Health inspection·March 5, 2026

42 CFR §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. 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 § 72311 Nursing Service General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition 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. 22 CCR § 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 1/21/2026, at 8:00 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident (FRI) regarding resident-to-resident abuse that occurred on 1/17/2026. The facility failed to: 1. Ensure Resident 1, who was under conservatorship and had quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), whom staff described as "childlike," was free from sexual abuse by Resident 2, who had a documented history of sexually disinhibited and boundary-violating behavior during a recent psychiatric hospitalization, when the hospital's behavioral precautions were discontinued upon admission to the facility and the facility failed to implement a behavioral care plan. 2. Identify and assess Resident 2's known sexually inappropriate behavior on admission, resulting in failure to develop or document an appropriate care plan using individualized precautions addressing his baseline behaviors or potential for escalation. 3. Follow its policy and procedure (P&P) titled "Abuse and Neglect Prohibition Policy," dated 6/2022, which indicated the facility prohibited abuse for all patients. As a result, on 1/17/2026, Resident 2 sexually assaulted Resident 1. A sexual assault examination conducted at a General Acute Care Hospital (GACH 2), on 1/17/2026, after the incident, indicated Resident 1 had brown ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) to the left medial (middle) anterior (front) labia minora (inner skin folds of the female external genitalia). a. Resident 1, was a 50-year-old female, admitted to the facility on 10/10/2024 and was readmitted on 11/12/2025. Resident 1's diagnoses included spastic quadriplegic cerebral palsy (the most severe form of cerebral palsy, characterized by significant stiffness and limited movement in all four limbs, the trunk, and the face), depression, and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). The Admission Record indicated Resident 1 was conserved (deemed by a court to be incapable of managing their own personal needs, finances, or safety, necessitating the appointment of a conservator to act on their behalf). A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/18/2025, indicated Resident 1 had severe cognitive impairment (a profound decline in thinking, memory, and reasoning, that prevents independent living). The MDS indicated Resident 1 required partial to moderate assistance from staff for dressing her lower body, and to transition from a sitting to standing position, or to walk distances of 10 feet to 50 feet. A review of Resident 1's progress note, dated 1/17/2026, indicated Resident 1 was observed engaging in sexual intercourse with Resident 2. The progress note indicated Resident 2 was asked to leave the room, and Resident 1 was observed lying on her bed with her lower body garments "down." The progress note indicated Resident 1 did not respond when asked if she was in pain or if she knew what had happened. A review of Resident 1's Change of Condition (COC) assessment, dated 1/17/2026, indicated an unidentified CNA informed the charge nurse that a male resident (Resident 2) was in Resident 1's room. The COC assessment did not indicate what occurred in the room prior to the patient being separated. The COC assessment indicated Resident 1 received a "vaginal exam" but did not specify what the exam entailed. Resident 1's physician was notified of the incident and ordered Resident 1 to be transferred to a GACH for further evaluation. A review of Resident 1's physician order, dated 1/17/2026, indicated to transfer Resident 1 to the emergency room for evaluation and treatment related to an observed sexual act. A review of Resident 1's Facility to Hospital Transfer Form, dated 1/17/2026, indicated Resident 1 was transferred to GACH 2 on 1/17/26 at 3:27 p.m. due to a "sexual act". A review of Resident 1's GACH 2 record titled "Adult/Adolescent Sexual Assault Examination - Narrative Addendum," dated 1/17/2026, indicated an addendum was made to the section of the assessment titled "Sexual Acts Described by the Patient". The addendum indicated Resident 1 resided in a nursing facility, and per Law Enforcement and facility staff, Resident 1's roommate ran out of her room asking for help. The record indicated that the facility staff found Resident 2 on top of Resident 1, forcing penile-vaginal penetration. A review of Resident 1's GACH 2 record titled "Adult/Adolescent Sexual Assault Examination - Anogenital Examination Female," dated 1/17/2026, indicated Resident 1 had brown ecchymosis to the left medial anterior labia minora. A review of Resident 1's GACH 2 record titled "Sexual Assault Aftercare Instructions", dated 1/17/2026, indicated Resident 1 received the following: 1. A sexual assault examination. 