Health inspection·March 12, 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 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 or 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 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. It was determined that the facility failed to ensure Patient 1 was free from sexual abuse, when Patient 2 was witnessed by Certified Nurse Assistant (CNA) 4 touching Patient 1’s breast with one hand while using the other hand to raise Patient 1’s shirt. This failure had the substantial probability of causing Patient 1 to experience anxiety, emotional distress, or fear of recurrence of sexual abuse which could subsequently lead to decreased engagement in social activities by Patient 1. On January 21, 2026, at 9 a.m., an unannounced visit was made to the facility to investigate an allegation of abuse. A review of Patient 1's admission record indicated Patient 1 was readmitted to the facility on September 18, 2025, with diagnoses which included dementia (condition affecting brain function, memory, and thinking skills), Alzheimer's (brain disorder affecting memory and cognitive functions), and major depressive disorder (persistent loss of interest/pleasure). A review of Patient 1’s History and Physical (H&P) completed on October 6, 2025, indicated Patient 1 did not have the capacity to make decisions. A review of Patient 1’s psychiatric (a medical practitioner specializing in the treatment of mental illness) note dated December 23, 2025, indicated, “...History...the patient frequently poses safety awareness problems...The patient has shown confusion, disorganization, disorientation, and a noticeable decline in cognitive function...her ability to do domestic task is impaired and is dependent on others...” A review of the Situation, Background, Assessment, Recommendation (SBAR - a communication tool that allows healthcare members to provide essential, concise information about an individual’s condition) dated January 18, 2026, indicated, “...patient (Patient 1) was touch (sic) inappropriately by another patient (Patient 2)...on 1/18/2026...family notified...Primary care Clinician notified...” On January 21, 2026, at 9:36 a.m., during a concurrent observation and interview, Patient 1 was observed to be alert and lying in bed. Patient 1 stated that she could not recall her breast being touched by another patient. During an interview on January 21, 2026, at 11:17 a.m., CNA 4 reported that on Sunday, January 18, 2026, at 4 p.m., she went outside to the smoking patio for a 10-minute break. During this time, she heard Patient 1 saying “no, no, no” and observed Patient 2 touching Patient 1’s breast with one hand while using the other hand to raise Patient 1’s shirt. CNA 4 stated that there were no other patients present and no staff supervising the 4 p.m. smoke break. On January 22, 2026, at 1:30 p.m., a concurrent observation and interview was conducted with Patient 2 (alleged abuser). Patient 2 was observed sitting in bed alert, oriented, and well-groomed accompanied by a sitter (trained staff member assigned to provide continuous bedside supervision). When asked about the incident occurring on January 18, 2026, Patient 2 stated he was on the smoking patio when Patient 1 came and parked her wheelchair next to him. Patient 2 stated the patient (Patient 1) held his hand and kissed it. He (Patient 2) stated he did not touch Patient 1, she (Patient 1) touched him. Patient 2 stated he did not touch Patient 1’s breast nor her shirt. Patient 2 stated a nurse walked up and took Patient 1 away from him. Patient 2 stated there was no facility staff supervising the smoking patio at that time. A review of Patient 2’s admission record indicated Patient 2 was readmitted into the facility on November 19, 2025, with diagnoses which included end stage renal disease (permanent kidney failure), nicotine dependence (compulsive need for nicotine), and absence of right leg above knee (Above the knee amputation [AKA]). A review of Patient 2’s H & P that was completed on January 7, 2026, indicated Patient 2 had the capacity to make decisions. A review of Patient 2’s psychiatric note dated January 21, 2026, indicated, “...psychiatrist consult f/u (follow up) due to what the patient did to another resident [Patient 1]...he stated that [name of Patient 1] was the one who started it by holding both of his hands and kissing them. He felt that what she did was an invitation and started fonding (sic) her...” A review of Patient 2’s care plan related to suspected inappropriate touching of another patient initiated on January 18, 2026, indicated an intervention which included implementation of increased supervision. A review of the five-day follow-up report of the facility related to the alleged sexual abuse involving Patient 1 and Patient 2 dated January 23, 2026, indicated, “...The aggressor was witness (sic) by staff touching the Victim’s [Patient 1] breast. Evidence suggests that the allegation of sexual abuse occurred. On January 22, 2026, at 3:33 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the facility process for handling sexual abuse included separating the victim and the perpetrator, ensuring safety for the victim, assessing, notifying the family, physician, law enforcement, and state agencies. The DON stated Patient 1 is a dependent patient requiring supervision and should not have been outside on the smoke patio without supervision. A review of the facility policy titled, “Abuse Prevention Program,” dated January 2018, indicated, “...residents have the right to be free from abuse...This includes sexual...verbal abuse...as part of the resident abuse prevention, the administration will: protect our residents from abuse by anyone including facility staff, other residents...develop and implement policies and procedures to aid our facility in preventing abuse...of our residents...implement measures to address factors that may lead to abusive situations...identify and assess all possible incidents of abuse...investigate...any allegations of abuse...” Based on interview and record review, it was determined that the facility failed to ensure Patient 1 was free from sexual abuse, when Patient 2 was witnessed by CNA 4 touching Patient 1’s breast with one hand while using the other hand to raise Patient 1’s shirt. This failure had the substantial probability of causing Patient 1 to experience anxiety, emotional distress, or fear of recurrence of sexual abuse which could subsequently lead to decreased engagement in social activities by Patient 1. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.