Health inspection·March 13, 2026

CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (a)The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, 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. 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 1/23/2026, the California Department of Public Heath (CDPH) received a facility reported incident (FRI) indicating a resident (Resident 1) was kicked by Certified Nurse Assistant (CNA 1) on the right shin (the front of the leg below the knee). On 2/5/2026, the CDPH conducted an unannounced investigation at the facility. The facility failed to: 1. Ensure Resident 1 was free from physical abuse when CNA 1 kicked Resident 1 on the right shin. 2. Implement its undated policy and procedure (P&P) titled, " Abuse, Neglect & Exploitation Prohibition " which indicated the facility prohibited abuse for all residents. As a result of these failures, Resident 1 sustained pain and purplish discoloration to the right shin. Resident 1 was a 91-year-old female admitted to the facility on 5/26/2025 with diagnoses including metabolic encephalopathy (a problem in the brain, that can lead to personality change), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), and dementia (a progressive state of decline in mental abilities). A review of Resident 1's history and physical (H&P), dated 5/28/2025, indicated Resident 1 did not have the capacity to make decisions. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/5/2026, indicated Resident 1's cognition (ability to think and reason) was severely impaired. The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADLs) such as toileting and showering, and required partial assistance from staff for eating, oral hygiene, dressing, and positioning. A review of Resident 1's SBAR (a structured, four-step communication framework - Situation, Background, Assessment, Recommendation) form, dated 1/23/2026 at 3:04 p.m., indicated the Registered Nurse Supervisor (RN) 1 witnessed CNA 1 kick Resident 1. The SBAR indicated when RN 1 removed Resident 1 from the room, Resident 1 stated she [CNA 1] kicked her and she had pain. A review of Resident 1's Resident Data Collection form, dated 1/23/2026 at 8:05 p.m., indicated Resident 1 had pain and discoloration to the right leg. During an interview, on 2/6/2026 at 2:00 p.m., with Resident 1, Resident 1 pointed and rubbed her right leg when asked what happened. Resident 1 did not elaborate further about the incident with CNA 1. Resident 1 stated she felt safe at the facility. During an interview on 2/5/2026 at 3:00 p.m., with RN 1, RN 1 stated, on 1/23/2026 at approximately 1:00 p.m., while at Nurses' Station 1, across from Resident 1's room, she overheard CNA 1 tell Resident 1 his curtain was pulled because his roommate needed privacy. CNA 1 instructed Resident 1 to return to her side of the room. RN 1 stated she then looked toward Resident 1's room and observed CNA 1 kick Resident 1 on the right leg. RN 1 stated she immediately removed Resident 1 from the room for safety and reported the incident to the Director of Nursing (DON) and the Administrator. RN 1 stated Resident 1 pointed to her right leg and stated she was hit. RN 1 stated Resident 1 was assessed and noted to have right leg discoloration (red in color) and pain. RN 1 stated residents should feel safe in the facility because the facility was the residents' home. A review of the facility's 5-day summary staff to resident incident, dated 1/28/2026, indicated Resident 1 expressed CNA 1 kicked her. RN 1 stated she observed CNA 1 kick Resident 1. The summary indicated the allegation was valid and substantiated. A review of CNA 1's Disciplinary Action Record, dated 2/2/2026, indicated CNA 1 was involved in an incident on 1/23/2026 in which staff reported witnessing CNA 1 kick a resident (Resident 1). The record indicated CNA 1 was terminated for causing harm to the resident and for violating the facility's abuse policy. A review of the facility's undated P&P, titled "Abuse, Neglect & Exploitation Prohibition", indicated each resident had the right to be free from mistreatment, neglect, and abuse. The facility failed to: 1. Ensure Resident 1 was free from physical abuse when CNA 1 kicked Resident 1 on the right shin. 2. Implement its undated P&P titled, " Abuse, Neglect & Exploitation Prohibition ", which indicated the facility prohibited abuse for all residents. As a result of these failures, Resident 1 sustained pain and a purplish discoloration to the right shin. These violations resulted in actual physical harm to Resident 1 and demonstrated the facility's failure to protect the resident from abuse.