Health inspection·October 9, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint number 2600856. A Class B Citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations: §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. (a) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Title 22 California Code of Regulations: § 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 8/26/2025, the California Department of Public Health (CDPH) received a complaint regarding resident's right. On 8/27/2025, the CDPH made an unannounced visit to the facility to investigate the allegations. The facility failed: 1.To prevent a third incident of resident-to-resident altercation between Residents 1 and 2. 2. Follow its Policy and Procedure (P&P) titled" Abuse Prevention and Management" by failing to report an incident of verbal abuse on 7/31/2025 and 8/10/2025, as well as an incident of physical abuse on 8/11/2025, to the CDPH in a timely manner as required in the facility's P&P. As a result, there was a delay in investigating the altercation between Residents 1 and 2 resulting in Resident 1 going to Resident 2's new room and provoking a fight which led to Resident 1 hitting Resident 2 on the nose and Resident 2 hitting Resident 1 on the back of the head thereby placing both residents at risk for further abuse. A review of Resident 1's Admission Record indicated the facility originally admitted Resident 1 on 12/2/2024, and most recently on 7/3/2025, with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), Type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Anxiety disorder (feelings of persistent fear and worry), hypothyroidism (thyroid gland does not produce enough thyroid hormone), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), other abnormalities of gait (walking) and mobility, peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), coronary artery dissection ( - a slow progressive separation of the layers of the heart vessels), and atrial fibrillation (heart dysrhythmia). A review of Resident 1's Minimum Data Set (MDS - a resident assessment) dated 7/10/2025, indicated Resident 1's cognition (mental ability to make decisions for daily living) was intact. The MDS indicated Resident 1 required set up assistance (Helper sets up or cleans up; resident completes activity. Helper only assists before or after activity) with toileting and showering. Resident 1 was independent (Resident completes activity by themselves with no assistance from helper) with transfers (moving between surfaces) from bed to chair. A review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 7/16/2025, with diagnoses including Osteomyelitis (inflammation of bone or bone marrow, usually due to infection), difficulty walking, Essential hypertension (HTN-high blood pressure) and diabetes mellitus. A review of Resident 2's MDS dated 7/23/2025, indicated Resident 2's cognition (mental ability to make decisions for daily living) was intact. Resident 2 required moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting, showering and transfers (moving between surfaces) from bed to chair. A review of Resident 1's care plan titled," The resident exhibits behaviors including fabricating and confabulating stories, provoking other residents into arguments and fights, hitting the medication cart, making false accusations and demonstrating inappropriate behaviors towards staff" initiated 1/13/2025, revised 6/25/2025, stated that one goal was that Resident 1 will effectively express concerns and needs without resorting to verbal or physical aggression. Interventions included monitoring and documenting instances of inappropriate behaviors, including triggers, frequency and responses. Staff were to maintain a behavior log to identify patterns and inform care strategies. During a review of Resident 1's SBAR communication form (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/31/2025, indicated while unnamed Licensed Vocational Nurse (LVN) was in the room administering intravenous (IV) medication to Resident 2, Resident 1's table was moved from the walkway. After which Resident 1 became angry and verbally aggressive toward the unnamed LVN. Resident 2 then asked Resident 1 to be nice, and Resident 1 began cursing at both the unnamed LVN and Resident 2. Resident 1 then walked up to Resident 2 and lifted his cane towards Resident 2 as if Resident 1 was going to hit Resident 2 with the cane. Room changes were offered, however both residents refused. The medical doctor (MD) 1 was informed however the unnamed LVN was awaiting a response. During a review of Resident 1's SBAR dated 8/10/2025, indicated at 9:05 a.m., Resident 1 was yelling, cursing and accusing Resident 2 of stealing a shirt. Resident 2 then became upset and yelled back at Resident 1, both exchanging verbal, racial remarks. Safety precaution measures were implemented, and both residents were relocated to prevent further escalation. MD 1 was informed and recommended staff to monitor and redirect as needed. A record review of Resident 1's Nursing progress note dated 8/10/2025, timed at 3:57 p.m., indicated frequent visual checks to prevent another altercation occurring throughout shift. A record review of Resident 2's Nursing progress note dated 8/10/2025, timed 4 p.m., indicated that the unnamed LVN encouraged Resident 2 to switch rooms for safety, Resident 2 initially refused but agreed to move to another room. A record review of Resident 1's Nursing progress note dated 8/11/2025, timed 12:41 a.m., indicated Resident 1 was sleeping. No further documentation was found regarding the monitoring of Resident 1. A review of Resident 1's care plan initiated 8/11/2025 titled, "Resident exhibits verbal aggression characterized by the use of inappropriate offensive, and racially charged language towards staff, causing distress and disruption in care environment such as the N word and "black B word" and similar expressions" revealed that Resident 1's care plan does not include any goals. The only intervention listed is to ensure staff have clear protocol for managing verbal aggression to maintain safety and a respectful care environment. A review of Resident 1's care plan titled, "Resident exhibits verbal aggression including use of profanity and racial