Health inspection·March 6, 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. (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, § 72311. Nursing Service- General. (a) Nursing service should 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 should 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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. § 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be implemented to ensure that patient related goals and facility objectives are achieved. 22 CCR § 72527. Patient's 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 1/6/2026, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate an allegation indicating Resident 2 sexually abused Resident 1. The facility failed to: 1. Implement its Policy and Procedure (P&P) titled, "Abuse Prevention and Management," which indicated the facility did not condone any form of resident abuse. 2. Ensure a care plan was developed when Resident 2 was admitted to the facility on 12/12/2025 with a history of inappropriate exposure of his private parts and harassing female staff and residents, on 12/13/2025 when Resident 2 exhibited inappropriate behavior towards a nursing staff, made sexually explicit (language or behavior that clearly and openly describes sexual activity, nudity, or erotic content) and inappropriate verbal comments to a Certified Nurse Assistant (CNA) and, on 12/15/2025, when Resident 2 inappropriately touched and verbalized wanting to go to bed with a CNA. 3. Ensure Resident 2 was not left unsupervised with another resident (Resident 6) after Resident 2 exhibited sexually inappropriate behavior, aggressive behavior and agitation following redirection by nursing staff on 12/19/2025. As a result, on 12/19/2025, Resident 2 sexually abused Resident 1 and on the same day, Resident 2 physically abused Resident 6. These failures had the potential to cause psychological harm (emotional or mental injury that an individual may experience due to various actions, experiences, leading to negative effects on their mental well-being) to Residents 1 and 6, severe physical injuries, hospitalization or death to Resident 6 and placed other residents in the facility at risk for sexual and physical abuse by Resident 2. 1). Resident 1 was a 75-year-old female admitted to the facility on 1/16/2025 and readmitted on 3/19/2025. Resident 1's diagnoses included hemiplegia (total paralysis of the arm, leg and trunk on the same side of the body) and hemiparesis (weakness on one side of the body affecting the arm, leg and/or face) following cerebral infarction (loss of blood flow to a part of the brain) affecting left non-dominant side, dementia (a progressive state of decline in mental abilities), depression, and anxiety disorder (mental health condition characterized by excessive worry, fear and nervousness that can interfere with daily life). A review of Resident 1's History and Physical (H&P) dated 9/26/2025, indicated Resident 1 did not have the capacity to consent (unspecified) due to dementia. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/18/2025, indicated Resident 1 was usually able to understand and be understood by others. Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to maximal assistance (Helper does more than half the effort. Helper lifts or holds trunks or limbs and provides more than half the effort) for Activities of Daily Living (ADLs-activities a person performs daily) such as oral hygiene, upper body dressing, personal hygiene, bed mobility (the ability to roll from lying on back to left and right side, and return to lying on back on the bed) and transfers (the ability to transfer to and from a bed to a chair or wheelchair). Resident 1 was dependent (Helper does all the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete activity) for toileting hygiene, showering/bathing self, lower dressing and walking 10 feet. A review of Resident 1's Situation, Background, Assessment, Recommendation Communication Form (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) dated 12/19/2025, indicated on 12/19/2025 (time not specified), Resident 1 was resting on her bed when a male resident (Resident 2) entered her room and engaged in in appropriate behavior by lowering his pants. A review of Resident 1's clinical record did not indicate the resident consented (give permission) to engage in sexual activity with Resident 2. During an interview on 1/6/2026 at 12:55 p.m., with Resident 1, Resident 1 stated sometime before Christmas, a resident (Resident 2) went into her (Resident 1's) room, removed his and her (Resident 1) pants and kissed her on her face. Resident 1 stated she was traumatized (shocked, shaking, shivering) by the incident, had to sleep with the lights on for two weeks and was afraid that Resident 2 would enter her room again. 