Health inspection·November 19, 2025

The following citation reflects the results of the California Department of Public Health during the investigation of two facility reported incidents. Incident numbers: 2634504 and 2634537. The inspection was limited to the specific incidents investigated and does not represent the findings of a full inspection of the facility. The facility was found to be not in compliance with 42 CFR 483.1-483.75 - Subpart B - Requirements for Long Term Care Facilities. State Class A citation 230022723 was issued for incident numbers 2634504 and 2634537 at Title 42 CFR §483.12 §483.12 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. 22 CCR § 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. On 10/3/25 at 2:30 pm, an unannounced visit was conducted at the facility to investigate allegations of physical abuse and verbal abuse of two residents by Certified Nursing Assistant (CNA) 2. On 10/1/25 at 9:30 pm, CNA 1 witnessed CNA 2 roughly turning, slapping and holding down Resident 1’s hands and arms, causing a skin tear to Resident 1’s left wrist during patient care. Later, at 10:30 pm, CNA 1 witnessed CNA 2 placing a pillow over Resident 2’s face and verbally telling her to shut up. CNA 1 did not immediately report these incidents to the facility administrator and to other officials in accordance with state and federal law and in accordance with the facility’s policies and procedures. The failure to report these events immediately to a supervisor and within two hours to the appropriate state and federal entities allowed for continued verbal and physical abuse and mental anguish for Residents 1 and 2.    Findings: A review of the facility’s policy and procedures (P&P) titled “Abuse Prevention and Reporting” revised 3/27/25, indicated [Facility’s name] shall ensure an abuse-free environment for the residents of the Skilled Nursing Facility (SNF) by establishing an effective abuse prevention program and shall report suspected or known resident abuse per all state and federal regulations. The P&P defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish…. d. Mental abuse includes, but is not limited to, humiliation, harassment and threats of punishment or deprivation. e. Physical abuse includes, but not limited to, hitting, slapping, pinching, and kicking. i. verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms aimed at residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. During a record review of Resident 1’s admission record, printed 10/3/25, indicated Resident 1 was an 82-year-old female admitted to the facility on 8/13/25 with diagnoses that included Alzheimer’s dementia (a progressive, irreversible brain disorder that causes memory loss, confusion, and a decline in mental ability) and acute back pain. Resident 1 was unable to make her own health care decisions. During a review of Residents 1’s Quarterly Minimum Data Set (MDS, a data driven clinical assessment) dated 7/30/25, section C -(Cognitive patterns, the ability to think clearly, reason and remember) indicated a Brief Interview for Mental Status (BIMS, a test for memory and thinking ability with a range of scores from 00 for severe cognitive impairment to a score of 15 for intact cognition) was conducted, and Resident 1 scored a 4 indicating severe cognitive impairment, for scores between 0-7. Section E- (Behavior assessment) indicated Resident 1 did not exhibit physical or verbal behavioral symptoms (i.e. hitting, pushing, screaming or cursing) directed toward others and did not have episodes of refusing care. Section GG-Functional Abilities indicated Resident 1 was dependent on staff for toileting. Section H -Bowel and Bladder indicated Resident 1 was incontinent (having no control with) bowel and bladder and wore briefs (disposable underwear that collects urine and feces) that required the staff to change. During an interview with CNA 1 on 10/8/25 at 3:16 pm, CNA 1 stated that during patient care for Resident 1 she had witnessed CNA 2 grab Resident 1’s hands and arms and push them into Resident 1’s chest.  CNA 1 stated CNA 2 turned Resident 1 roughly and quickly when they were changing her brief. CNA 1 stated she had witnessed this treatment of Resident 1 by CNA 2 since 9/1/25, but on 10/1/25 it was the worst she had seen.  CNA 1 stated that on 10/1/25 at 9:30 pm, Resident 1 received a skin tear when CNA 2 grabbed Resident 1’s arm and rolled her roughly. CNA 1 stated she reported the rough treatment of Resident 1 by CNA 2 to Licensed Nurse (LN) A on 10/2/25 at 3:45 pm (18 hours after the incident.) CNA 1 stated that she should have reported it right away. During an interview with LN A on 10/3/25 at 3:29 pm, LN A stated that CNA 1 told him the previous evening that, on 10/1/25, at 9:30 pm, CNA 2 grabbed Resident 1’s hands, slapped them on her chest, struck her arms, and caused a skin tear on her left wrist due to rough handling. LN A said he reported the alleged abuse by sending an email to his Director of Nursing. LN A stated, “Since I did not witness the abuse, I am not the one to fill out an abuse report.”  