Health inspection·February 9, 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 1/9/26, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to conduct a Federal Recertification Survey and to investigate a Facility Reported Incident regarding abuse. The facility did not provide adequate supervision to protect Resident 112 from physical abuse when a Licensed Nurse (LN) witnessed Resident 25 hit Resident 112 on the face on 12/12/25. Resident 112 sustained a scratch and redness on his right cheek. This failure resulted in physical injury and potential emotional distress that could negatively affect Resident 112's physical and psychosocial well-being. Record review of Resident 25's "ADMISSION RECORD," indicated, Resident 25 was admitted to the facility in early 2025 with diagnoses including schizophrenia ( a chronic, severe brain disorder that causes people to interpret reality abnormally, often involving hallucinations (seeing/hearing things not there), delusions (false, fixed beliefs), and disorganized thinking) and depression (a common but serious mental health disorder characterized by a persistent, lasting, and overwhelming feeling of sadness, emptiness, or loss of interest in daily life, lasting at least two weeks). Resident 25 was discharged from the facility on 12/18/25 (prior to the investigation). Record review of Resident 112's "ADMISSION RECORD," indicated, Resident 112 was admitted to the facility in 2020 with diagnoses including depressive disorder. Record review of Resident 112's "Minimum Data Set," (an assessment tool) dated 11/4/25, indicated Resident 112's BIMS (Brief Interview for Mental Status, a cognitive assessment with a range of scores from 0-15) score was 14 out of 15 suggesting intact mental functioning. During a concurrent observation and interview on 1/7/26, at 10:52 a.m. with Resident 112, Resident 112 was in the dining room playing table cards. When asked how he was doing, he responded in Spanish and motioned his hands indicating someone had hit him. When asked if the person who had hit him was still in the building and he motioned his hands that the other resident was no longer in the facility. During an interview on 1/7/26, at 10:52 a.m. with Resident 112, in the presence of Licensed Nurse (LN) 3 who interpreted Resident 112's responses from Spanish to English language, Resident 112 explained he was hit twice in his room and once outside of his room by his previous roommate (Resident 25). Resident 112 stated a Certified Nursing Assistant (CNA) witnessed the event in the room, but the CNA did not do anything. Resident 112 stated when Resident 25 was his roommate he was scared and not able to sleep at night. Resident 112 stated he did not tell anyone regarding the incident in his room because he believed that no one would believe him. Resident 112 stated that Resident 25 called him the devil and Resident 25 was seeing snakes. Resident 112 stated the second time (he was hit by Resident 25) the nurse saw what happened and she intervened. Resident 112 stated he was minding his own business and was sitting out in the hallway when Resident 25 came out of nowhere and hit him on both sides of his head and he did not have the time to react. Resident 112 stated the "other resident" was his previous roommate. Resident 112 stated the "other resident" was no longer in the facility and had not seen him and went somewhere else. During an interview on 1/8/26, at 2:31 p.m., with Resident 112 in the presence of LN 3 who interpreted for Resident 112, Resident 112 stated he felt that what had happened to him was a physical abuse because the "other resident" had hit him out of nowhere and hitting was an abuse. During an interview on 1/8/26, at 4:23 p.m., the Social Service Director (SSD) explained LN 5 had witnessed Resident 25 hit Resident 112 on the right cheek and sustained a scratch and some redness. The SSD stated this incident happened quickly and it was a spur of the moment. The SSD stated Resident 25 had a verbal outburst calling staff devils and talking about snakes. The SSD also stated Resident 25 had visual hallucinations such as seeing snakes. The SSD added at times Resident 25 stood up and lunged at staff. The SSD stated Resident 25's family had reported he had cycles of episodes every few years. During an interview on 1/9/26, at 7:40 a.m., Certified Nurse Assistant (CNA) 1 stated Resident 25 had behaviors of shouting at others. CNA 1 stated Resident 25 shouts when provoked and sometimes Resident 112 provokes Resident 25. CNA 1 also stated she had seen Resident 25 and Resident 112 exchanging words and at times could be verbally aggressive with each other. CNA 1 stated she was not aware of any other past physical altercations between Resident 112 and Resident 25, just the exchange of words. During an interview on 1/9/26, at 7:55 a.m., CNA 2 explained that Resident 112 had been in the room the longest, he was like the guard, and if he did not like his roommate, he made a way to do something so the roommate would be moved elsewhere. CNA 