Health inspection·October 17, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint number 2605354. A Class B Citation was written. REGULATORY VIOLATIONS: California 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. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; Title 22, California Code of Regulations: § 72521 Administrative Policies and Procedures. (a.). Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. 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. Title 22, California Code of Regulations: § 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: (5) To receive all information that is material to an individual patient's decision concerning whether to accept or refuse any proposed treatment or procedure. The disclosure of material information for administration of psychotherapeutic drugs or physical restraints or the prolonged use of a device that may lead to the inability to regain use of a normal bodily function shall include the disclosure of information listed in Section 72528(b). (8) To be free from discrimination based on sex, race, color, religion, ancestry, national origin, sexual orientation, disability, medical condition, marital status, or registered domestic partner status. (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. (15) To meet with others and participate in activities of social, religious and community groups. (16) To retain and use personal clothing and possessions as space permits, unless to do so would infringe upon the health, safety or rights of the patient or other patients. On 9/3/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding the allegation that facility residents were physically assaulted by the facility's administration team. The facility failed to: 1.Implement its policy and procedures (P&P) titled," Abuse and Neglect" by failing to protect Resident 3 from mental abuse (intentional, willful, or reckless verbal or nonverbal action) and physical abuse (deliberate aggressive or violent behavior with the intention to cause harm) by not depriving Resident 3 of her motorized power wheelchairs(MPWC - a battery-operated device designed for individuals with mobility impairments, providing assisted motion with motorized base and a control system, typically a joystick) on 9/1/2025 that was necessary for her to attain or maintain physical, mental, and psychosocial well-being. 2. Ensure unidentified facility corporate staff (Person from the main company not a regular employee of the facility) did not remove Resident 3's MPWC on 9/1/2025, and place Resident 3 into manual wheelchairs (MWC - mobility device on wheels that provides support for individuals with limited mobility propelled by the user or the care giver manually pushing the chair) against Resident 3's wishes/will/consent. 3. Ensure Resident 3 was not confined in bed, and denied mobility from 9/1/2025 to 9/2/2025, when the facility corporate staff deprived the resident of her preferred mobility device without clinical justification or consent. 4. Ensure Resident 3 was not subjected to intimidation (to make them feel frightened, afraid, or timid, often to force them to do something or to discourage them from acting) when the unidentified facility corporate staff removed Resident 3 MPWC. As a result, Resident 3 was subjected to mental and physical abuse while under the care of the facility. Resident 3 experienced loss of autonomy (the right and ability to govern or control oneself and make one's own choices), dignity, and independence, which caused psychosocial harm (the negative mental or physical health impact resulting from psychosocial hazards, which are factors in the design or management of work that cause stress), including anxiety (nervousness), helplessness, and emotional distress. A review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility on 10/10/2012 and most recently on 6/8/2024 with diagnoses including multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), Parkinson's Disease (PD- a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) without dyskinesia (broad term to describe involuntary, uncontrollable movements), scoliosis (condition where the spine twists and curves to the side), neuromuscular dysfunction of bladder(neurological disorder that disrupts bladder control), generalized muscle weakness, osteoarthritis (OA-a progressive disorder of the joints, caused by a gradual loss of cartilage), depression, neuralgia (nerve pain), carpal tunnel syndrome (inflamed nerve in the wrist) and dependence on wheelchair. A review of Resident 3's care plan initiated 7/24/2025 indicated Resident enjoys participating in activities and socializing with peers. Resident also independently participates in community activities however at risk for decreased participation due to Parkinson's scoliosis, muscle weakness and dependence on electric wheelchair and staff for ADLs. The goal was for Resident 3 to maintain or improve the current level of engagement in activities to enhance quality of life and psychosocial well-being. Interventions included assisting Resident 3 in accessing patio for fresh air and leisure. A review of Resident 3's MDS dated 8/6/2025 indicated Resident 3's cognition was intact. Resident 3 required maximum assistance (the helper does more than half the effort to complete the activity) with toileting, bathing, and showering. Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity) with transfers (moving between surfaces) from bed to chair. The same MDS indicated Resident 3 was dependent on the use of the MWC. During a concurrent observation and interview on 9/3/2025 at 12:12 p.m. with Resident 3 inside her room, Resident 3 was observed seated in her MPWC during the interview. Resident 3 stated, "The facility took my MPWC because they said it was dangerous. I did not have my MPWC for two days and I just stayed in bed all day." Resident 3 explained that she was provided with a manual wheelchair (MWC), but it lacked footrests, and she could only use her right arm. She stated, "I complained about it and had my family call, and they gave me my chair back yesterday (9/2/2025) evening." Resident 3 reported that she has never had any accidents or hit anyone or anything while using her MPWC. She stated she has had an MPWC for 12 years and is currently using her second chair. She added that the company trained her on how to use the chair each time she received a new one. Resident 3 disclosed that she has multiple sclerosis (MS), which limits her ability to walk or use her legs and arms. Regarding the events of 9/1/2025, Resident 3 stated that approximately six unidentified individuals entered her room and "kind of ganged up on me." She said she had never seen these people before. They informed her that she could no longer use her MPWC inside the facility and would only be allowed to use it outside. Resident 3 recalled that a Hoyer lift (A type of patient lift used to safely transfer individuals with limited mobility from one place to another) was used to transfer her from the MPWC to her bed. She could not recall the exact time the MPWC was taken but remembered crying in bed all day because she no longer had access to it. She was told the MPWC was "downstairs charging." Resident 3 stated that when the MWC was brought to her, she was told, "The nurses will push you around the facility where you want to go." She expressed skepticism, saying, "Yeah right, they don't have enough staff for that because I like to go a lot of places." Resident 3 became tearful during the interview and shared that she enjoys going to the local college for facials and haircuts. She had planned to go on 9/2/2025 but was unable to because she did not have her MPWC. During an interview on 9/3/2025 at 1:09 p.m. Resident 1 stated, "On 9/1/2025 there was a lady (unidentified) here from corporate barking orders. She came with a social worker guy and some other people (unidentified staff)." She observed the group speaking with both Resident 2 and Resident 3 about their use of motorized power wheelchairs (MPWCs). Resident 1 stated, "I know Resident 3 has had the MPWC for a very long time with no problems until these people showed up demanding to confiscate the chairs and store them in the garage." Resident 1 became tearful during the interview and added, "Resident 3 was in bed for two days crying after they took the MPWC and I felt so bad. They took away Resident 3's chair (MPWC) and by doing that they took away Resident 3's independence-and that was not okay." During an interview on 9/3/2025 at 3:49 p.m., Resident 4 stated she and Resident 1 went to check on Resident 3 after her MPWC was taken. Although she could not recall the exact date, she stated, "Resident 3 just stayed in bed crying all day. We checked on her for two days." Resident 4 recalled that on 9/1/2025, she observed facility staff entering Resident 3's room with a Hoyer lift. She stated, "They lifted Resident 3 out of the chair (MPWC) and put Resident 3 in the bed." Shortly afterward, she saw a maintenance staff member driving Resident 3's MPWC down the hallway toward the back elevator. Resident 4 stated there were approximately five individuals involved, none of whom introduced themselves. She said, "We had no clue who they were. They just said, 'We're taking your chair." During an interview on 9/4/2025 at 2:56 p.m., the Director of Nursing (DON) stated that she spoke with Family Member 1 (FM 1) on 9/2/2025, regarding Resident 3's MPWC and informed FM 1 that an evaluation would be conducted. The DON visited Resident 3 on the same day but could not recall whether the MPWC was present in the room. She noted that Resident 3 was in bed during the visit. The