Health inspection·December 9, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few .Claiming roommate [Resident 2] punched him repeatedly in the face and chest 25 times .Has wounds to right head laceration [deep cut], [NAME] [sic] to right forehead, wound to right lip, bleeding from right ear, nd [and] skin tear to right hand. Victim [Resident 1] and assaulter [Resident 2] separated immediately, 911 called. Around 0510 [5:10 AM] Cops arrived and [paramedics] arrived .took [Resident 1] to [acute care hospital] .A review of Resident 1's Nurses Note, dated 12/4/25, at 5:20 AM, indicated, .[Resident 1] face covered in blood, resident stated my roommate attacked me, he punched me 25 times, all over in my face, bump noted to right eyebrow with laceration, skin tear to left brow, bleeding from his mouth, bleeding from his right ear, and a skin tear to his right hand .[Resident 1] stated, look at what he did to my ear, while pointing at his ear with his right hand.A review of Resident 1's clinical record titled, Emergency Documentation, dated 12/4/25, indicated, .[Resident 1] is a [AGE] year old male presenting from nursing home for assault.[Resident 1] per report was assaulted in his sleep by another nursing home resident. He was hit multiple times in the face with a fist.[Resident 1] has lacerations to the face and scalp as well as bleeding from the right ear lobe. [Resident 1] is complaining of generalized pain mostly across the head.Presentation is consistent with a closed head injury and soft tissue trauma.A review of Resident 1's Nurses Note, dated 12/4/25, at 12:45 PM, indicated, .[Resident 1] back in facility.[Resident 1] noted with stitches to middle left eyebrow, laceration to right earlobe and scattered bruising to the face.A review of Resident 1's Nurses Note, dated 12/4/25, at 9:36 PM, indicated, .[Resident 1] is on day 1 s/p [status post] hospitalization d/t [due to] resident [Resident 1] to resident [Resident 2] altercation.Noted resident [Resident 1] with laceration to forehead with stitches and some dry blood of resident (Resident 1) face.A review of Resident 1's Social Services Progress Note, dated 12/5/25, indicated, .SSD [Social Services Director] asked pt [patient] how he was doing. [Resident 1] stated, I feel like I got hit by a truck.SSD asked pt if recalls incident from yesterday .[Resident 1] replied, Yes, a man that I thought was trustworthy hit me with his fist at least 12 times.During a concurrent observation and interview on 12/4/25, at 2:54 PM, with Resident 1, in his room (a resident room with 3 beds), Resident 1 was observed to be seated on the bed farthest from the door. Resident 1 was noted to have dark purple discolorations on both eyebrows, stitches were noted on the left eyebrow, stitches were noted on the forehead between the brows, and a dark bluish-purple discoloration noted on the right earlobe. Resident 1 stated that he was hurt badly and Resident 2 smashed his face and beat him up. Resident 1 further stated he was lying in bed but was awake in the morning of the incident. Resident 1 stated he saw his roommate (Resident 2) who stood up from his bed (the middle bed in the room next to Resident 1's bed) and started hitting him. Resident 1 further stated there was no curtain between them, and they were the only two persons in the room. Resident 1 stated he did not fight back. Resident 1 further stated when he realized he was hurt; he walked out of the room and asked the staff for help.During an interview on 12/4/25, at 3:07 PM, with Resident 1's Family Member (FM) 1, FM 1 stated she had visited him the day before on 12/3/25, and had not seen any injuries on his face. FM 1 further stated she was worried that the physical aggressiveness episode would likely have a possible negative impact on Resident 1's personality, especially given his dementia. FM 1 stated she felt terrible about what had happened to Resident 1.During an interview on 12/4/25, at 3:34 PM, with licensed nurse (LN) 1, LN 1 stated the AM (morning) shift told her about the altercation between Resident 1 and Resident 2. LN 1 further stated the fight happened during the (latter part) of night shift on 12/4/25, and Resident 1 came out of the room (in the early morning) with a bloody face. LN 1 stated Resident 1 was sent to the hospital and returned the same day around 12:45 PM during the AM shift. LN 1 further stated that Resident 2 was admitted to the facility in mid- November and was observed with a bad (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555105 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Noble Care Center 2740 North California Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few mouth as Resident 2 was heard yelling expletives (swear words) to others. LN 1 stated she witnessed Resident 2 throwing food, medicines, and trays if Resident 2 was unhappy. LN 1 stated Resident 1 had dementia and sometimes showed behaviors like increased agitation and restlessness. LN 1 further stated that it was not a good idea to have Resident 1 and Resident 2 in the same room because both had known behavioral issues. LN 1 explained with the history of Resident 1 and Resident 2, they should not have been placed together. LN 