Health inspection·November 19, 2025

The following reflects the findings of the California Department of Public Health (CDPH) during the investigation of complaint number 2627117. A Class A Citation was written. §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. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment §483.40 Behavioral health services. Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. § 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (A) The admission of a patient. (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (C) An unusual occurrence, as provided in Section 72541, involving a patient. (D) A change in weight of five pounds or more within a 30-day period unless a different stipulation has been stated in writing by the patient's licensed healthcare practitioner acting within the scope of his or her professional licensure. (E) Any untoward response or reaction by a patient to a medication or treatment. (F) Any error in the administration of a medication or treatment to a patient which is life threatening and presents a risk to the patient. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). (c) Licensed nursing personnel shall ensure that patients are served the diets as ordered by the attending licensed healthcare practitioner acting within the scope of his or her professional licensure. 22 CR §72523: §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. . . . (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. On 10/8/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident related to allegation regarding fall with injury. The facility failed to: 1. Protect Resident 4 from Resident 1 when Resident 1 became combative, aggressive, and deliberately pulled and disconnected Resident 4's urine drainage collection bag connected to the indwelling urinary catheter tubing in accordance with Resident 4's care plan titled, "The resident has foley catheter: Neurogenic bladder (a condition where the nerves that control the bladder are damaged, leading to abnormal bladder function)" initiated 6/16/2025. 2. Relocate residents to an alternate location when Resident 1 exhibited aggressive behavioral problems, worsening psychosis (a mental health condition characterized by a loss of touch with reality), and impulsive and risky behavior on 9/21/2025 during the 3 pm to 11 pm shift and continued onto the 11 pm to 7 am shift, in accordance with facility P&P titled " Abuse Prevention/Prohibition" dated 1/25/2025. 3. Prevent Resident 1 from barricading herself with Resident 2 and Resident 4 inside Room A on 9/21/2025 on the 11pm to 11 am shift. 4. Promptly notify a physician that Resident 1 was aggressive and combative and had pulled and disconnected Resident 4's indwelling urinary catheter bag from the indwelling foley catheter on 9/21/2025 during the 11pm to 7 am shift in accordance with the facility's policy and procedures (P&P) titled, "Emergency and/or Alternative Physician Care" dated 1/25/25, and the facility's P&P titled "Change in a Resident's Condition or Status" dated 1/25/2025. 5. Initiate and document the incident that occurred on 9/21/2025 during the 11 pm - 7 am shift involving Resident 1, Resident 2, and Resident 4 in accordance with the facility P&P titled "Accidents and Incidents - Investigating and Reporting" dated 1/25/2024, and P&P titled, "Change in a Resident's Condition or Status ." 6. Assess Resident 1, Resident 2, and Resident 4 when: a. Resident 1 became combative, aggressive and barricaded herself in Room A with Resident 1 and Resident 2 inside the room. b. Resident 1 pulled and disconnected Resident 4's indwelling catheter urinary bag from the indwelling urinary catheter according to facility P&P titled "Behavioral Assessment, Interventions and Monitoring," dated 1/26/2025 7. Identify, evaluate and implement accident risks and hazard interventions for Resident 1 by failing to immediately call emergency medical services (EMS - refers to a system that provides medical care to individuals who are experiencing sudden, serious, or life-threatening health emergencies) and Psychiatric (a branch of medicine that focuses on the diagnosis, treatment, and prevention of mental health disorders) Emergency Team (PET - is a group that includes a law enforcement officer and a mental health clinician to respond to mental health crises) when Resident 1 started exhibiting signs of mental health crisis (a state of acute distress or emotional turmoil that poses an immediate threat to the individual's well-being and safety, or the safety of others) on 9/21/2025 during 3pm-11pm and 11pm-7am shifts according to facility P&P titled, "Behavioral Assessment, Interventions and Monitoring" dated 1/26/2025. As a result of the facility's failures: 1. Resident 4 was at risk to suffer severe pain, trauma (a physical injury caused by external forces like accidents or violence) to the urethra and bladder from tears and strictures that would have resulted in potentially life-threatening complications such as hematuria (blood in the urine), permanent urinary tract damage including rupture of the bladder, increased risk of infections and complications related to forcefully pulling the inflated balloon (is part of the indwelling catheter that is inflated with sterile water once inside the bladder to hold the catheter in place, which is necessary for continuous drainage of urine). Resident 4 was also at increased risk to suffer further psychological (affecting or related to the mental and emotional state of a person) disturbance, and safety concerns. 2. Resident 1 broke a fire alarm mounted on a wall, took and held a sharp piece of the broken cover/guard and tried to cut Registered Nurse (RN) 2. 3. Resident 2 was unable to sleep and suffered emotional trauma exhibited by Resident 2 screaming when Resident 1 became physically aggressive, combative and barricaded (is any object or structure that creates a barrier or obstacle to control, block passage) herself and Resident 2 and Resident 4 inside Room A on 9/21/2025 on the 11pm -7am shift. 