Health inspection·November 12, 2025

AMENDED: 11/21/2025 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. 22 CCR §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. On 10/9/2025 at 12:10 p.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate Facility Reported Incidents regarding resident-to-resident altercations. The facility failed to provide the following interventions, including but not limited to: 1. Implement its policy and procedure (P&P) titled, “Abuse, Neglect and Exploitation” which indicated each resident had the right to be free from abuse and neglect when Resident 9 was not prevented from punching both Resident 8 and Resident 11 As a result of this failure, Resident 9 punched Resident 8 and Resident 11 in the mouth and were transferred to the General Acute Care Hospital (GACH) for evaluation and treatment. Resident 8 was an 85-year-old male, who was initially admitted to the facility on 4/25/2023 and readmitted on 5/2/2025. Resident 8’s diagnoses included metabolic encephalopathy (a condition where the brain’s function is altered), dementia (a progress state of decline in mental abilities), and anxiety (a state emotional state characterized by feelings of unease, worry, or apprehension). A review of Resident 8’s History and Physical (H&P), dated 9/4/2025, indicated Resident 8 did not have the capacity to make medical decisions. A review of Resident 8’s Minimum Data Sheet ([MDS]- a resident assessment tool), dated 7/1/2025, indicated Resident 8’s cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 8 was dependent (total care) on staff for personal hygiene, dressing, and eating. A review of Resident 8’s Change of Condition (COC), dated 10/8/2025, indicated Resident 8 had a cut inside his lip with bleeding. A review of Resident 8’s Progress Notes, dated 10/8/2025, indicated Resident 8 had discoloration on his face and was transferred to the GACH for a Computed Tomography ([CT] -a medical imaging procedure that uses X-rays to create detailed images of the body) of the head. A review of Resident 8’s GACH records, dated 10/8/2025, indicated Resident 8 had bruising around the right eye.   Resident 11 was a 47-year-old male, who was admitted to the facility on 10/3/2025 with diagnoses including subdural hemorrhage (a condition where blood collects under brain’s outer cover), epilepsy (characterized by recurrent seizures), and depression (a mood disorder marked by persistent sadness and a loss of interest). A review of Resident 11’s undated H&P indicated Resident 11 had the capacity to understand and make decisions. A review of Resident 11’s COC, dated 10/8/2025, indicated Resident 11 entered Resident 9’s room to use the restroom and (Resident 9) attempted to hit Resident 11. During an interview on 10/9/2025 at 3:14 p.m., with Resident 11, Resident 11 stated he was instructed by staff to use another restroom (Resident 9’s restroom) because his restroom was not working. Resident 11 stated while using the restroom, Resident 9 opened the door and began hitting him in the mouth, causing his (Resident 11’s) lip to bleed. Resident 11 stated “I don’t feel safe in the facility.” Resident 9 was a 57-year-old male, who was admitted to the facility on 8/26/2025 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), depressive disorder, and anxiety. A review of Resident 9’s H&P, dated 10/3/2025, indicated Resident 9 had the capacity to make needs known but did not have the capacity to consent.   A review of Resident 9’s MDS, dated 8/29/2025, indicated Resident 9’s cognition was moderately impaired. The MDS indicated Resident 9 required partial/moderate assistance (helper does more than half the effort and helper lifts, holds, or support trunk or limbs, but provides less than half the effort) for personal hygiene, showering, and dressing.  The MDS indicated Resident 9 had psychiatric mood disorders of depression and schizophrenia. A review of Resident 9’s Care Plan titled, “The resident had behavioral problem: mood swings ranging from pleasant to irritable,” dated 8/30/2025, the Care Plan interventions indicated to intervene as necessary to protect the rights and safety of others. A review of Resident 9’s COC, dated 10/8/2025, indicated Resident 9 was aggressive towards roommate (Resident 8) and placed on one-to-one supervision (a staff member provides continuous dedicated attention to one person for safety and security reasons). A review of Resident 9’s Order Summary Report, dated 10/8/2025, indicated the physician ordered to provide one-to-one sitter (supervision) at the bedside and to report aggressive behaviors. A review of Resident 9’s COC, dated 10/8/2025, indicated Resident 9 had behavioral changes (physical aggression) and had attempted to strike at Resident 11. Resident 10 was a 68-year-old male, who was initially admitted to the facility on 5/26/2025 and readmitted on 7/10/2025. Resident 10’s diagnoses included