Health inspection·November 21, 2025

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. (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Code of Federal Regulations, Title 42, Section 483.10(a) Resident Rights. (a) The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Code of Federal Regulations, Title 42, Section 483.24 Quality of Life. Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. (b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) of this section for the following activities of daily living: (1) Hygiene - bathing, dressing, grooming, and oral care, (3) Elimination - toileting, 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: Code of Federal Regulations, Title 42, Section 483.25(e) Incontinence. (e)(1) The facility must ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. California Code of Regulations, Title 22, Section 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. 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. (d) Each patient shall be provided care which shows evidence of good personal hygiene, including care of the skin, shampooing and grooming of hair, oral hygiene, shaving or beard trimming, cleaning and cutting of fingernails and toenails. The patient shall be free of offensive odors. (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by orders of a licensed health care practitioner acting within the scope of his or her professional licensure. (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (2) Encouraging, assisting and training in self-care and activities of daily living. (5) Providing care to maintain clean, dry skin free from feces and urine. (6) Changing of linens and other items in contact with the patient, as necessary, to maintain a clean, dry skin free from feces and urine. California Code of 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. (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. 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. California Code of Regulations, Title 22, Section 72557. Equipment and Supplies. (a) Equipment and supplies in each facility shall be of the quality and in the quantity necessary for care of patients as ordered or indicated. At least the following items shall be provided and properly maintained at all times: On 9/29/25 at 8 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to conduct a recertification survey. The Department determined the facility failed to protect the residents' right to be free from neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress) for 5 of 35 sampled residents (Resident 23, Resident 46, Resident 86, Resident 56 and Resident 4) when, Resident 23, Resident 46, Resident 86, Resident 56, and Resident 4 who required the use of incontinent briefs (a type of absorbent material worn to soak up urine and/or contain feces) were told by unidentified nursing staff to urinate and/or defecate (feces) in their bed, due to the lack of available incontinent briefs during the weekend of Saturday 9/27/25 and Sunday 9/28/25. This failure resulted in the psychological and emotional distress of Resident 23, Resident 46, Resident 86, Resident 56, and Resident 4 feeling upset, uncomfortable, embarrassed, degraded (loss the respect for), and uncared for. 1a. A review of Resident 23's "ADMISSION RECORD," indicated Resident 23 was admitted to the facility in Summer of 2022 with diagnoses including anxiety disorder (a mental health condition characterized by feelings of fear, worry, unease, and nervousness). A review of Resident 23's "Minimum Data Set," (MDS - a resident assessment tool), "Section C: Cognitive Patterns," (an assessment of the mental abilities and functions the brain uses to think, learn, remember, pay attention, process information and solve problems) dated 9/16/25, indicated Resident 23's Brief Interview for Mental Status (BIMS - a screening tool used in long-term care to assess a resident's cognitive function [the mental processes like thinking, memory, and perception, that a person uses to understand and respond to their environment] Scoring = 13-15 indicates normal intact cognitive function, 8-12 moderate cognitive impairment, 0-7 signifies severe cognitive impairment) was 15 out of 15 indicating Resident 23 had normal intact cognitive function. A review of Resident 23's MDS, "Section H: Bladder [part of the body that holds urine] and Bowel [part of the body that holds feces]," dated 9/16/25, indicated Resident 23 was always incontinent (when a person has no control of when they pass urine or feces) of bladder and bowel. A review of Resident 23's care plan, (a personalized document that outlines a resident's healthcare needs, goals, and interventions) revised 6/10/24, indicated, "... [Resident 23] has bowel and bladder incontinence...Impaired mobility [a limitation in a person's ability to purposefully move their body, affecting their independence]...Requesting x4 [4 briefs to be in the residents room] large briefs..." During a concurrent observation and interview on 9/29/25, at 10:20 AM, with Resident 23, in Resident 23's room, five incontinent briefs were observed in a small clear bag located on Resident 23's bed. Resident 23 stated the briefs were returned to her today. Resident 23 was observed crying and upset. Resident 23 stated the facility ran out of briefs on 9/27/25 and 9/28/25 and that the facility had also run out of incontinent briefs a few weeks prior to 9/29/25. Resident 23 explained that Central Supply (CS 1 - the person in charge of ordering and stocking supplies) was on leave (absent from work) and when CS 1 went on leave the facility supplies were not available as usual. Resident 23 cried and explained that she should not have to worry about when she received her next incontinent brief and that she had never felt so uncared for in her life. During an interview on 9/29/25, at 1:21 PM, CS 2 confirmed the facility ran out of briefs on 9/27/25 and 9/28/25. CS 2 further stated the Administrator (ADM) had to borrow briefs on Monday 9/29/25, from other facilities because the delivery of the incontinent briefs was delayed. During an interview on 9/30/25, at 8:04 AM, CNA 5 verified the facility ran out of incontinent briefs on 9/27/25 