2. Collection of a sexual assault kit (a standardized kit used by medical professionals to collect and preserve physical, forensic evidence from a survivor's body or clothing after a sexual assault). 3. Preventative treatment for sexually transmitted infections (STI, an infection spread between people through direct contact during vaginal, anal, or oral sex): chlamydia, gonorrhea, and syphilis. 4. Emergency contraception (medication to prevent pregnancy after unprotected sex). A review of Resident 1's progress note, dated 1/18/2026, indicated Resident 1 returned to the facility on 1/17/2026 at 11:45 p.m. A review of Resident 1's progress notes, dated 1/18/2026 at 3:03 p.m., indicated Resident 1 was being monitored for alleged assault. The progress note indicated Resident 1 complained of abdominal pain. During an observation on 1/21/2026 at 8:26 a.m., Resident 1 was observed exiting her room. An attempt was made to interview Resident 1, but Resident 1 refused to speak and walked away. b. A review of Resident 2's GACH 1 Emergency Department (ED) note, dated 12/23/2025, indicated Resident 2 was admitted to GACH 1 on 12/23/2025 for evaluation of confusion, frequent wandering, and walking around more than usual. The ED note indicated Resident 2 had a history of depression (a common, serious mood disorder characterized by persistent, intense feelings of sadness, emptiness, or a loss of interest in activities), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 2's GACH 1 nursing narrative note, dated 12/25/2025, indicated Resident 2 was aggressive towards staff. The note further indicated Resident 2 displayed "noticeably sexually inappropriate behavior," and began to masturbate (the deliberate self-stimulation of one's own genitalia to produce sexual pleasure) while looking at a Certified Nursing Assistant (CNA) that was present in his room. The note indicated Resident 2 was placed on precautions for sexually inappropriate behavior. A review of Resident 2's GACH 1 physician order, dated 12/25/2025, indicated Resident 2 was placed on general precautions for sexually inappropriate behavior. The order indicated it was discontinued on 12/29/2025 due to Resident 2's discharge from GACH 1. A review of Resident 2's GACH 1 nursing narrative note, dated 12/29/2025, indicated on 12/29/2025 at 4:40 p.m., Licensed Vocational Nurse (LVN) 1 provided report (a critical, organized exchange of patient information between nurses to ensure continuity of care, safety, and efficient management) to the facility. The note indicated Resident 2 was discharged from GACH 1 on 12/29/2025 at 5:23 p.m. A review of an untitled and undated facility document, completed by Registered Nurse (RN) 1, indicated a summary of the nursing report provided to RN 1 by LVN 1. The document indicated Resident 2 had "sexually inappropriate behavior." A review of Resident 2's Admission Summary, dated 12/29/2025, written by RN 1, did not indicate Resident 2's sexually inappropriate behavior or interventions to address the resident's sexually inappropriate behavior. Resident 2, was a 68 year-old male, admitted to the facility on 12/29/2025 with diagnoses including metabolic encephalopathy (a broad term for brain dysfunction caused by systemic illness, chemical imbalances in the blood, or toxins, rather than structural brain damage) and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 2's MDS, dated 1/2/2026, indicated Resident 2 was usually understood and usually understood others. Resident 2 had moderate cognitive impairment (noticeable memory or thinking changes that exceed normal aging but do not severely impact daily life). Resident 2 required partial to moderate assistance from staff (staff do less than half of the effort to complete the task) for toileting hygiene, getting dressed, and mobility while in and out of bed. Resident 2 did not have impairments to any extremities. A review of Resident 2's progress note, dated 1/17/2026, indicated Resident 2 was observed engaging in sexual intercourse