1 stated the incident (12/4/25) could have been prevented if Resident 2 had been admitted to a different room that suited him better.During an interview on 12/4/25, at 3:49 PM, with certified nurse assistant (CNA) 1, CNA 1 stated Resident 1 had been in his current room for a while. CNA 1 further stated Resident 1 got anxious easily and needed to be handled with patience. CNA 1 further stated she needed to adjust her tone of voice because Resident 1 could become agitated quickly. CNA 1 stated Resident 1's dementia sometimes made him act out, and he had the potential to hurt others. CNA 1 further stated Resident 2 had been observed displaying aggressive behavior since his admission, such as throwing things and breaking the hand sanitizer attached by the room door. CNA 1 stated if the facility had reviewed Resident 1 and Resident 2's behavior history before placing them in the same room, the incident might have been prevented. CNA 1 further stated the room assignment should have been carefully considered to avoid conflicts between Resident 1 and Resident 2.During a concurrent interview and record review on 12/5/25, at 9:50 AM, with LN 2, Resident 2's electronic health record (EHR) was reviewed. LN 2 stated she had heard about the altercation between Resident 1 and Resident 2. LN 2 further stated Resident 2 often behaved aggressively, like throwing plates and yelling. LN 2 stated Resident 2 refused to take his morning psychotropic (any substance that primarily affects the mind, emotions, and behavior) medication even after being told about the risks and benefits. LN 2 further stated Resident 2's behavior was very unpredictable, being calm one moment and suddenly aggressive the next. LN 2 stated she had noticed a change in Resident 2's behavior on 11/28/25, when Resident 2's aggressive actions escalated from verbal outbursts to physical actions, such as breaking things like the hand sanitizer dispenser on the wall, the sliding window, and trying to confront other residents. LN 2 further stated Resident 2 showing both verbal and physical aggression was becoming a danger to himself and others. LN 2 stated she called the Medical Doctor (MD) at that time (11/28/25), who ordered that Resident 2 be sent out for further care. LN 2 further stated the MD agreed with LN 2 that Resident 2 was becoming a danger to himself and others. LN 2 checked the Medication Administration Record (MAR - used to record all medications given to a patient) for November and December 2025 and confirmed that Resident 2 did not get his morning psychotropic medication since he was admitted . LN 2 stated she informed the MD about Resident 2's refusal to take his psychotropic medication. LN 2 further stated Resident 2's refusal to take his psychotropic medication caused his behavior to get worse. LN 2 stated Resident 2's noncompliance put him at increased risk of becoming more aggressive. LN 2 further stated Resident 2's compliance in taking his medication was very important for managing his behavior.During an interview on 12/5/25, at 10:59 AM, with LN 4, LN 4 stated she conducted the Nursing Clinical admission Evaluation for Resident 2 on 11/18/25. LN 4 confirmed that when Resident 2 was admitted , Resident 2 was disoriented and confused. LN 4 stated Resident 2 showed signs of agitation and Resident 2 cursed at the staff (on 11/18/25). LN 4 further stated Resident 2 refused the skin assessment and cursed at her when LN 4 tried to explain why it was necessary. LN 4 stated Resident 2 reported multiple hallucinations during the assessments. LN 4 confirmed that she documented a change in condition on 11/19/25 because Resident 2 had refused a new admission blood draw. LN 4 explained to Resident 2 the importance of blood draw, but Resident 2 replied, No one is putting any [expletive] needles in me.During an interview on 12/5/25, at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555105 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Noble Care Center 2740 North California Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few 11:26 AM, with LN 5, LN 5 stated Resident 2 had behaved very aggressively towards the staff on 12/4/25, making threats and using curse words. LN 5 further stated Resident 2 was very agitated when the police arrived to check on him. LN 5 stated Resident 2 was offered assistance on the day of the incident, but Resident 2 became more agitated. LN 5 further stated when the ambulance arrived to take Resident 2 to the hospital as ordered by the MD, Resident 2 continued to threaten the staff aggressively. LN 5 stated it was a bad idea to have Resident 1 and Resident 2 in the same room together because both residents had aggressiveness. During a concurrent interview and record review on 12/5/25, at 12:30 PM, with the Social Service Director (SSD), Resident 1 and 2's EHR were reviewed. The SSD stated that when she arrived on the morning of 12/4/25, she received a report about the altercation between Resident 1 and Resident 2. The SSD further stated Resident 1 was sent to the hospital. The SSD stated Resident 2 was sitting in the hallway outside of his room and was very agitated. The SSD confirmed Resident 2 had a history of behaviors such