Health inspection·March 10, 2026

B Citation F600 Code of Federal Regulations, Title 42, Section §483.12 483.12(a)(1) Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by anyone. Cal. Code Regs. Tit. 22, § 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. On 01/27/2026, the Department made an unannounced visit to the facility to investigate three Facility Reported Incidents regarding resident abuse. The facility failed to implement effective interventions to keep two residents (Resident 1 and Resident 2), in a sample of eleven, who had a prior altercation in the facility's dining room on 1/1/26, apart to prevent further incidents. As a result, on 1/5/26 Resident 1 and Resident 2 were in the facility's dining room again when they got into a physical altercation and Resident 1 was transferred to the hospital due to his injuries and then transferred to a different SNF facility. This deficient practice revealed that care planned interventions to keep Resident 1 and Resident 2 safe were not implemented resulting in injuries to Resident 1 including left wrist and left eye swelling, a hematoma of the left zygoma (swelling, bruising, and potential tenderness to the cheekbone), an abrasion (a scraped skin injury) to the forehead, complaints of pain, and was transferred to the emergency room. Although Resident 1 could not articulate how this made him feel, potentially due to a diagnosis of an unspecified intracranial injury (a brain injury where the exact nature is not fully defined during the initial diagnosis and includes symptoms of headaches, dizziness, confusion, or memory loss), a reasonable person in Resident 1's position, who was subjected to physical abuse and a facility initiated transfer (not initiated or requested by the resident) to another skilled nursing facility after discharge from the emergency room, would be expected to experience significant psychosocial harm including fear, anxiety, depression, withdrawal, and feelings of hopelessness. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility in 2025 with diagnoses which included traumatic subarachnoid hemorrhage (bleeding in the space around the brain leading to sudden, severe headaches, and confusion) and unspecified intracranial injury (a brain injury where the exact nature is not fully defined during the initial diagnosis. Symptoms include headaches, dizziness, confusion, or memory loss). A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility in 2025 with diagnoses which included unspecified intracranial injury and generalized anxiety disorder (characterized by persistent, excessive, and uncontrollable worry about everyday events or activities). During an interview 1/27/26 at 1:40 p.m., Licensed Nurse (LN) 2 stated she had seen Resident 2 being aggressive when he grabbed a Certified Nursing Assistant (CNA) by his shirt (on 1/15/26). During an interview on 1/27/26 at 1:51p.m., CNA 2 stated some days Resident 2 was nice and some days Resident 2 was not nice. CNA 2 stated before the incident (on 1/5/26) Resident 2 had yelled at staff when Resident 2 did not get his way. CNA 2 stated Resident 1 did not have behavior issues while residing at the facility. During an interview on 1/27/26 at 2:58 p.m., the Social services Director (SSD) stated on 1/5/26 he went to the dining room after hearing a loud sound coming from the dining room. The SSD stated upon arriving inside the dining room he saw staff had separated Resident 2 from Resident 1. The SSD stated on 1/5/26 Resident 2 had rolled his wheelchair into the dining room where Resident 1 was watching TV. The SSD stated Resident 2 then struck Resident 1 with his hands several times on the left side of Resident 1's face. The SSD stated Resident 1 was evaluated and sent out to hospital. The SSD stated on 1/1/26 Resident 2 had a prior physical altercation with Resident 1. The SSD further stated to avoid further incidents from happening Resident 2 should have been on 1:1 care (used for residents requiring constant, uninterrupted, and direct observation for safety, behavioral, or medical reasons). The SSD stated behavior monitoring every hour for Resident 2 should have been implemented and both Resident 1 and Resident 2 should have been kept separate from each other for safety after the first incident. During an interview on 1/27/26 at 3:10 p.m., LN 1 Stated Resident 2 had been aggressive in the past and had refused to follow directions from staff. LN 1 stated since Resident 2 had been aggressive and had a prior altercation with Resident 1 (1/1/26), Resident 2 should have been kept away from Resident 1. LN 2 stated the second altercation between Resident 1 and Resident 2 could have been avoided if staff had always kept an eye on Resident 2. LN 2 stated when the second altercation happened (1/5/26) Resident 1 got injured and something even worse could