2 stated that about two weeks prior to this incident she overheard Resident 25 saying things about faith, talking about God, and saying that he was being taken away from the place where he wanted to stay. CNA 2 also explained that she noticed Resident 25 did not want to go back to his room because Resident 112 had guns and he was a bad person. CNA 2 stated she also noticed Resident 25 who was previously quiet was now very talkative and talked a lot. CNA 2 further explained before the incident happened that day, Resident 25 went out to the patio, and she followed him to calm him down and to encourage him to go back inside the building. CNA 2 stated prior to the incident that both Resident 112 and Resident 25 were shouting at each other in their own language. CNA 2 stated she tried everything to calm them down but Resident 25 was triggered and hit Resident 112 as he was coming in from the patio. CNA 2 stated she was at the nurse's station doing her charting when she heard the commotion. CNA 2 stated when Resident 25 reentered the building, Resident 112 was sitting at the nurse's station and Resident 112 said something to Resident 25, Resident 25 then approached Resident 112 and hit him. During an interview on 1/9/26, at 9:34 a.m., LN 5 stated she witnessed Resident 25 hit Resident 112 on the face. LN 5 explained the morning of the incident, Resident 25 and Resident 112 were sitting next to each other in the hallway near the North Nurses Station when suddenly, she heard yelling from Resident 25 who stood up from his chair and walked towards Resident 112. LN 5 further explained as she was going to assist and stop the altercation, Resident 25 was already standing and had hit Resident 112 twice on the face before she could intervene. LN 5 stated Resident 112 is mellow for the most part, but has had previous verbal arguments with other resident he was roommates with. Record review of Resident 25's "Care Plan Report," dated 8/14/25, indicated, "...auditory hallucinations AEB [as evidenced by] hearing voices telling pt. [patient] "Be careful" [and] visual hallucinations AEB seeing snakes and the devil..." Record review of Resident 25's "Care plan Report," dated 10/2/25, indicated, "...Potential for mood problem...Observe for signs and symptoms of...racing thoughts...increased irritability...flight of ideas...agitation or hyperactivity..." During an interview on 1/9/26, at 10:45 p.m., the Administrator (ADM) stated that Resident 25 was transferred to another facility due to hallucinations. The ADM stated Resident 25 had a psychiatric diagnosis. The ADM also stated that things happen in an instance and did not guarantee nothing was going to happen. The ADM added that staff could not anticipate every resident's move every day. During an interview on 1/9/26, at 12:29 p.m., the Director of Nursing (DON) stated Resident 25 was transferred to another facility due to escalated behavior and needed to be evaluated. The DON also stated that she was aware of Resident 25's diagnosis of schizophrenia on admission. The DON stated Resident 25 had very rare intermittent behavior that was more verbal with staff and not with other residents. The DON stated that the goal for every resident staying in the building was their safety and any altercations would make the residents feel unsafe, fearful, or scared. During a record review of the facility's policy and procedure (P&P) titled, "Abuse: Prevention of and Prohibition Against," revised date 8/25, indicated, "...It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment...Training...The Facility will engage in training and orienting its new and existing staff of topics which relate to the delivery of care and service in the post-acute setting. Topics of such training will include, but not limited to...Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms include, but are not limited to, the following...Aggressive and/or catastrophic reactions of residents...Outbursts or yelling out...The Facility will provide oversite and supervision of staff in connection with the above, to confirm that its policies prohibiting abuse...are being implemented...The Facility will act to protect and prevent abuse and neglect from occurring within the Facility by...Identifying, correcting, and intervening in situations in which abuse...is more likely to occur...Identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict...Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating..." Therefore, the facility did not provide adequate supervision to protect Resident 112 from physical abuse when a LN witnessed Resident 25 hit Resident 112 on the face on 12/12/25. Resident 112 sustained a scratch and redness to his right cheek. This failure resulted in physical injury and potential emotional distress that could negatively affect Resident 112's physical and psychosocial well-being, and is a violation of the aforementioned regulations, which had a direct or immediate relationship to the health, safety, or security of Resident 112 and is a B citation.