Health inspection·January 20, 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. 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 11/6/25, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate one Facility Reported Incident regarding abuse. The department determined the facility failed to protect Resident 4 from physical abuse in accordance with facility policy and procedure titled "Unmanageable Residents," revised 4/10, and facility P&P titled "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," revised 4/21, when Resident 3, with a history of aggressive behavior, hit Resident 4 in the face with a water pitcher on 10/9/25. As a result of this failure, Resident 4 was sent to the emergency room with a facial contusion (bruise), facial lacerations (a torn, ragged wound or cut through the skin, typically caused by blunt force trauma or a sharp object) to the upper lip and right eyebrow which required stitches (threads used to sew up wounds to hold the skin together for healing), and pain. This deficient practice affected Resident 4's psychosocial and physical well-being. A review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility in 2021 with diagnoses which included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with other behavioral disturbances and anxiety disorder (more than occasional worry or fear). A review of Resident 4's Admission Record indicated Resident 4 was admitted to the facility in 2024 with diagnoses which included dementia and anxiety disorder. During an interview on 11/10/25 at 1:10 p.m., Licensed Nurse (LN) 3 stated, on 10/9/25 around 2:30 p.m. she heard a sound and went inside Resident 4's room. LN 3 stated, upon entering the room she saw Resident 3 leaning over Resident 4's bed. LN 3 stated Resident 4 was lying in her bed and crying. LN 3 stated Resident 4 stated, "Why would [Resident 3] do that...why did [Resident 3] hit me with that thing?" LN 3 further stated Resident 4 had a cut and was bleeding a lot from her upper lip and right side of the face near the temple area. LN 3 stated Resident 4 was sent to the hospital and Resident 4 returned from the hospital with stitches (a medical device used to hold body tissues together) on her right eyebrow and upper lip. During an interview on 11/10/25 at 1:34 p.m., LN 4 stated, before the incident on 10/9/25, Resident 3 had yelled and had aggressive behavior towards staff and other residents. LN 4 stated on 10/9/25 when LN 4 went inside Resident 4's room, she saw Resident 3 leaning next to Resident 4 and yelling at Resident 4. LN 4 stated she saw a water pitcher was on the floor inside Resident 4's room. LN 4 further stated Resident 4 looked scared and Resident 4's facial grimacing made LN 4 think that Resident 4 was in pain. LN 4 stated Resident 4 was bleeding from her upper lip and above her right eyebrow. During an interview on 11/10/25 at 2:02 p.m., Certified Nursing Assistant (CNA) 3 stated Resident 3 had yelled at staff in the past. During an interview on 11/10/25 at 2:05 p.m., with Resident 4, Resident 4 stated Resident 3 hit her. Resident 4 stated her lips hurt and she was scared when Resident 3 hit her. During an interview on 11/10/25 at 4:15 p.m., the Director of Nursing (DON), the DON stated Resident 3 had a behavioral history of being aggressive. The DON stated, Resident 4 received stitches to the laceration (cut) on her lip and eyebrow. The DON stated the incident may have caused Resident 4 emotional distress. During an interview and concurrent record review, on 12/29/25 at 3:26 p.m., Resident 3's MAR (Medication Administration Record, it serves as a central communication tool among various healthcare providers, ensuring continuity of care, especially during shift changes in place), dated 7/25 through 10/25, and Resident 3's "MD [Medical Doctor]/NP [Nurse Practitioner] Progress Note," dated 8/4/25, was reviewed with LN 5. LN 5 stated Resident 3 had a history of behavioral disturbance (when someone acts out in ways that disrupt their own life and relationships, like having frequent angry outbursts, defying rules, being impulsive, or having trouble focusing). LN 5 confirmed Resident 3's MAR, dated 7/25 through 10/25, did not contain behavior monitoring (the behavior monitoring process involves thorough assessment, identifying specific triggers (antecedents), tracking behavior and responses, developing an individualized care plan, implementing person-centered interventions, and continuous evaluation). LN 5 confirmed Resident 3's MAR, dated 