 stated he went to Resident 6 and started to take them off him. Resident 5 stated Resident 6 then hit him. Resident 5 was observed walking around the unit wearing white medical tape on his jacket with his name handwritten with black ink. "L.V.N. [licensed vocational nurse]," was also written underneath his name. On 1/8/26 at 12:43 P.M., an interview was conducted with certified nursing assistant (CNA) 1. CNA 1 stated she was working on 12/25/25 and had witnessed the incident between Resident 3 and Resident 5 while in the dining room. CNA 1 stated Resident 3 was in front of the meal cart and Resident 5 was holding onto Resident 3's wheelchair handle. CNA 1 stated Resident 3 told Resident 5 to let go and he did not like to be told that. CNA 1 stated Resident 5 punched Resident 3 in the mouth with a closed fist. CNA 1 stated, "It was a hard hit." CNA 1 stated she saw blood in Resident 3's mouth and the resident was screaming and saying, "It hurts, it hurts." CNA 1 stated she was right next to the residents when the altercation happened, but things happened so fast and without warning. CNA 1 stated based on her abuse prevention training, this incident was "physical abuse." CNA 1 further stated she was also present during an incident in the dining room on 11/14/25 with Resident 5 and Resident 4. CNA 1 stated Resident 4 was touching the meal carts and that Resident 5 did not like that. CNA 1 stated Resident 5 pushed Resident 4 "away [from the meal carts] so hard when he fell, I was afraid he'd die because he may have hit his head." CNA 1 stated Resident 5's behavior was "impulsive" and seemed to come out of nowhere. CNA 1 stated she was not aware of what triggered Resident 5's aggressive behavior. On 1/8/26 at 3:30 P.M., an interview was conducted with the assistant director of nursing (ADON). The ADON stated Resident 5 "gets triggered by other residents." The ADON stated Resident 5 was specifically triggered when residents went in his room, opened his closet, and went into or were around the food carts during meals. The ADON stated Resident 5 thought he was a licensed nurse and wanted to control who touched the food carts. The ADON stated on 12/30/25, Resident 6 did go into Resident 5's room and into his closet. The ADON stated Resident 6 did put on Resident 5's clothing. The ADON stated Resident 5 would have been triggered by this incident. On 1/9/26 at 10:06 A.M., an interview was conducted with CNA 2. CNA 2 stated Resident 5 got agitated by other residents. CNA 2 stated she was not aware of any behavioral triggers or of a PTSD diagnosis for Resident 5. CNA 2 stated all staff on the unit should be aware of any of Resident 5's behavioral triggers to prevent the resident from being triggered. CNA 2 stated Resident 5 thought about theft and seemed focused on people frequently stealing. CNA 2 stated based on her facility provided abuse prevention training, whether provoked or unprovoked, being punched in the mouth was "physical abuse." On 1/9/26 at 10:20 A.M., an interview was conducted with CNA 3. CNA 3 stated she was familiar with Resident 5 and his behavior. CNA 3 stated Resident 5 would get upset and yell when other residents were yelling. CNA 3 stated Resident 5 was focused on his belongings and potential theft. CNA 3 stated Resident 5 was concerned about who entered his room because he thought the person was coming into his room to steal. CNA 3 stated Resident 5 did not like it when other residents were around the food carts because he thought they were going to steal the food. CNA 3 stated Resident 5 thought he was a nurse who worked at the facility. CNA 3 stated Resident 5 would "help other residents by pushing their wheelchairs." CNA 3 stated she did not think it was a "good idea" for Resident 5 to wear medical tape identifying himself as a licensed vocational nurse. CNA 3 stated other confused residents on the unit could approach him thinking he was the nurse and Resident 5 may react aggressively toward them. CNA 3 stated Resident 5 believed he was a staff nurse which may empower him. CNA 3 stated all staff on the unit should be aware of Resident 5's behavioral triggers to prevent his aggression. CNA 3 stated based on her facility provided abuse prevention training, when Resident 5 punched another resident, this was physical abuse. CNA 3 further stated Resident 5 was not aware Resident 6 had been in his room most of the day on 12/30/25. CNA 3 stated she was not present during the altercation but was aware Resident 5 had caught Resident 6 wearing his clothing. CNA 3 stated this would have triggered Resident 5's aggression. CNA 3 stated Resident 5 and Resident 6's rooms were right next door to each other and were too close together. On 1/9/26 at 11:19 A.M., a joint interview and record review was conducted with licensed nurse (LN) 1. LN 1 stated she provided care to Resident 5 yesterday. LN 1 stated she did not know Resident 5 had behavioral triggers. LN 1 stated it was important for all staff on the unit to know what Resident 5's triggers were to avoid his aggressive behavior. LN 1 stated she was unaware of Resident 5's PTSD diagnosis and triggers. LN 1 stated residents with PTSD could become aggressive and hurt others when triggered. LN 1 reviewed Resident 5's care plans and stated Resident 5's behavioral triggers were not identified and care planned. LN 1 stated this should have been done. LN 1 stated she saw Resident 5 wearing medical tape on his jacket identifying himself as an L.V.N. LN 1 stated it was not safe for him to present himself as a staff nurse. LN 1 stated if other residents approached Resident 5 thinking he was the nurse, it may trigger his aggression and lead to an altercation. LN 1 stated it may also empower Resident 5 to have perceived authority over other residents. LN 1 stated based on her facility provided training, punching another resident was physical abuse. LN 1 further stated she thought Resident 5 and Resident 6's rooms should not have been right next to each other as Resident 6 was easily confused and could enter Resident 5's room. On 1/9/26 at 2 P.M., a joint interview and record review were conducted with LN 2. LN 2 stated Resident 5 was triggered by other residents yelling and things had to be a certain way for him because he believed he built the building and "was in charge." LN 2 stated, "We play along with him to avoid his aggression or anger." LN 2 stated Resident 5 believed other people stole his things. LN 2 stated Resident 5 "[was] usually the aggressor" with other residents on the unit. LN 2 reviewed Resident 5's clinical record and stated his care plans did not identify resident-specific triggers or interventions to prevent the resident from being triggered. LN 2 stated she was not aware Resident 5 identified himself as a staff nurse in writing on medical tape that was worn on his jacket. LN 2 stated this was unacceptable. LN 2 stated it may give him a feeling of authority over others and was not safe. On 1/9/26 at 3 P.M., a joint interview and record review was conducted with the director of staff development (DSD). The DSD stated she provided the abuse prevention training in the facility. The DSD stated residents with unmanaged behaviors could lead to altercations and abuse.