LN A confirmed that he sent an email to his DON about the reported abuse but did not call anyone or fill out any forms. During a concurrent interview and email review with the Director of Nursing (DON) on 10/3/25 at 2:30 pm, the DON stated that on the morning of 10/3/25, she read an email from LN A indicating that CNA 2 was abusing residents. The email dated 10/2/25 at 6:58 pm, by LN A indicated: “[CNA 1] reported to me that they have witnessed [CNA 2] be verbally abusive towards multiple residents and physically abusive to [Resident1]. While I was completing wound care on [Resident 1’s] skin tear, [CNA 1] stated to me that they feel like the skin tear was caused by [CNA 2] being too rough when completing care. I asked them to elaborate. [CNA 1] stated that [CNA 2] often yelled at [Resident 1] and other residents when they (CNA 2) got frustrated and was rough when completing care on residents. [CNA 1] also stated that [CNA 2] takes [Resident 1’s] hands and often slams them against her chest and slaps her arms and legs around. [CNA 1] also stated that they (CNA 1) try to complete rounds by themselves, especially [Resident 1] so that she isn’t yelled at or hit again or any resident. [CNA 1] also stated that other staff have expressed the same concern and witnessed her yelling and being rough with other residents” During a concurrent observation and interview with Resident 1 and the DON in the DON’s office on 10/3/25 at 3:20 pm, Resident 1’s left forearm was observed to have a bandage wrapped around Resident 1’s left hand extending up to the middle of her forearm. The DON removed the bandage and revealed a purple and reddish bruise approximately 3 to 4 inches (about 9 cm) long on the top of the forearm, along with a skin tear in the bruised area. The DON stated that Resident 1 does not normally bruise. During a record review of Resident 2’s admission record, printed 10/3/25, indicated Resident 2 was a 78-year-old female admitted to the facility on 5/19/25 with diagnoses that included Alzheimer’s dementia, chronic (ongoing) pain, joint pain of the leg, and anxiety disorder. Resident 2 was unable to make her own health care decisions. During a record review of Resident 2’s Quarterly MDS dated 9/1/25, section C indicated a BIMS was conducted, and Resident 2 scored a 9 indicating moderate cognitive impairment. Section E indicated Resident 2 had daily behaviors that included yelling and screaming and making disruptive sounds. Section GG- indicated that both legs were impaired, Resident 2 was unable to feed herself, required maximal assistance (helper does more than half the effort) with going to the bathroom, upper and lower body dressing, personal hygiene (washing and drying face), and rolling from left to right while in bed. Resident 2 was unable to stand or transfer in and out of bed without total assistance from staff.  Section H indicated Resident 2 was incontinent with bowel and bladder and wore briefs that required the staff to change. During a phone interview with CNA 1 on 10/8/25 at 3:16 pm, CNA 1 stated “CNA 2 always says shut up, knock it off, and stop screaming to Resident 2. I noticed CNA 2 saying these things to Resident 2 since the beginning of September 2025. On 10/1/25 at 10:30 pm, we were changing Resident 2’s brief while she was in bed. Resident 2 was screaming, and CNA 2 put a pillow over Resident 2’s face and said, try screaming, stop screaming [Resident’s name]! Resident 2 was unable to remove the pillow by herself, so I removed it.” CNA 1 stated that when they were done changing and positioning Resident 2, CNA 2 threw blankets over Resident 2’s face. CNA 1 said “I was so afraid, and I know I should have said something that night. I knew it was wrong. I should have reported it right away, but I was scared.” CNA 1 stated she notified the Director of Nursing (DON) on 10/3/25 at 9:03 am. (35 hours after the incident). During an interview with the DON on 10/3/25 at 2:30 pm, the DON stated that CNA 1 had called her at 9:03 am that same day, to report that on 10/1/25, Resident 2 had yelled during care, and CNA 2 had placed a pillow over Resident 2’s face. During an observation and interview with Resident 2 on her bed in her room on 10/3/25 at 2:58 pm, Resident 2 was lying on her back, facing the ceiling. Three pillows supported her head from behind and both sides, and the covers were pulled up to her chest. Resident 2 spoke continuously but incoherently and did not respond to any questions. She continued to utter nonsensical words throughout the interaction. During a phone interview on 10/6/25, at 11:02 am, CNA 2 confirmed that she worked the night shift on 10/1/25 through the morning of 10/2/25. CNA 2 stated that Resident 2 talked frequently and often yelled, which she found overwhelming. CNA 2 stated that she became frustrated when Resident 2 yelled and confirmed that at one point, a pillow had fallen onto Resident 2’s face. During an interview with the DON on 10/3/25 at 4:20 pm, the DON stated that witnessed or suspected abuse at any time should be reported to herself immediately, CDPH, Ombudsman and the Sherriff office within two hours and this was not done by LN A or CNA 1, and it should have been. In violation of the above cited standards, the facility failed to ensure that residents were free from abuse. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Residents 1 and 2 and constitutes an A citation.