2). Resident 2 was a 68-year-old male, admitted to the facility on 12/12/2025, with diagnoses including muscle weakness, and schizoaffective disorder bipolar type (a mental health illness that can affect thoughts, mood and behavior with episodes of mania [high energy, euphoria/irritability] and sometimes depression) and history of increasing psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) resulting in inappropriate exposure of his private parts and harassing female staff and residents, from a General Acute Care Hospital (GACH 1). A review of Resident 2's History and Physical (H&P) dated 12/13/2025, indicated Resident 2 could make needs known but could not make medical decisions. The H&P indicated Resident 2 was admitted (to the facility) after transferring from GACH 1 due to sexually inappropriate behavior, agitation and neurologic complaints (symptoms caused by disorders of the brain and nervous system). A review of Resident 2's care plan for the month of 12/2025, did not indicate a plan of care with interventions that were developed to address Resident 2's history of inappropriate sexual behavior when the resident was admitted from GACH 1 on 12/12/2025. A review of Resident 2's Progress Notes dated 12/13/2025 at 2:03 p.m., indicated on 12/13/2025 during the 7:00 a.m.-3:00 p.m. shift, Resident 2 exhibited inappropriate behavior (unspecified) toward nursing staff on two occasions. The Progress Notes indicated Resident 2 made sexually explicit and inappropriate verbal comments (unspecified) directed toward a CNA (not identified). The Progress Notes indicated staff redirected Resident 2 and informed Resident 2 that his behaviors were inappropriate and unacceptable. The Progress Notes indicated Resident 2's behavior would be monitored. A review of Resident 2's Progress Notes dated 12/15/2025 at 4:05 p.m., indicated Resident 2 was seen touching a CNA (not identified) inappropriately. The Progress Notes indicated Resident 2 told the unnamed CNA that he (Resident 2) wanted to go to bed with her. A review of Resident 2's care plan for the month of 12/2025 did not indicate a Care Plan was initiated to address Resident 2's inappropriate sexual behaviors on 12/13/2025 and 12/15/2025. A review of Resident 2's care plan titled, "Resident has behavior problem related to bipolar disorder m/b (manifested by) mood swings, schizophrenia (a mental illness that is characterized by disturbances in thought) m/b delusional thoughts and aggressiveness" dated 12/15/2025, indicated nursing interventions included to intervene as necessary to protect the rights and safety of others. A review of Resident 2's MDS dated 12/19/2025, indicated Resident 2 was able to understand and be understood by others. The MDS indicated Resident 2 required partial/moderate assistance for ADLs such as toileting hygiene, showering/bathing self, upper/lower body dressing, putting on/taking off footwear, transfers and walking 10 feet. Resident 2 did not use any assistive devices (equipment to help with ambulation) and had no impairment on both upper and lower extremities. Resident 2 exhibited behavior symptoms (physical symptoms such as hitting or scratching self, pacing, public sexual acts and disrobing in public). A review of Resident 2's SBAR dated 12/19/2025, indicated Resident 2 had physical aggression and was observed entering Resident 1's bedroom, lowered his pants, approached Resident 1 and Resident 2 exhibited sexually inappropriate behavior towards the resident (Resident 1). The SBAR indicated staff (unspecified) redirected Resident 2 back to his room (with roommate, Resident 6) and was shouting during redirection. The SBAR indicated Resident 2 was instructed to remain in his room. The SBAR indicated the Physician was notified of the incident on 12/19/2025 at 2:45 p.m. and ordered to transfer Resident 2 to a GACH for further evaluation and management of behavior. The SBAR did not indicate the type of staff supervision provided for Resident 2 pending the resident's transfer to the GACH (GACH 2). A review of Resident 2's Progress Note dated 12/19/2025 at 3:25 p.m., indicated (on 12/19/2025) at approximately 3:15 p.m., Resident 2 was