Health inspection·April 16, 2026

42 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, 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. 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 § 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. On 3/5/2026, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident (FRI) regarding an allegation of resident-to-resident abuse that occurred on 3/4/2026. The facility failed to: 1. Ensure Resident 1 was free from physical abuse when Resident 2 punched Resident 1 in the face. 2. Follow the facility’s policy and procedure (P&P) titled, “Abuse Prevention and Prohibition Program,” which indicated each resident had the right to be free from abuse, neglect, and mistreatment. As a result, Resident 1 sustained nasal (nose) fractures (broken bones), a nosebleed, and bump on the forehead which required a transfer to the general acute care hospital (GACH) for evaluation and treatment. Resident 1 was a 68-year-old male admitted to the facility on 1/19/2026 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and major depressive disorder (a mental health condition characterized by persistent and intense feeling of sadness or loss of interest that interferes with daily functioning). A review of Resident 1’s history and physical (H& P), dated 2/3/2026, indicated Resident 1 had the capacity to make all decisions. A review of Resident 1’s Minimum Data Set (MDS -a resident assessment tool), dated 2/24/2026, indicated Resident 1’s cognition (ability to think) was intact. The MDS indicated Resident 1 was dependent on staff for activities of daily living including dressing, bathing and personal hygiene. Resident 1 was dependent upon a wheelchair for mobility. Resident 1 was 66 inches tall and weighed 300 pounds. Resident 1 required a mechanical lift and the assistance of 2 staff to transfer from the wheelchair. A review of Resident 1’s Change of Condition Evaluation (COC) dated 3/4/2026, indicated Resident 1 was in an altercation with Resident 2 in the smoking patio resulting in Resident 2 hitting Resident 1 in the face. Resident 1’s nose was bleeding and a raised area was noted on his forehead. A review of Resident 1’s plan of care (POC), dated 3/4/26, indicated Resident 1 sustained a nasal fracture and was at risk for further nose bleeds, impaired respiratory exchange, nasal facial pain, edema, bruising and psychosocial issues. A review of Resident 1’s Transfer form, dated 3/4/2026, indicated on 3/4/2026 at 6:15 p.m., Resident 1 was transferred to an acute care hospital due to a forehead bump and nosebleed after being punched in the head by Resident 2. A review of Resident’s 1’s GACH emergency department (ED) note, dated 3/4/2026, indicated Resident 1 had an altercation with another resident in which he was punched in the face. Resident 1 was punched and had a nosebleed and hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) in the middle of his forehead, and complained of pain, headaches, and dizziness. Resident 1’s computed tomography (CT scan- a non-invasive imaging procedure to create detailed images of the body) scan of the facial bone, revealed the resident had a nasal bone fracture and a left medial (middle) orbital (eye) wall fracture. During an interview on 3/5/2026 at 1:00 p.m., Resident 1 stated he threw coffee on him (Resident 2) because Resident 2 cussed at him and called him fat. Resident 2 was a 71-year-old male originally admitted to the facility on 4/22/2025 and readmitted on 6/19/2025. Resident 2’s diagnoses included cerebral ischemia (lack of blood flow to the brain causing brain cells to die) and alcohol dependance (excessive alcohol consumption). A review of Resident 2’s MDS, dated 1/20/2026, indicated Resident 2’s cognition was intact. Resident 2 was independent with activities of daily living including eating, upper body dressing and personal hygiene. Resident 2 required partial assistance from staff (staff does less than half the effort) with showering, Resident 2 required supervision (verbal cues only from staff with putting on footwear, lower body dressing and toileting hygiene. Resident 2 was able to walk independently but used a wheelchair for mobility. Resident 2 was 65 inches tall and weighed 142 pounds. A review of Resident 2’s H&P, dated 6/20/2025, indicated Resident 2 had capacity to understand and make all decisions. A review of Resident 2’s change of condition (COC) form, dated 3/4/2026, indicated Resident 2 and Resident 1 had a verbal and physical altercation resulting in Resident 1 throwing coffee on Resident 2’s face. Resident 2 then stood from his wheelchair and hit Resident 1 in the face. During an interview on 3/5/2026 at 1:15 p.m., Resident 2 stated he hit Resident 1 in the nose because Resident 1 threw coffee in his face. Resident 1 was blocking the door with his wheelchair, and Resident 2 could not get out. Later, Resident 2 went out to the patio and Resident 1 said if Resident 2 called him names and cussed at him again, he will throw his coffee at Resident 2. Resident 2 stood up from his wheelchair and told Resident 1 “to try it.” Resident 1 threw his coffee on Resident 2’s face, and Resident 2 hit Resident 1 in his face. During interview on 3/5/2026 at 2:15 p.m., with the Director of Nurses (DON), the DON stated she just received notification from the GACH that Resident 1 had a nasal fracture. When asked if a copy of the x-ray report was available the DON stated they did not have a hard copy of the report yet. A review of the facility’s policy and procedure (P&P) dated 8/1/2023 titled, “Abuse Prevention and Prohibition Program” indicated each resident had the right to be free from abuse, neglect, and mistreatment. Staff must not permit anyone to engage in verbal, mental, or physical abuse. The facility failed to: 1. Ensure Resident 1 was free from physical abuse when Resident 2 punched Resident 1 in the face. 2. Follow the facility’s P&P titled, “Abuse Prevention and Prohibition Program,” which indicated each resident had the right to be free from abuse, neglect, and mistreatment. As a result, Resident 1 sustained nasal fractures, a nosebleed, and bump on the forehead which required a transfer to the GACH for evaluation and treatment. This violation resulted in actual physical harm to Resident 1 and demonstrated the facility’s failure to protect the resident from abuse.