Health inspection·January 20, 2026

§483.12 Freedom from Abuse, Neglect, and Exploitation (a)(b)(1)(3)(5) 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. § 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. § 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. § 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 12/3/2025, the California Department of Public Heath (CDPH) received a facility reported incident (FRI) indicating a resident (Resident 2) pushed another resident (Resident 1). On 12/5/2025, the CDPH conducted an announced investigation at the facility. The facility failed to: 1. Ensure Resident 1 was free from physical abuse when Resident 1 was pushed to the floor by Resident 2. 2. Implement its policy and procedure (P&P) titled, "Abuse and Neglect Prohibition Policy" dated 6/2022, which indicated it was the facility's policy to prohibit abuse for all residents. As a result of these failures, Resident 2 pushed Resident 1 to the floor on 11/30/2025, and Resident 1sustaining a 1-inch posterior (back of the head) scalp (skin covering the head) laceration (skin tear) which required evaluation and treatment in a general acute care hospital (GACH). Resident 1 received two staples (a piece of thin wire with a long center portion and two short end pieces) for the scalp laceration. Resident 1 was a 75-year-old female admitted to the facility on 11/20/2025 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), type 2 diabetes mellitus (DM-a condition where the body can't properly use or produce insulin [hormone to regulate blood sugar level] leading to high blood sugar levels), and paranoid schizophrenia. A review of Resident 1's history and physical (H&P), dated 10/25/2025, indicated Resident 1 required redirection. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/1/2025, indicated Resident 1's cognition (ability to think and reason) was moderately impaired. The MDS indicated Resident 1 required partial assistance from staff (helper does less than half the effort to lift, hold, support the trunk and limbs) for activities of daily living (ADLs- activities such as bathing, dressing and toileting, which a person performs daily). A review of Resident 1's change of condition (COC) form, dated 11/30/2025 at 11:53 p.m., the COC indicated the charge nurse observed Resident 2 approaching Resident 1 and pushing Resident 1 to the floor. The COC indicated Resident 1 hit the back of her head on the floor and was bleeding from the head. The COC indicated the charge nurse placed a towel against Resident 1's head to stop the bleeding and immediately called 911. A review of Resident 1's Skilled Nursing Facility (SNF) to Hospital Transfer form, dated 12/1/2025 at 12:12 a.m., indicated Resident 1 was transported to the GACH after another resident pushed her resulting in Resident 1 hitting her head and bleeding. A review of Resident 1's GACH emergency room (ER) records, dated 12/1/2025, indicated Resident 1 arrived at the ER after Resident 1 was pushed by another resident and fell, and hit the back of her head on the ground. The ER records indicated Resident 1 sustained minor blunt head trauma and a 1-inch laceration to the posterior scalp. The ER records indicated staples were used to staple the laceration and Resident 1 was discharged back to the facility on the same day (12/1/2025). A review of Resident 1's head computerized tomography scan (CT - a type of imaging that uses X-ray techniques to create detailed images of the body) dated 12/1/2025, indicated there was no acute intracranial abnormality (structural changes within the skull) with right parietal (located at the top and back of the head) skin staples. During an interview on 12/5/2025 at 12:30 p.m. with Resident 1, Resident 1 stated she was talking with Resident 4 in the hallway outside Resident 4's room (date and time unknown) when Resident 2 suddenly pushed her for no reason. Resident 1 stated, "When I fell, I hit the back of my head on the floor, I had to go to the hospital, and they put two staples in the back of my head." Resident 2 was a 75-year-old female originally admitted to the facility on 6/6/2023 and readmitted on 9/24/2025. Resident 2's diagnoses included bipolar disorder (a mental health condition causing extreme mood swings), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). A review of Resident 2's H&P, dated 6/8/2025, indicated Resident 2 was admitted to the GACH for psychiatric evaluation due to increased agitation and aggressive behaviors. The H&P indicated Resident 2 did not have the capacity to make medical decisions. A review of Resident 2's MDS, dated 11/27/2025, indicated Resident 2's cognition was severely impaired. The MDS indicated Resident 2 required moderate assistance from staff for all ADLs. A review of Resident 2's COC, dated 12/1/2025, indicated on 11/30/2025 Resident 2 was physically aggressive towards her peers. The COC indicated on 11/30/2025 at 11:53 p.m., Licensed Vocational Nurse (LVN 1) observed Resident 2 pushing Resident 1 and Resident 1 fell and hit the back of her head. During an interview on 12/8/2025 at 3:45 p.m. with the Director of Nursing (DON), the DON stated on 11/30/2025, Resident 2 pushed Resident 1 to the ground which caused Resident 1 to sustain a laceration to the back of her head. The DON stated Resident 1 sustained an injury and was transferred to a GACH, where she received 2 staples to her head. During a review of the facility's P&P titled, "Abuse and Neglect Prohibition Policy" dated 6/2022, indicated it was the facility's policy to prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all residents and if the suspected abuse was a resident-to-resident incident, the resident who threatened or attacked another resident would be removed from the setting or situation. The facility failed to: 1. Ensure Resident 1 was free from physical abuse when Resident 1 was pushed to the floor by Resident 2. 2. Implement its P&P titled, "Abuse and Neglect Prohibition Policy" dated 6/2022, which indicated it was the facility's policy to prohibit abuse for all residents. As a result of these failures, Resident 2 pushed Resident 1 to the floor on 11/30/2025 and Resident 1sustaining a 1.0-inch posterior scalp laceration which required evaluation and treatment in a GACH. Resident 1 received two staples for the scalp laceration.