polyneuropathies (disorders that affect nerve function in multiple areas of the body), respiratory disorders (conditions that affect the lungs and airways, making it difficult to breathe) and Diabetes Mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 10’s H&P, dated 7/12/2025, indicated Resident 10 had the capacity to understand and make medical decisions. During an interview on 10/9/2025 at 2:30 p.m., with Resident 10, Resident 10 stated during the night shift (on 10/8/2025 at around 4:00 a.m.), Resident 8 was making noise (not sure of what he was saying) and Resident 9 was upset about the noise. Resident 10 stated Resident 9 got out of the bed and started hitting (to get him to be quiet) Resident 8 in the face. During an interview on 10/9/2025 at 2:40 p.m., with Resident 10, Resident 10 stated (on 10/8/2025 at around lunch time), Resident 11 was using the restroom and Resident 9 yelled at Resident 11 “Get out of my room!”. Resident 10 stated Resident 9 “wacked” Resident 11. Resident 10 stated Resident 11 had his arms up in a defensive position to block the hits from Resident 9. During a telephone interview on 10/14/2025 at 9:40 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 10/8/2025 at 4:00 a.m., she heard groaning from Resident 8’s room. CNA 1 stated Resident 8 flinched (nervous movement as a reaction to fear) when she (CNA 1) approached his bed. CNA 1 stated Resident 8’s nose and mouth were bloody and appeared swollen. CNA 1 stated Resident 9 was yelling, “Can you make him (Resident 8) shut up!” During an interview on 10/14/2025 at 2:39 p.m., with Restorative Nurse Assistant (RNA) 1, RNA 1 stated on 10/8/2025 during the 7 a.m. to 3 p.m. shift, she was assigned to provide one-to-one supervision to Resident 9 for safety. RNA 1 stated she was speaking to another resident in the room (Resident 10) and lost sight of Resident 9. RNA 1 stated Resident 9 went to the restroom while another resident (Resident 11) was also in the (shared) restroom and both residents (Resident 9 and Resident 11) got into an altercation. RNA 1 stated Resident 11 reported Resident 9 hit him on his mouth. During an interview on 10/14/2025 at 1:20 p.m., with the Director of Staff Development (DSD), the DSD stated Resident 9 was placed on one-to-one supervision on 10/8/2025. The DSD stated if RNA 1 had monitored Resident 9 closely, Resident 9 would not have hit another resident (Resident 11) in the mouth. The DSD stated the facility failed to follow the abuse policy by not keeping Resident 8 and Resident 11 safe from Resident 9. During an interview on 10/22/2025 at 11:40 a.m., with the Assistant Administrator (AADM), the AADM stated RNA 1 did not follow the facility’s abuse policy. The AADM stated, had RNA 1 checked the restroom before Resident 9 (who was supposed to be monitored) entered the restroom, there would not have been a physical altercation between Resident 9 and Resident 11. A review of the facility’s P&P titled, “Safety Program Statement,” dated 7/2016, indicated the facility will provide a safe environment for patients. The P&P indicated employees will comply with and follow safety rules and work practices. A review of the facility’s P&P titled, “Protection of Resident,” dated 12/2017, indicated the facility will provide a safe resident environment and will protect and monitor residents from abuse. The P&P indicated the facility would prevent resident-to-resident abuse. A review of the facility’s P&P titled, “Abuse and Neglect Prohibition Policy,” dated 6/2022, indicated it is the facility’s policy to prohibit abuse through prevention of occurrences, identification of possible incidents which need investigation and protection of residents during investigation. The P&P indicated physical abuse includes hitting, slapping, pinching, and kicking. The P&P indicated the facility will provide the resident with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe. The P&P indicated actions to prevent abuse was included identifying, correcting and intervening in situations in which abuse was more likely to occur. This includes analysis of the features of the physical environment that may make abuse more likely to occur, supervision of staff to identify inappropriate behaviors and monitoring of residents with needs and behaviors which might lead to conflict, such as residents with a history of aggressive behavior or have behaviors such as entering other resident’s rooms. The facility failed to: 1. Implement its P&P titled, “Abuse, Neglect and Exploitation” which indicated each resident had the right to be free from abuse and neglect when Resident 9 was not prevented from punching both Resident 8 and Resident 11 As a result of this failure, Resident 9 punched Resident 8 and Resident 11 in the mouth and were transferred to GACH for evaluation and treatment. This violation had a direct or immediate relationship to the health, safety, or security of residents.