have happened to Resident 1. During an interview on 1/27/26 at 3:24 p.m., CNA 1 stated Resident 2 did not follow staff's direction when staff helped Resident 2 with care. CNA 1 stated at times Resident 2 got angry with staff and refused to get his clothes changed. CNA 1 stated both Resident 1 and Resident 2 should have been kept separate from each other after the first altercation to avoid a second altercation from happening. CNA 1 stated Resident 2 would not have hurt Resident 1 if staff had kept an eye on Resident 2. CNA 1 further stated Resident 2's behavior should have been monitored. During an interview on 1/27/26 at 3:32 p.m., with Resident 3, Resident 3 stated on 1/5/26 he witnessed staff put Resident 1 on a gurney (a hospital bed with wheels) in the hallway outside the dining room. Resident 3 stated the staff were getting ready to take Resident 1 to the hospital after Resident 1 got hurt during an altercation with Resident 1. Resident 3 stated he saw blood and bruises on Resident 1's face. During a concurrent interview and record review on 1/27/26 at 4:45 p.m., with the Director of Nursing (DON), the DON stated the second altercation between Resident 1 and Resident 2 could have been avoided if Resident 2 was monitored for his aggressive behavior. The DON further stated if both Resident 1 and Resident 2 were kept separate from each other the incident on 1/5/26 would not have happened. The DON noted that failing to separate residents with a history of altercations posed a safety risk. The DON confirmed Resident 1 had swelling on his left wrist and swelling under his left lower eye after the second altercation with Resident 2. During a phone interview on 1/29/26 at 1:51 p.m., with the Director of Rehab (DOR), the DOR stated on 1/5/26 at the time of the second incident she was in her office when she heard yelling and screaming coming from the dining room. The DOR stated when she entered the dining room, she saw Resident 2 hitting Resident 1's face and chest area several times with his hand. The DOR stated she redirected Resident 2 to sit back in his wheelchair, because Resident 2 was trying to stand up. The DOR stated staff separated Resident 1 and she separated Resident 2 who was at that time yelling and cursing using derogatory words. The DOR stated she heard Resident 1 say that Resident 2 hit him. The DOR further stated there was a prior altercation between Resident 1 and Resident 2 on 1/1/26 and she was the witness to that first incident too. The DOR stated on 1/1/26 around 5 p.m. she was in her office when she heard yelling in the dining room. The DOR stated on 1/1/26 she saw Resident 2 stand up from his wheelchair, push Resident 1, and then swung and hit Resident 1. The DOR stated when Resident 2 pushed Resident 1, Resident 1 pushed Resident 2 back. The DOR stated she redirected Resident 2 to sit back in his chair. The DOR stated Resident 2's mother was there in the dining room on 1/1/26 and Resident 2's mother told staff that Resident 1 had tried to grab her food and Resident 2 did not like that. The DOR stated she noticed Resident 2's behavior had changed within the last month, and Resident 2 looked agitated. The DOR stated Resident 1 had been nice, he smiled and talked, she had never seen Resident 1 with any aggressive behavior issues. The DOR further stated both Resident 1 and Resident 2 had their rooms changed after the first incident and staff were made aware of the intervention to keep both Resident 1 and Resident 2 separate from each other. The DOR stated both Resident 1 and Resident 2 got into a physical altercation on 1/5/26 and the intervention of keeping both residents separate was not followed. During a phone interview on 2/18/26 at 8:29 a.m., with the Assistant Director of Nursing (ADON), the ADON stated on 1/5/26 Resident 1 and Resident 2 had got into an altercation where Resident 2 struck Resident 1's head multiple times. The ADON stated Resident 1 was sent to the hospital after the altercation. The ADON further stated Resident 1 was transferred from the hospital to sister facility (a closely related, often co-owned or affiliated, location-frequently in senior living, healthcare, or industrial sectors-that shares ownership, management, or services) because Resident 1 had got into multiple altercations with Resident 2. The ADON stated she was not aware if anyone from the facility had discussed with Resident 1 about his transfer to another facility. During a phone interview on 2/18/26 at 8:56 a.m., with the Director of Nursing (DON), the DON stated Resident 1 was admitted to sister facility on 1/6/26. The DON stated Resident 1 was confused, and Resident 1 repeated himself. The DON stated Resident 1 did not have a responsible person listed on his health record. Th DON further stated Resident 1 had RP's contact name listed on his medical record