with another patient (Resident 1). The progress note indicated Resident 2 stated he had sexual intercourse with Resident 1 because "she didn't tell him not to." The progress note indicated Resident 2 stated Resident 1 did not give consent for sexual intercourse. A review of Resident 2's progress notes, dated 1/18/2026, indicated Resident 2 was transferred to GACH 3 for further evaluation. A review of Resident 2's GACH 3 Emergency Physician Note, dated 1/18/2026, indicated Resident 2 was brought to GACH 3 following one episode of non-consensual sexual abuse. The note indicated Resident 2 stated he had sexual intercourse with another patient because "she did not object." Resident 2's diagnoses included sexual behavior, danger to others, and assault. A review of Resident 2's GACH 3 Physician Note, dated 1/21/2026, indicated Resident 2 was admitted to the behavioral health unit for a psychiatric admission and psychiatric hold (an involuntary 72-hour detention for mental health evaluation when a person is deemed a danger to themselves or others, or gravely disabled due to mental illness) for danger to others and grave disability (someone unable to meet their basic needs due to a mental health issue). During an interview on 1/12/2026 at 8:34 a.m., Resident 4 (Resident 1's roommate) stated on 1/17/2026, she was asleep when the incident occurred between Resident 1 and Resident 2. Resident 4 stated she saw Resident 2 come into their room multiple times prior to the incident. Resident 2 would make flirtatious faces at Resident 1 and attempt to talk to her. Resident 4 stated she would yell at Resident 2 and ask him to leave their room. Resident 4, was a 71- year-old female, admitted to the facility on 11/20/2025 and was most recently readmitted on 1/8/2026. Resident 4's diagnoses included chronic obstructive pulmonary disorder (COPD, a chronic lung disease causing difficulty in breathing) and type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 4's MDS, dated 1/2/2026, indicated Resident 4 had some difficulty with daily decision making in new situations, but did not exhibit inattention, disorganized thinking, or altered level of consciousness (ALOC, a state of reduced alertness, confusion, or lack of awareness). During an interview on 1/21/2026 at 8:30 a.m., Resident 3 (Resident 1's roommate) stated she walked in on Resident 1 and Resident 2 having sex. Resident 3 stated Resident 2 was on top of Resident 1, exposed, and not underneath a blanket. Resident 1's pants were down and Resident 2 was not wearing any pants. Resident 3 stated she ran out into the hallway and immediately found a nurse to report the incident. Resident 3 stated she then left right away and did not see anything else that occurred. Resident 3, was a 65-year-old female, admitted to the facility on 10/27/2025. Resident 3's diagnoses included hypertension (high blood pressure) and muscle wasting and atrophy. A review of Resident 3's MDS dated 10/31/2025, indicated Resident 3 had clear speech, was able to be understood and understood others. During an interview on 1/21/2026 at 11:05 a.m., CNA 1 stated on 1/17/2026, Resident 1's roommate (Resident 3) ran into the hallway requesting staff assistance. Resident 3 gestured staff to enter the room quietly. CNA 1 stated she entered the room without announcing herself and observed Resident 1's privacy curtain drawn. The foot of Resident 1's bed was visible. She (CNA 1) observed shoes and jeans at the foot of the bed, and overheard moaning from behind the curtain. She (CNA 1) pulled the curtain open and observed Resident 2 on top of Resident 1. The residents were facing each other and actively engaged in sexual intercourse. Resident 2 jumped from Resident 1's bed and ran out of the room. Resident 1 had her incontinence brief and pants pulled down to her knees. As soon as Resident 2 left the room, Resident 1 curled into a fetal position (lying on the side with the back curved, head bowed forward, and arms and legs drawn in toward the chest) and refused to talk. Resident 1 was placed on 1:1 monitoring (a high-level safety intervention in healthcare where a dedicated staff member provides continuous, direct, in-person supervision to a single patient) after the incident occurred. During an interview on 1/21/2026 at 11:50 a.m., CNA 2 stated on 1/17/2026, she was assigned to Resident 1's care. CNA 2 stated she entered the room and observed Resident 1 lying in her bed with her incontinence brief and pants pulled down. She (CNA 2) was familiar with Resident 1 and desc