4. Resident 1 fell and suffered a right elbow dislocation (a medical condition where the bones in a joint are forced out of their normal position), a closed fracture (fx-break in a bone) coronoid (refers to a sharp, triangular projection from a bone) right (R) ulna (long bone in the forearm stretching from the elbow to the wrist), fx R radial head (the uppermost, cylindrical end of the radius bone in the forearm), and close fx of tuft of distal phalanx of finger. Resident 1 was transferred to general GACH for further evaluation and care. Resident 1 had closed reduction external fixation (CREF- a surgical procedure used to treat bone fractures without open surgery) R elbow. Resident 1 suffered right arm pain from 9/22/2025 to 9/23/2025. A review of Resident 4's admission record indicated Resident 4, a 64-year-old female, was originally admitted to the facility on 3/26/2025 with diagnoses that included acute kidney failure (sudden onset and significant decline in kidney function that leads to an accumulation of waste products in the blood), chronic (ongoing) kidney disease stage 4 (a serious condition where the kidneys have severely declined in function), anxiety disorder (mental health condition excessive and persistent worry, fear, and nervousness), Post Traumatic Stress Disorder (PTSD- is a mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it), dementia (a progressive decline in cognitive functions, such as memory, thinking, language, and judgment), and depression (persistent feelings of sadness, hopelessness, and loss of interest in activities previously enjoyed). A review of Resident 4's Physician's Progress Notes dated 1/25/2025, indicated "(Resident 4) with foley (indwelling catheter) in place recently placed during hospital admission, 8/29. Will d/c (discontinue/remove) foley. If not able to void (pass urine), facility will replace foley. Can consider suprapubic tube (a thin, flexible tube inserted through the abdominal wall into the bladder to drain urine) if this remains a long-term issue." A review of Resident 4's History and Physical notes dated 6/15/2025, under heading titled Subjective, indicated ... Hospital course was notable for ... urinary retention (a condition where a person is unable to completely empty their bladder) requiring foley catheter placement. Foley catheter trial and follow up to be coordinated with skilled nursing facility (SNF). A review of Resident 4's care plan titled "The resident has foley catheter: Neurogenic bladder" initiated on 6/16/2025, indicated the resident will be/remain free from catheter related trauma... A review of Resident 4's Order Summary Report dated 9/1/2025 to 9/30/2025, indicated Resident 4 had a physician's order for indwelling catheter for neurogenic bladder and urinary retention. A review of Resident 4's Physician telephone order dated 9/6/2025 at 2:24 pm, indicated "Foley Catheter-May insert 22Fr (French-size of the foley catheter)/5CC (cubic centimeters [unit of measurement]) PRN (as necessary) if leakage, blockage, dislodgement or soled for urinary retention as needed leaking or disconnected." A review of Resident 4's Minimum Data Set (MDS-a resident assessment tool), dated 9/22/2025, indicated Resident 4's cognition (the mental ability to understand and make decisions of daily living) was severely impaired. Resident 4 had no impairment to upper extremities (arms) and impairment on one side to lower extremities (legs). Resident 4 used a wheelchair for mobility. Resident 4 required substantial/maximal assistance with eating, oral hygiene, upper body dressing, and was dependent with toileting, shower/bathe self, lower body dressing, and personal hygiene. Resident 4 was dependent when standing but did not walk. A review of Resident 1's admission record indicated Resident 1, a 63-year-old female, was originally admitted to the facility on 7/23/2025 with diagnoses that included psychosis dementia, hypertension (high blood pressure), depression, anxiety (mental health condition excessive and persistent worry, fear, and nervousness). A review of Resident 1's care plan on Behavior initiated 7/25/2025, indicated Resident 1 has a behavior problem related to resident with history of non-compliance with medications, ADL, and worsening psychosis, impulsive and risky behavior. The care plan indicated to intervene as necessary to protect the rights and safety of others... remove from situation and make alternate location as needed. Administer medications as ordered. A review of Resident 1's MDS, dated 7/29/2025, indicated Resident 1's cognition (the mental ability to understand and make decisions of daily living) was severely impaired and required setting up or assistance with eating. Resident 1 required partial to moderate assistance with oral care, toileting hygiene, upper and lower body dressing, putting on footwear and personal hygiene. Resident 1 was independent with moving from sitting to lying position and standing and was ambulatory. A review of Resident 1's Situation Background Assessment Recommendation (SBAR) Communication Form dated 9/22/2025 and untimed, indicated Resident 1, "Had behavior outburst and striking out uncontrollably with no trigger. Today this AM, remains with aggression without apparent provocation." The SBAR indicated Resident 1 was a danger to self or others and had verbal and physical aggression. While being evaluated via telehealth psychiatry consult, the resident abruptly stood up from a wheelchair, grabbed the phone from the nurse and forcefully threw the phone at the wall. A review of Resident 1's care plan related to "The resident has potential to be physically aggressive related to anger, dementia, depression, history of harm to others, and poor impulse control," initiated 9/22/2025, indicated interventions include monitor and document observed behavior and attempted interventions in behavior log, and monitor/document/report PRN any signs and symptoms (s/sx) of resident posing danger to self and others. The care plan goal includes Resident 1 will not harm self or others. A review of Resident 1's care plan related to ph