remarks, during interpersonal conflicts with roommate," initiated 8/12/2025, includes goal that physical altercations will be prevented through early interventions and staff monitoring. Interventions include maintaining separate living arrangements, when possible, to reduce direct triggers and prevent escalation. Implement and maintain safety precautions during high-risk interactions (i.e. increased staff presence). During an interview on 8/27/2025, at 1:35 p.m., with the MD, the MD stated Resident 1 should have been discharged a long time ago. Resident 1 had no skilled need to be at the facility. Resident 1 left the facility often driving a vehicle. Resident 1 was very aggressive and attacked multiple residents. During an interview on 8/27/2025, at 2 p.m., with the Director of Medical Records (DMR), the DMR stated there was no SBAR dated 8/11/2025 found in either Resident 1 or Resident 2's chart. During an interview on 8/27/2025, at 2:13 p.m., LVN 1 stated, "Resident 2 never stole Resident 1's shirt. Resident 1 had all belongings locked in a closet and Resident 1 was the only one with a key to that closet. During a concurrent interview and record review on 8/27/2025, at 3:10 p.m., with the Director of Nursing (DON), Resident 1's electronic medical record was reviewed. The DON was unable to show a care plan with interventions to prevent another incident after Resident 2 moved to another room. The DON was unable to show evidence of an interdisciplinary team note (IDT) conducted after the Resident 2 switched rooms. The DON was unable to show evidence of monitoring either one of the residents after Resident 2 switched rooms. During a concurrent interview and record review on 8/27/2025, at 3:55 pm, with the LVN 1, Resident 1's Nursing progress dated 8/11/2025, and timed at 2:16 p.m., was reviewed. The progress note was struck out indicating a reason: wrong chart. The struck-out progress note indicated the LVN 1 was walking (on 8/10/2025) by Resident 2's new room when arguing was heard. The LVN 1 looked inside of the room and saw Resident 1 arguing with Resident 2. The LVN 1 attempted to deescalate the very heated argument. LVN 1 managed to get Resident 2 to step aside so Resident 1 could exit the room. Resident 1 still refused to leave so the LVN 1 stepped in between both residents and attempted to help Resident 1 pass by to exit the room. As Resident 1 was exiting the room they were both calling each other names. As Resident 1 was passing by Resident 2, Resident 1 swung at Resident 2 and hit Resident 2 on the nose. Resident 2 then struck back at Resident 1 and hit Resident 1 on the back of the head. Resident 1 was then pushed out of the room. LVN 1 stated, "The note was struck out because I wasn't sure if I was supposed to document it on Resident 1 or Resident 2's chart. My plan was to go back and document it on Resident 2's chart since Resident 2 was the victim, but it slipped my mind". "Resident 1 was in the wheelchair (w/c) when this happened, I am the one who wheeled Resident 1 out of the room". "After this we notified the police, and they came and gave both residents an order to stay 25 feet away from each other". "I was the charge nurse on 8/11/2025 and I informed the nurses the two residents had a verbal altercation the day before, so they were aware." During a concurrent interview and record review on 8/27/2025, at 4:11 p.m., with the Administrator (Adm), a fax confirmation page and abuse report dated 8/12/2025 were reviewed. The abuse report indicated physical as the type of abuse being reported with Resident 1 as the abuser and Resident 2 as the victim. The fax confirmation sheets indicated the report was faxed to CDPH, the police department and the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities). The Adm stated, "We reported the incident of physical abuse on 8/11/2025. However, we did not report the incident of verbal abuse on 8/10/2025." The Adm stated, "I was aware of both incidents, and all forms of abuse should be reported to CDPH within 2 hours." A review of the facility's policy and procedures (P&P) titled," Abuse Prevention and Management" revised 5/30/2024, indicated, a. "Abuse" is defined as the willful, deliberate infliction of injury, unreasonable confinement, involuntary seclusion, and physical or chemical restraint not required to treat symptoms, and/or imposed for the purposes of discipline or convenience, intimidation, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source or punishment with resulting physical harm, pain, or mental anguish. Abuse includes the neglect and deprivation of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well­being. Abuse also includes verbal abuse, sexual abuse, physical abuse, mental abuse, or abuse facilitated or enabled by the use of technology that causes physical harm, pain, or mental anguish. b. "Verbal abuse" is defined as any use of oral, written, gestured communication, or sounds that willfully includes disparaging and derogatory terms directed to residents within their hearing distance, regardless of age, ability to comprehend, or disability...Notification of Outside Agencies for All Allegations of Abuse. c. The Administrator or designated representative will notify law enforcement, by telephone immediately, or as soon as practicably possible, but no longer than (2) hours of an initial report AND send a written SOC341 report to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within (2) hours. The facility failed: 1.To prevent a third incident of resident-to-resident altercation between Residents 1 and 2. 2. Follow its P&P titled" Abuse Prevention and Management" by failing to report an incident of verbal on 7/31/2025 and 8/10/2025, as well as an incident of physical abuse on 8/11/2025, to the CDPH in a timely manner as indicated in the facility's P&P. As a result, there was a delay in investigating the altercation between both residents resulting in Resident 1 going to Resident 2's new room and provoking a fight which led to Resident 1 hitting Resident 2 on the nose and Resident 2 hitting Resident 1 on the back of the head thereby placing both residents at risk for further abuse. The above violations had a direct relationship to the health, safety, and security of Residents 1 and 2.