Health inspection·December 12, 2025

California Code of Regulation, 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 Regulation, 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. Code of Federal Regulations, Title 42, § 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. 483.12(a)(1) The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. It was determined based on interview and record review, the facility failed to ensure the patient was free from physical abuse when a Certified Nursing Assistant (CNA) struck the patient (Patient 1) across the face. This failure had the potential to cause physical harm and psychosocial distress to the patient. On October 30, 2025, at 8:54 a.m., an unannounced visit was conducted at the facility to investigate an allegation of physical abuse. On October 30, 2025, Patient 1's record was reviewed. Patient 1 was admitted to the facility on September 16, 2025, with diagnoses which included dementia (a condition characterized by persistent loss of intellectual functioning), and schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia [chronic mental health condition that affects a person’s thoughts and behavior], such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression, bipolar type (a mental health condition that combines symptoms of schizophrenia and bipolar disorder (mental health condition characterized by extreme shifts in mood, energy, and behavior). Further review of record indicated that Patient 1 was discharged from the facility on October 27, 2025. A review of Patient 1's "Medication Administration Record (MAR)," order dated September 16, 2025, indicated, "...Valproic Acid (medication to treat mood disorder) Oral Solution 500 MG (milligram - unit of measurement) give 10 ml (milliliter - unit of measurement) by mouth three times a day for Mood D/O (disorder) M/B (manifested by) anger outburst..." A review of Patient 1’s “History and Physical,” dated September 19, 2025, indicated, “...DECISION MAKING CAPACITY...Can make decisions...” A review of Patient 1’s “Progress Notes,” dated September 22, 2025, at 1:05 p.m., indicated, “...Patient is seen and evaluated...Resident has hx (history) of anger outburst, hearing voices, yelling...Staff reported pt (patient) has episodes of violent bx (behavior), striking out...Continue to provide non-pharmacological interventions and monitor for changes in mood and behavioral changes...” A review of Patient 1's psychiatric evaluation, dated September 22, 2025, indicated, "...patient has episodes of violent bx (behavior)...striking out...Plan: monitor behavior of striking out x (times) 14 days...continue to provide non-pharmacological interventions...monitor for changes in mood and behavioral changes..." A review of Patient 1’s “IDT (Interdisciplinary Team - a group of healthcare professionals),” dated October 20, 2025, at 3:50 p.m., indicated, “...Investigation regarding allegation of resident [Patient 1] being struck by a CNA [CNA 2] ...Team was investigating an episode of this resident striking a CNA [CNA 2] in (sic) the chest while the CNA was charting. Upon interview of the resident [Patient 1] at first resident denied that there had been any altercation. Resident returned a few minutes later and said, “Are you talking about when I hit that nurse and she hit me back in the face”. Resident has BIM (Brief Interview of Mental Status – a tool to check cognitive levels) score of 10 (moderately impaired cognitive level) ...has capacity to make her own decisions...During interview with the CNA [CNA 2] who is alleged to have struck this resident she asserted that she did not strike the resident. Per the CNA she put her finger in the resident’s face, shaking her finger and telling the resident “Do not hit me”...CNA states that raising her finger and shaking it in front of anyone is culturally acceptable in her country and that it is a routine part of their communication...” A review of Patient 1's care plan, dated October 20, 2025, indicated, "...Focus: altered behavior patterns...Goals: reduce the episodes of behavior daily...Interventions: provide reality awareness...encourage verbalization of feelings and concerns...address appropriately...provide redirection..." On October 30, 2025, at 1:40 p.m., CNA 1 was interviewed. CNA 1 stated it would be inappropriate for a patient or staff member to hit a patient, as it would be considered abuse. On October 30, 2025, at 2:49 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated Patient 1's behavior was aggressive most of the time. On October 30, 2025, at 5:20 p.m., during an interview, the Administrator (ADMIN) stated that on October 18, 2025, she received a report that Patient 1 punched the CNA (CNA 2) on the chest. The ADMIN stated that when interviewed the patient alleged the CNA (CNA 2) hit her. The ADMIN stated the CNA denied hitting the patient but said she waved her (CNA 2) finger at the patient, which the ADMIN stated was inappropriate and is considered a form of abuse. Concurrently, the surveillance video was reviewed with the ADMIN. The surveillance video showed that the patient punched the CNA (CNA 2) but did not show the CNA waving her finger at the patient (Patient 1). However, the surveillance video showed the CNA’s (CNA 2) right hand went up and moved towards the left (CNA’s left when facing the patient) at the same time the patient’s face moved towards the right (patient’s right when facing the CNA). The ADMIN validated what was seen in the video surveillance of what occurred on October 18, 2025, that the patient did strike at the CNA and that CNA 2 struck back at the patient (Patient 1). The ADMIN stated the CNA (CNA 2) was terminated on October 24, 2025. A review of the facility’s policy and procedure titled “Abuse, Neglect, Exploitation or Misappropriation Prevention Program," revised April 2021, indicated, "...Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse...Protect residents from abuse, neglect...by anyone including...facility staff...Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems...help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts..” Based on interviews and record reviews, it was determined that the facility failed to ensure the patient was free from physical abuse, when a CNA struck Patient 1 across the face. This failure had the potential to cause physical harm and psychosocial distress to the patient. This violation had a direct or immediate relationship to health, safety, or security of the patients.