for financial decisions. During a phone interview on 2/18/26 at 10:59 a.m., with the Administrator (ADM), the ADM stated on 1/5/26 Resident 2 hit Resident 1's face in the dining room. The ADM further stated Resident 1 had discoloration around his eyes and Resident 1's wrist was hurting because Resident 1 tried to block Resident 2 from hitting him. The ADM stated Resident 1 was sent to the hospital after the altercation. The ADM stated she did not discuss with Resident 1 about his transfer to sister facility. The ADM stated Resident 1 was listed as his own responsible party on his admissions record. The ADM stated to keep Resident 1 and Resident 2 separate and avoid any further altercations, she had called the hospital and notified the hospital to transfer Resident 1 to another facility. The ADM stated to ensure Resident 1's safety he was sent to a sister facility. The ADM further stated she could not find any documents that stated Resident 1 was notified about his transfer to sister facility. During a phone interview on 2/18/26 at 9:26 a.m., with Resident 1, Resident 1 stated his hand was sprained and he was sent to the hospital because he was in pain. When asked about the incident Resident 1 stated, that guy borrowed twenty three thousand dollars . Resident 1 was unable to answer who had borrowed the twenty three thousand dollars. Resident 1 kept on repeating himself stating, "he has aneurism, he has aneurism, he sprained [Resident 1's] hand." Resident was unable to answer when asked if a staff had discussed with Resident 1 about his transfer to another facility. Resident 1 was unable to answer if he had got into an altercation with another resident. Resident 1 further repeated himself by stating, "...the Chinese guy turned [Resident 1's] bed over." Resident 1 was unable to answer who had an aneurism and who turned his bed over. During a phone interview on 2/18/26 at 10:38 a.m., with the Representative Payee (RP), the RP stated no one had notified her about Resident 1's transfer to another facility prior to Resident 1's discharge from the hospital. The RP stated she is not responsible for making Resident 1's healthcare decision. The RP further stated she is listed on Residents 1's healthcare record as Resident 1's financial contact person. The RP stated she called the facility in December 2025 to pay for Resident 1's rent at the facility. Review of Resident 1's "Progress Notes," dated 1/1/26, indicated, "... [Resident 1] had physical altercation with [Resident 2]..." Review of Resident 1's "Change in Condition Evaluation," dated 1/1/26, indicated, "... [Resident 1] physically abused...No change of condition noted after the altercation..." Review of Resident 1's "Care Plan," initiated on 1/2/26 and revised on 1/7/26, indicated, "Focus...alleged resident to resident altercation ...Goal...No Altercation...Interventions...monitor for pain...separate residents..." Review of Resident 1's "Interdisciplinary Notes," dated 1/5/26, indicated, "... [Resident 1] observed [Resident 2] and Family Member eating, went over to the table and tried to grab food from the visitors plate. [Resident 2] stood up and pushed [Resident 1] away and then [Resident 1] reached over the table, pushed [Resident 2] and then hit him in the head...[Resident 1 and Resident 2] were separated by Stations [a designated workspace within a healthcare facility] and will be monitored for delayed mental Anguish and physical injuries...Date...of Event 1/1/26..." Review of Resident 1's "Change in Condition Evaluation," dated 1/5/26, indicated, "... [Resident 1] physically abused...left wrist and lower left eye swelling..." Review of Resident 1's "Care Plan," initiated on 1/5/26 and revised on 1/7/26, indicated, "Focus...alleged resident to resident altercation ...Goal...No Altercation...Interventions...Send resident to acute [hospital] for further eval [evaluation]..." Review of Resident 1's "Progress Notes," dated 1/5/26, indicated, "...[Resident 1] had an altercation with [Resident 2] on 1/5 at 3PM. It was noted that [Resident 1] was struck on the left side of the face multiple times...Upon interview with [Resident 1], [Resident 1] noted that [Resident 2] had approached [Resident 1] and struck [Resident 1] out of nowhere, when asked if [Resident 1] feels safe, [Resident 1] did not answer. AMR [American Medical Response-ambulance company] was in the room upon interview and [Resident 1] was transported to [Hospital]..." Review of Resident 1's "Progress Notes," dated 1/5/26, indicated, "...[Resident 1] was physically abused by [Resident 2]...According to the Activity Director, who witnessed the incident, she was engaged in another task when she turned around and observed [Resident 2] approach [Resident 1] and strike [Resident 1] multiple times to the head shielding with his left arm...Upon assessment [Resident 1]