transported by paramedics to GACH 2. During an interview on 1/6/2026 at 3:29 p.m., with Registered Nurse Supervisor (RN 1), RN 1 stated on 12/19/2026, Resident 1 yelled for help, and a Certified Nurse Assistant (CNA [unable to recall name]) saw Resident 2 in Resident 1's room, lowering his pants. Resident 1 reported to the CNA and RN 1 that Resident 2 touched her (Resident 1) vagina. During an interview on 1/7/2026 at 1:09 p.m., with the Director of Nursing (DON), the DON stated Resident 2 was admitted to the facility on 12/12/2025 with a history of inappropriate exposure of his private parts and harassing female staff. The facility did not create a care plan to address Resident 2's inappropriate sexual behaviors that include interventions to monitor for sexual inappropriateness and Resident 2's whereabouts due to his ability to wander in the facility. The DON stated the facility should have created a care plan to protect other residents (from being abused by Resident 2). During a phone interview on 1/7/2026 at 2:22 p.m. with RN 3, RN 3 stated when she entered Resident 1's room on 12/19/2025 (time not specified), she witnessed Resident 2 putting his pants back on. RN 3 stated Resident 2 pulled his pants down when he saw RN 3 in the room. RN 3 stated Resident 1 reported to her that Resident 2 kissed her, touched her and put his fingers inside her vagina. RN 3 stated Resident 2 pushed her and attempted to go back inside Resident 1's room when he was redirected out of Resident 1's room. RN 3 stated LVN 1 walked Resident 2 back to his room. 3). Resident 6 was a 73-year-old male, originally admitted to the facility on 7/30/2021 and readmitted on 11/9/2022. Resident 6's diagnoses included muscle weakness and low back pain. A review of Resident 6's H&P dated 11/30/2024, indicated Resident 6 had the capacity to understand and make decisions. A review of Resident 6's MDS dated 11/14/2025, indicated Resident 6 was able to understand and be understood by others. Resident 6 was dependent on staff for ADLs such as toileting hygiene, showering/bathing self, dressing, lying to sitting on side of the bed, sitting to standing (the ability to come to a standing position from sitting in a chair, or on the side of the bed) and transfers. A review of Resident 6's Change in Condition (COC) dated 12/19/2025 at 3 a.m., indicated on 12/19/2025, Resident 6 reported he was physically assaulted by another resident (Resident 2). The COC indicated Resident 6 was struck on his legs three times (by Resident 2). During an interview on 1/7/2026 at 8:30 a.m., with Resident 6, Resident 6 stated on 12/19/2025 at 2:55 p.m., Resident 2 entered his room and told him (Resident 6) that he (Resident 2) wanted to suck his (Resident 6) penis. Resident 6 stated Resident 2 attempted to pull his blanket off to expose him (Resident 6) and when Resident 2 could not pull his blankets off, Resident 2 hit him on his right leg three times. During an interview on 1/7/2026 at 9:48 a.m., with CNA 3, CNA 3 stated on 12/19/2025 around 2:55 p.m., she heard Resident 6 scream for help. CNA 3 stated Resident 6 informed her that Resident 2 asked him to suck his penis and the resident (Resident 2) hit him on the leg three times. During an interview on 1/7/2026 at 2:11 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated on 12/19/2026, (after the alleged sexual abuse incident with Resident 1), she redirected Resident 2 back to his room (with Resident 6), LVN 1 stated she should have placed Resident 2 in a single room and not have left Resident 2 unattended with another resident, as Resident 2 had previously shown intent to assault other residents, and to that measure, would have served to protect other residents from a repeat incident of abuse. During a concurrent interview and record review on 1/7/2026 at 3:00 p.m., with the Administrator (ADM), the P&P titled "Abuse Prevention and Management" dated 5/30/2024, was reviewed. The ADM stated sexual abuse was non-consensual sexual contact of any type, sexual harassment, sexual coercion or sexual assault. The facility should identify, correct, and intervene in situations where abuse or exploitation are more likely to occur as indicated in the P&P. The facility should provide a safe environment for the residents as indicated by the situation. A review of the facility's P&P titled, "Comprehensive Person-Centered Care Planning," dated 11/2018, indicated the facility will provide a person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obta