as: cussing at staff, refusing all basic care, angry outbursts, breaking a hand sanitizer machine off the wall and used it to break sliding door, verbalizing racial comments towards staff when staff attempting to provide care, and multiple episodes of urinating on the floor. The SSD stated it was suggested to move Resident 2 to a different room because of Resident 2's behavior. The SSD stated the suggestion was documented by a licensed nurse on 12/2/25, attempting to move Resident 2 to another room, but Resident 2 refused. The SSD confirmed that on 11/28/25, Resident 2's condition changed as Resident 2's verbal aggression turned into physical aggression. The SSD stated this issue was not addressed when the Interdisciplinary Team (IDT - group of professionals who work together toward a common goal for usually a patient or client) met on 12/1/25. The SSD further stated it was important to review and discuss Resident 2's behavior and appropriate interventions during the IDT meeting to ensure the safety of both Resident 1 and Resident 2.During a concurrent interview and record review on 12/9/25, at 2:07 PM, with the Director of Nursing (DON), the DON confirmed that a change in condition was documented on 11/28/25, when Resident 2 grabbed the pill crusher and slammed it on the floor. The DON stated it was a new behavior for Resident 2. The DON further stated Resident 2 was moved to the back for better visibility, but the DON later clarified that no room change happened, and Resident 2 stayed in the same room since admission. The DON confirmed that she knew Resident 2 was not consistent in taking his psychotropic medication. The DON stated Resident 2's noncompliance with psychotropic medication contributed significantly with Resident 2's worsening behavior.During an interview on 12/10/25, at 2:52 PM, with the Mental Health Nurse Practitioner (NP), the NP confirmed that she had examined and evaluated Resident 2 on 11/20/25. The NP stated she recommended (ordered) increasing the psychotropic medication to 100 mg (milligram) in the morning and at bedtime, for a total of 200 mg per day, to manage Resident 2's schizophrenia shown by anger outbursts. The NP further stated she did not know that Resident 2's MD had recommended (ordered) increasing the psychotropic medication to 150 mg twice a day 11/19/25. The NP stated she was not aware that Resident 2 was not taking his morning psychotropic medication but was taking his evening psychotropic medication. The NP further stated that she was not aware that Resident 2's psychotropic medication recommendation was not carried out, and no changes were made since admission. The NP stated that she had not known about Resident 2's change in condition, which led to his behavior worsening from verbal to physical aggression on 11/28/25. The NP stated that she had examined and evaluated Resident 1 previously. The NP further stated that she managed Resident 1's moodiness and schizophrenia symptoms, such as anger outbursts, by adjusting his psychotropic medications. The NP stated that Resident 1 and Resident 2 should not have been in the same room because they both had known behavior issues. The NP further stated that Resident 2's refusal to take his psychotropic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555105 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Noble Care Center 2740 North California Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete medication contributed to his behavior getting worse. The NP stated that if she had known Resident 2 was still taking his bedtime medication, she would have recommended increasing the dose at night. The NP further stated that it was everyone's responsibility to keep all residents safe. The NP explained that this was a top priority because residents were here to heal and not to get injured.During an interview on 12/10/25, at 3:40 PM, with Medical Doctor (MD), the MD confirmed that both Resident 1 and Resident 2 were under his care. The MD stated that he did not remember the nurses informing him about the Mental Health NP's visit on 11/20/25 or the recommendation for psychotropic medication for Resident 2. The MD further stated that Resident 2's behavior escalated on 11/28/25. The MD stated that looking back on what happened with Resident 1 and Resident 2, it was clear they should not have been placed in the same room for safety reasons. The MD explained if a resident was agitated with escalating behaviors then it would need to be addressed sooner such as placing the resident in a single room or a room with direct line of sight (maintaining clear, unobstructed visual access between staff and resident for safety). When asked if the facility followed the abuse policy to ensure residents safety, the MD stated, not in retrospect. The MD stated it was everyone's responsibility to ensure the residents' safety.Review of an undated facility policy and procedure titled, Abuse, Neglect and Exploitation, indicated, .Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident.that prohibit and prevent abuse.III. Prevention of Abuse.D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict. Event ID: Facility ID: 555105 If continuation sheet Page 5 of 5