Health inspection·April 10, 2026

The following reflects the findings of the California Department of Public Health during the investigation of a facility reported incident. Facility Reported Incident Number: 2707612 Citation B was written. REGULATORY VIOLATIONS: Code of Federal Regulations, Title 42 F600 §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. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. California Code of Regulations, Title 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. On 01/09/2026 an unannounced visit was conducted at the facility to investigate a facility reported incident regarding abuse. The facility failed to ensure one (Resident 1) out of 6 sampled residents was free from physical abuse when a staff physically hit Resident 1 on the face. This failure resulted in a slap on the right side of the face of Resident 1 by CNA A which was witnessed by CN A B. This failure had the potential to put Resident 1 in psychosocial distress. This failure had the potential to compromise the safety of the residents in the facility. FINDINGS: A review of Resident 1's medical record indicated an admission date of 10/30/25. Resident 1's diagnoses included but were not limited to muscle weakness, bipolar disorder (a mental health condition that causes extreme mood swings) and fracture of one rib, right side, sequela (residual effect that persists after the acute phase of an illness has resolved). A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 11/6/25, indicated a brief interview for mental status score of 5 (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident; a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. A review of Resident 1's Nurse's Notes dated 1/3/26 at 10:14 p.m. indicated, "Resident is on COC [Change of Condition] monitoring for swelling to the left radial wrist and skin discoloration on the left inner thigh..." A review of Resident 1's Nurse's Notes dated 1/4/26 indicated, "Received x-ray [an imaging study] results for left wrist...noted with mild degenerative joint disease of the left wrist..." A Facility Reported Incident (FRI) sent by the facility to California Department of Public Health (CDPH) received on 1/5/26 indicated, "received report that around 215pm a CNA requested assistance from alleged abuser to assist with care for the patient. During providing care, the patient grew agitated and scratched to the left side of the alleged CNA's face. Primary patient's CN A stated that (the) one other CN A was scratched, CN A then slapped the right side of the patient's Face. CN A was immediately removed from the care of the patient ..." The accompanying Report of Suspected Dependent Adult/Elder Abuse (SOC 341) indicated date/time of incident was 1/4/26 2:15 p.m. A review of eInteract SBAR Summary for Providers dated 1/4/26 15:40 indicated: "... Outcomes of Physical Assessment: ... Nursing observations, evaluation, and recommendations are: According to the assigned CN A of AM shift, CN A witnessed another CN A who was not assigned to the resident, slap the resident [name of Resident], to the right side of the face, stating a "medium" slap as the description. Neither soft nor hard. All of this incident occurred while the CN A who abused the resident, tried to help provide a brief change to the resident. ... Primary Care Provider Feedback: Monitor for Psychosocial and emotional well being post abuse for 72 hrs. Monitor latent effect on the right face for 7 days...." During an interview with CNA B on 2/11/26 at 12:22 p.m., CNA B stated that on the day of the incident at around 2:00 p.m. (1/4/26), CNA A was helping her clean and change Resident 1. CNA B stated, CNA A insisted on holding Resident 1's wrist even after telling her not to because it was uncomfortable for Resident 1. CNA B stated Resident 1 was able to free her hands and hit CNA A's face. CNA B then stated she witnessed CNA A hit Resident 1 back in the face and left the room. CNA B also stated, Resident 1 sat up on the bed and was pointing at her wrist to her. A review of CNA A's employee records indicated she was hired on 9/22/25. Her background screening was done on 9/17/25 and her last training on Abuse was during her date of hire on 9/22/25. A review of facility's policy and procedure (P&P) entitled "Abuse Prevention and Management" revised 5/30/24, the P&P indicated, "1. Definitions ...d. 'Physical Abuse' is defined as, but not limited to, hitting, slapping, punching, and/or kicking. It also includes corporal punishment which is physical punishment used to correct and/or control behavior.... 2. Screening employees, registry, contracted, or temporary agency staff, or students from affiliated academic institutions: a. The facility will screen potential employees for history of abuse, neglect, or mistreating residents, including attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries... 3. Training... a. The facility conducts mandatory staff training programs during orientation, annually and as needed on: ... v. understanding resident behavioral symptoms that many increase the risk of abuse and neglect and how to respond. 4. Prevention... d. The Facility identifies corrects, and intervenes in situations in which abuse, neglect, exploitation, misappropriation of resident property and/or mistreatment is more likely to occur.... " This failure had the potential to compromise the safety of the residents in the facility. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.