DON asked Resident 3 whether she had ever been trained on how to use the MPWC. According to the DON, Resident 3 either said "no" or could not remember. The DON stated, "As far as I know, no one's chair was taken away." She further stated, "FM 1 never said to me that Resident 3's chair was taken away; FM 1 was just calling to make sure Resident 3 would have the MPWC for an appointment the next day." During an interview on 9/4/2025 at 3:45 p.m. with the Vice President (VP) regarding the removal of Resident 3's MPWC. The VP stated, "Resident 3 cannot manage the MPWC with her hands because she has Parkinson's and multiple sclerosis; have you seen her?" The VP reported observing Resident 3 traveling from the activity room to her room and stated that Resident 3 was not managing the MPWC properly. According to the VP, Resident 3 told her that she needed the MPWC to go to different places. The VP responded by instructing Resident 3 to call a staff member to push her in a MWC whenever she wanted to go somewhere, stating, "That is their job." The VP stated that a Hoyer lift was used to transfer Resident 3 from the MPWC to her bed, and an MWC was provided. The VP did not observe what happened to the MPWC after the transfer. She also confirmed that she did not speak with Resident 3's physician prior to removing her from the MPWC, nor did she speak with the DON upon entering the facility or informing the DON of the plan to remove residents from their MPWCs. The VP concluded by stating, "At the end of the day, my corporation took over and we were looking at the safety of the building, and according to the policy, they cannot have MPWC in the building." During an interview on 9/4/2025 at 4 p.m., the Medical Doctor (MD) 1 stated, "Yes, I know Resident 3 very well, and there is no way Resident 3 can use a manual wheelchair. Resident 3 does not have the strength, and Resident 3's posture is bad; Resident 3 would not be able to tolerate sitting in an MWC." MD 1 questioned why the facility would provide Resident 3 with a MWC, stating that doing so would be "the equivalent of leaving Resident 3 in bed." MD 1 emphasized that Resident 3 can use the MPWC independently and does not need to wait for staff to push her. He added, "Honestly, that patient-to-staff ratio does not even support someone coming to wheel Resident 3 everywhere she wants to go." MD 1 described Resident 3 as very independent and noted that she enjoys going to many places. MD 1 also expressed concern about the psychological impact of removing the MPWC, stating, "Resident 3 has MS, which comes with a lot of depression. If the facility takes away Resident 3's MPWC and gives her an MWC, they are taking away her independence, which can worsen depression. MD 1 further stated, "Resident 3 has had the MPWC for 12 years. I would think Resident 3 would be used to using it. I have never seen Resident 3 run into anything or anyone in the MPWC." During a concurrent observation and interview on 9/4/2025 at 4:19 p.m. with the maintenance assistant (MA) in the rear hallway of the facility. The observation took place near a locked bathroom adjacent to the rear service elevator, across from the kitchen. The MA stated, "On 9/1/2025, the VP and the CSM called me to move the MPWC from Resident 3's room, and I brought it here." The MA indicated that the MPWC was stored in the area near the locked bathroom. The MA further stated, "I didn't see any other MPWC here when I brought the chair here." During an interview on 9/4/2025 at 4:30 p.m., Family Member (FM) 1 stated, "Resident 3 called me and said the facility was taking away the MPWC and Resident 3 would have to use a manual wheelchair." FM 1 reported that the DON later called back and said there had been a misunderstanding and that Resident 3 would get the MPWC back. FM 1 stated that when Resident 3 initially called, she was very concerned because she did not know where the facility had taken the MPWC. FM 1 described Resident 3 as "quite disturbed," adding, "I think for good reason because having the MPWC is Resident 3's only means of independence." FM 1 explained that Resident 3 regularly attends weekly multiple sclerosis meetings at the local college, participates in the singing and jazz club, and receives haircuts and facials. FM 1 emphasized that Resident 3 has found many valuable resources in the community. FM 1 stated that Resident 3 called back on 9/2/2025, very happy because she had received her MPWC back and was able to attend the MS Achievement Center for her weekly meeting. FM 1 concluded by stating, "Resident 3 was left with a MWC and stayed in bed for 24 hours." A review of the facility policy and procedures (P&P) titled," Abuse and Neglect", reviewed 11/2024, the P&P indicated: 1. "Abuse" is defined at §483 .5 as "the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes depri