Health inspection·March 11, 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. (a) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 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, but not be limited to, 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 i s a change in the patient's condition. (2) Implementing 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 72521, Administrative Policies and Procedures (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. 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 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 2/11/26 at 1:50 p.m., the California Department of Public Health (the Department) conducted an unannounced visit at the facility to investigate an entity reported incident regarding a sexual abuse allegation of Resident 1 (Patient 1) by Patient 2. As a result of the investigation, the department determined the facility failed to protect Patient 1 from abuse by Patient 2 when Patient 1 was found crying and saying, "Get him away from me," as Patient 2 was inappropriately touching Patient 1's genitals. This failure has resulted in Patient 1's right to be free from abuse not being protected and could potentially result in emotional distress that could negatively affect Patient 1's psychosocial well-being. Review of Patient 1's "Admission Record," indicated that Resident 1 was admitted 1/9/25 with diagnoses including cerebral palsy (a group of permanent movement and posture disorders caused by damage to or abnormal development of the brain) and contracture of the right elbow (shortening or ligaments of muscle around a joint as a result the elbow can't bend or straighten). Review of Patient 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 1/14/26 indicated, Patient 1 had severe cognitive (memory) impairment (loss). Review of Patient 2's "Admission Record," indicated that Patient 2 was admitted on 8/4/20 with diagnosis including unspecified dementia (a progressive state of decline in mental abilities). Review of Patient 2's MDS dated 12/4/25, indicated that Resident 2 had intact cognition (memory). Review of Interdisciplinary Team (IDT-a team of health care professionals that form a care plan for residents) notes dated 2/9/26 indicated, on 2/9/26, around 2:30 p.m., Certified Nursing Assistant (CNA) 2 came forward, in attendance with CNA 1 for the recheck on both patients. CNAs 1 and 2 stated, upon entering the room, they (CNAs 1 & 2) found Patient 2 sitting at the end of Patient 1's bed with his pants down. His back was to the door, but they could see his left hand stretched out to Patient 1's bed. Upon looking they discovered Patient 2's hand was underneath Patient 1's gown and his (Patient 2) other hand was on his own genitalia area...Patient 2 immediately started to stand to pull up his pants. During an interview on 2/11/26 at 2:32 p.m., with CNA 1, stated he went into Patient 1's room after doing evening care on Sunday (2/8/26) and discovered Patient 2 was sitting on Patient 1's bed with his (Patient 2) briefs pulled down. Patient 2 had his right hand on his genitals and left hand on Patient 1's hip. When CNA 1 pulled Patient 1's covers off him, he (CNA 1) could see Patient 1's penis was exposed out of his brief. After the alleged abuse incident, Patient 1 stated, "Get him [Patient 2] away from me," and was tearful. During an interview on 2/11/26 at 3:02 p.m., the Director of Social Services (DSS), stated the incident was reported to the Grass Valley police and Patient 1 was moved to a new room. During an interview on 2/11/26 at 4:16 p.m. with CNA 2, she stated she was asked to come into Patient 1's room with CNA 1. CNA 2 stated that she saw Patient 2 on edge of Patient 1's bed and that Patient 2 did not have brief or underwear on. CNA 2 saw his (Patient 2) brief on the floor. And Patient 2 was trying to pull on his pants. Patient 2's right hand was under Patient 1's gown and that Patient 1's penis was exposed. CNA 2 saw Patient 2 move his hand away from Patient 1. Patient 1 was lying in bed in a fetal position curled up and crying. During an interview on 2/11/26 at 4:50 p.m. with the Assistant Director of Nursing (ADON), she stated she would consider this incident a sexual abuse. The ADON further stated that every resident has the right to be free from abuse in the facility. During a review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation, and Misappropriation," revision 10/12/23, the P&P indicated, "Abuse of any type will not be tolerated in this facility at any time... Each resident has the right to be free from abuse... residents must not be subjected to abuse by anyone including, other residents..." Therefore, the department determined the facility failed to protect Patient 1 from abuse by Patient 2 when Patient 1 was found crying and saying, "Get him away from me," as Patient 2 was inappropriately touching Patient 1's genitals. This failure has resulted in Patient 1's right to be free from abuse not being protected and could potentially result in emotional distress that could negatively affect Patient 1's psychosocial well-being. This violation had a direct or immediate relationship to the health, safety, or security of Long-Term Care patients or residents.