10/25, indicated behavior monitoring was not started until 10/9/25. LN 5 further stated Resident 3's behavior monitoring was not done daily after Resident 3 had an altercation with staff on 7/25/25. Resident 3's "MD/NP Progress Note," dated 8/4/25, indicated, "...continue to provide supportive care...Diagnosis...Unspecified dementia, unspecified severity, with agitation...Restlessness and agitation...Agitation and violent behavior: [Resident 3] gets agitated at times, continue with supportive care and close monitoring...Monitor neuro [Neurological; the overall condition and function of your brain, spinal cord, and nerves, assessed through tests checking alertness, memory, movement, sensation, reflexes, and coordination to identify any issues affecting how you think, feel, and move]/mental status [how someone was thinking, feeling, and behaving]..." LN 5 stated a behavior monitoring log on Resident 3's MAR should have been implemented following the doctors progress note which indicated to monitor Resident 3's mental status on 8/3/25 in order to track Resident 3's behavior changes daily. During an interview on 12/29/25 at 3:40 p.m., LN 6 stated that when a doctor ordered behavior monitoring, a tracking log should have been implemented on the residents MAR to monitor the resident's behavior and mental status. LN 6 stated behavior monitoring documentation on the MAR would have helped facility staff track a resident's behavior to note if it was getting worse which could lead to more altercations. During an interview and concurrent record review on 12/29/25 at 4:05 p.m., Resident 3's MAR's, dated 7/25 through 10/25, and Resident 3's untitled Medical Doctor's (MD) History and Physical (H&P) note, dated 8/3/25, were reviewed with the DON. The DON confirmed there was no behavioral monitoring log implemented after the first incident on 7/25/25 when Resident 3 was aggressive towards staff. The DON stated there should have been behavior monitoring on Resident 3's MAR according to Resident 3's MD H&P note, dated 8/3/25. Resident 3's H&P note, dated 8/3/25, indicated, "...[Resident 3] has multiple medical issues, [Resident 3] tends to get agitated at times but her mentation [the ability, activity, or result of using your mind to think] is around baseline...ASSESSMENT AND PLAN...Agitation and violent behavior: [Resident 3] gets agitated at times, continue with supportive care and close monitoring..." The DON confirmed there was no behavior monitoring listed on Resident 3's MAR until 10/9/25. The DON stated the purpose for the behavior monitoring on the MAR was to monitor a resident's behavior during the shift, notify the MD, and address any noted behaviors in an IDT meeting (Interdisciplinary Team, a collaborative group of healthcare professionals including doctors, nurses, therapists, and social workers, responsible for residents plans of care and coordination of medical care) for further interventions if appropriate. Review of Resident 3's behavior care plan, initiated on 4/26/21, indicated, " ...Focus...The resident has a behavioral symptom [related to] anxiety, dementia by resistive care, refusing [treatments], makes false accusation towards staff, standing in front of her room to prevent staff from entering to care for her roommates, followed by agitation, verbal outbursts, and striking at staff during redirection..." Resident 3's behavior care plan included the following intervention, initiated on 7/25/25, indicated, "...monitor for aggressive behaviors such as striking at staff and notify MD for any [change of condition] or escalation..." Review of Resident 3's "Care Plan," initiated on 7/25/25 and resolved date of 9/24/25, indicated, "Focus...Sustained issues during episode of aggression/striking out at staff. Did not want room mate [sic] to have care...Interventions...Alleviate stressors that causes the problem, Assess the physical and mental status of the resident, Monitor any behavioral changes among resident, Notify MD if any change in condition occurs, Provide comfortable environment to the resident..." Review of Resident 3's "Progress Notes," dated 7/25/25, indicated, "...It was reported that [Resident 3] exhibited aggressive behavior toward staff who were providing care to her roommate. [Resident 3] was observed swinging at staff members...CNAs attempted to redirect and explain the situation, however [Resident 3] was not receptive at the time..." Review of Resident 3's "SBAR [Situation, Background, Assessment, and Recommendation; a verbal