and 9/28/25. CNA 5 explained that when she checked other nursing stations and supply closets in the facility, the areas did not have incontinent briefs available. CNA 5 stated that she did not have any briefs to put on the residents when she changed them and told a few residents if they went in the bed, she would change them. When asked if CNA 5 could recall which residents she told to go in their bed, she stated she could not recall. During a follow-up interview on 9/30/25, at 8:07 AM, Resident 23 stated the facility had run out of incontinent briefs on Sunday, 9/28/25. Resident 23 stated she had saved a couple of briefs just in case the facility ran out. Resident 23 further stated an unidentified staff member came into her room on 9/28/25 and took the incontinent briefs from her and stated the incontinent briefs were needed for another unnamed resident. Resident 23 cried and stated she had to go to the bathroom in her bed, and Resident 23 felt embarrassed, degraded, and further stated, "...it took every bit of dignity I had left away..." Resident 23 had three briefs left on her bed and stated she felt like she had to guard them. b. A review of Resident 46's "ADMISSION RECORD," indicated Resident 46 was admitted to the facility in mid-2024 with diagnoses including muscle weakness and difficulty walking. A review of Resident 46's MDS "Section C: Cognitive Pattern," dated 8/28/25, indicated Resident 46's BIMS was 15 out of 15 which showed Resident 46 had normal intact cognitive function. A review of Resident 46's MDS "Section H: Bladder and Bowel," dated 8/28/25, indicated Resident 46 was always incontinent of bladder and bowel. A review of Resident 46's care plan, revised 9/29/25, indicated, "...[Resident 46] has Bowel Incontinence...Resident [46] will be clean and dry with use of incontinence products and prompt incontinence care..." A review of Resident 46's care plan, revised 8/24/23, indicated, "...[Resident 46] has self care deficit with ADL [Activities of Daily Living - basic routine tasks that are necessary for independent self- care] functions: bathing, personal hygiene...toileting...[Resident 46] will be clean, dry, odor free...The resident will maintain dignity and self-esteem..." During an interview on 9/30/25, at 12:58 PM, in Resident 46's room, Resident 46 stated the facility ran out of incontinent briefs over the weekend (9/27/25 and 9/28/25) and further stated the shortage of incontinent briefs had happened before. Resident 46 explained she was upset because it was undignified (lacking dignity) and unsanitary (not clean) to go without incontinent briefs. During a follow-up interview on 10/2/25, at 7:15 AM, in Resident 46's room, Resident 46 stated that last Sunday (9/28/25) a Certified Nursing Assistant (CNA) whose name she could not recall, had come into her room looking for incontinent briefs and took two incontinent briefs from her dresser. Resident 46 further stated she asked the CNA what the facility was doing with the residents' money that incontinent briefs could not be provided. Resident 46 explained that the unidentified CNA did not respond to Resident 46's questions and just told Resident 46 that other unnamed residents needed them more and walked out of the room. Resident 46 stated she was upset and felt frustrated about the lack of incontinent briefs. c. A review of Resident 86's "ADMISSION RECORD," indicated Resident 86 was admitted to the facility early 2024 with diagnoses including paralytic syndrome (a condition characterized by loss of voluntary muscle control), muscle weakness, and reduced mobility (a physical impairment that restricts a person's ability to move freely/easily). A review of Resident 86's MDS "Section C: Cognitive Pattern," dated 7/16/25, indicated Resident 86's BIMS was 15 out of 15 which showed Resident 86 had normal intact cognitive function. A review of Resident 86's MDS "Section H: Bladder and Bowel," dated 7/16/25, indicated Resident 86 was always incontinent of both bladder and bowel. A review of Resident 86's care plan, revised 1/6/25, indicated, "...Resident [86] at risk for pressure ulcer development [area of skin damage]...r/t [related to] bladder and bowel Impairment...Will identify...provide treatment intervention...Follow facility policies...for the prevention/treatment of skin breakdown [a condition where the skin becomes damaged or injured leading to infection]..." During a concurrent observation and interview on 9/30/25, at 8:12 AM, with CNA 3, in Resident 86's room, CNA 3 checked Resident 86's room and confirmed Resident 86 did not have any incontinent briefs. CNA 3 further confirmed that the facility ran out of incontinent briefs over the weekend (9/27/25 and 9/28/25). CNA 3 stated the facility received some briefs on 9/29/25 from other facilities, but stated it was not enough for all the residents that needed them. CNA 3 further stated their usual process for providing residents with their needed incontinent briefs was that the previous shift's (a specific block of time during which a nurse works) CNAs were responsible to ensure each resident had the needed incontinence briefs before the CNA left for the day. CNA 3 explained on 9/28/25, CNA 3 alerted LN 9 and explained that the facility had run out of incontinent briefs. CNA 3 further explained LN 9 told her the ADM was contacted about the short supply of incontinence briefs. During an interview on 9/30/25, at 8:18 AM, CNA 4 stated that she worked on the weekend (9/27/25 and 9/28/25) and the facility had run out of incontinent briefs. CNA 4 further stated the facility also ran out of incontinent briefs a few weeks prior. CNA 4 explained that CS 1 normally ordered supplies but was out on leave. CNA 4 stated that after CS 1 went on leave, the facility had problems with maintaining the supply of incontinent briefs, as well as making sure each nursing station (a centralized area in a healthcare facility for nurse coordination, patient care, and record-keeping) had enough supplies prior to the weekends. CNA 4 further explained that the CNAs from each nursing station had gone and searched the facility and in the residents' rooms for incontinent briefs. CNA 4 stated they (CNA 4 and oth