or written communication tool that helps provide essential, concise resident information] Communication Form," dated 7/25/25, indicated, "...Resident was aggressive and swinging at staff and holding on tight to her shirt because [Resident 3] didn't want her roommate to be cared for. [Resident 3] had h/o aggressive behavior and striking to staff..." Review of Resident 3's "Progress Notes," dated 7/26/25, indicated, "... [Resident 3] noted with yelling and accusations to staff for turning off tv..." Review of Resident 4's hospital "Patient Education & Visit Summary," dated 10/9/25, indicated, "...Presenting Complaint: ...a laceration to the right side of eye and mid upper lip after an altercation with roommate...Patient Diagnosis: Facial contusion, Facial Laceration, Lip laceration..." Review of Resident 3's "Interdisciplinary Notes," dated 10/9/25, indicated, "...[Resident 3] was observed by staff standing next to [Resident 4's] bed and appeared agitated when staff inquired about the incident. Roommate [Resident 4] was noted to have injuries to her upper lip and right temple area above eyebrow...the roommate [Resident 4] stated that [Resident 3] hit her two times with an item, possibly a water pitcher as a puddle of water was found on the floor next to [Resident 4's] bedside with the water pitcher..." Review of Resident 3's "Change in Condition Evaluation," dated 10/9/25, indicated, "...staff responded to loud verbal aggression from [Resident 3's room], ...upon arrival, [Resident 4] noted with bleeding from upper lip and slight bleeding from right temple area above the eyebrow due to a small cut. Water pitcher was observed on the floor at bedside with water spilled on the floor... [Resident 3] hit [Resident 4] with water pitcher...loud verbal aggression..." Review of Resident 3's "MEDICATION ADMINISTRATION RECORD," order start date 10/9/25, indicated, "...monitor for aggressive behaviors (i.e. throwing items, striking) [every shift] notify MD when escalation in behavior is noted..." Review of Resident 4's "Health Status Note," dated 10/10/25, indicated, "...mild swelling to lip area... [Resident 4] complained of mild pain to head..." Review of Resident 3's "Interdisciplinary Notes," dated 10/10/25, indicated, "...[Resident 3] is not on any psychotropic medications [medicines that alter brain chemistry to affect mood, thoughts, and behavior] but exhibits behaviors including anxiety, care resistance, false accusations, standing in front of her room to prevent staff from entering to care for her roommates, followed by agitation, verbal outbursts, and striking at staff during redirection...On 10/9/25 at approx. 1415H [2:15 p.m.], [Resident 4] was noted with a bleeding/cut to the upper lip and a small cut with slight bleeding to the right temple above the eyebrow. Writer interviewed the resident who stated, [Resident 3] hit me with that thing two times. Why did she do that? Upon observation, a water pitcher was found on the floor with a puddle of water next to it. Per staff report [Resident 3] was standing next to [Resident 4's bed] when they responded to [Resident 4] yelling for help... [Resident 4] was transferred to acute care for further evaluation and treatment due to continued bleeding from the lip cut. [Resident 4] returned from the acute after a couple hours at 1800H [6 p.m.], and noted with 5 stitches [are the threads or strands used to sew up wounds to hold the skin together for healing] to upper lip and 2 stitches to her right temple area above the eyebrow..." Review of Resident 4's "Health Status Note," dated 10/11/25, indicated, "...On monitoring for resident-to-resident altercation S/P [status post] ER [emergency room] visit following evaluation and treatment for lacerations to upper lip and right temple... [Resident 4] complained of mild pain to head..." Review of Resident 3's "Social Service Progress Note," dated 10/15/25, indicated, "...SSA [Social Services Assistant] spoke with [Resident 3] regarding the recent resident-to-resident altercation in which [Resident 3] was identified as the aggressor...SSA inquired about [Resident 3's] prior roommates, and [Resident 3] stated that she did not like them because they wouldn't shut up... " During a review of a facility P&P titled "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," revised 4/21, the document indicated, " ...Residents have the right to be free from abuse...This includes but is not limited to freedom from corporal punishment...verbal, mental...or physical abuse...T