Health inspection·January 30, 2026

Code of Federal Regulations, Title 42, Section 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; Code of Federal Regulations, Title 42, Section 483.25(d) Accidents The facility must ensure that – (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents California Code of Regulations, Title 22, Section 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. California Code of Regulations, Title 22, Section 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. California Code of Regulations, Title 22, Section 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. California Code of Regulations, Title 22, Section 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. On 12/9/2025 at 10:00 AM, an unannounced visit was made to the facility to investigate a facility reported incident and complaint regarding an incident of alleged resident abuse. As a result of the investigation, California Department of Public Health (CDPH) determined that the facility failed to protect the resident’s right to be free from physical abuse by failing to protect Residents 2 and 3 from physical abuse. On 11/24/25, Resident 1 was observed by facility staff (Certified Nurse Assistant [CNA] 1) to be agitated, pacing back and forth in the room and swinging two metal wheelchair footrests in the air. CNA 1 failed to redirect and remove Resident 1 from the room leaving the roommates, Residents 2 and 3 inside the room with Resident 1.   This violation resulted in Resident 2 being physically abused by Resident 1 and Resident 3 fearful for her life on 11/24/2025. Resident 1 hit Resident 2 several times in the head with the metal wheelchair footrests while Resident 2 was in bed. Resident 2 sustained severe, multiple lacerations (a jagged or irregular tear in the skin, often with edges that do not line up, caused by blunt force or tearing), bruising and severe pain to the face. Resident 3 verbalized fear and frightened for her life as she witnessed Resident 1 attempt to strike her with the metal footrests.  The facility called 9-1-1 emergency services on 11/24/2025 at 12:08 AM, and Resident 2 was transferred to General Acute Care Hospital (GACH) 3. In GACH 3, Resident 2 was found to have sustained forehead soft tissue hematoma (collection of blood outside the blood vessel that forms a swollen area under the skin after an injury) as well as a right periorbital (around the eye socket) laceration. Resident 2’s Computerized Tomography scan (CT scan – imaging using x-ray [a photographic or digital image of the internal composition of a part of the body] technique to create detailed images of the body) indicated there was partial mild irregularity of the right nasal (internal part of the nose) bone and a questionable right anterior (front) nasal bone fracture (broken bone). Resident 2 was readmitted back to the facility on 11/25/2025 at 8:15 AM with derma bond (surgical glue) and steri-strips (sterile, adhesive, porous strips used to close small cuts, lacerations, and surgical incisions) applied to Resident 2’s facial injuries.   A review of Resident 1’s GACH 1 Records dated 5/21/2025, prior to admission to the facility, indicated Resident 1 was previously admitted to the GACH 1 Emergency Department (ED) due to an altercation with Family Member (FM) 1, threatening FM 1 with a knife. The GACH 1 ED record indicated Resident 1 was placed on a 5150 hold (involuntary psychiatric detention) at GACH 1 for being a danger to others.   A review of Resident 1’s Admission Record (AR), indicated the facility admitted Resident 1 to the facility on 5/22/2025, with diagnoses including dementia (a general term for a decline in thinking, memory, and reasoning skills severe enough to interfere with daily life) with behavioral disturbance (loss of memory and thinking ability with agitation and physical aggression), psychosis (loses of touch with reality, experiencing symptoms like hallucinations (seeing/hearing things not there) and delusions (false beliefs), along with confused thinking and speech.   A review of Resident 1’s care plan initiated on 5/23/2025 indicated Resident [1] had a behavioral symptom manifested by delusions as evidenced by the resident saying the resident “hears God’s voices all the time.” The care plan indicated the care plan goals for the resident’s behavior was to not result in harm or injury to self or others. The care plan interventions included for facility staff to provide behavioral management or modification as needed, such as providing redirection when exhibiting inappropriate behavior.   A review of Resident 1’s History and Physical (H&P) dated 5/24/2025, indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated Resident 1 came from GACH 1 for altered mentation (confusion, not acting right, altered behavior), metabolic encephalopathy (brain dysfunction caused by illness) and dementia.     A review of a care plan developed for Resident 1 and initiated on 6/14/2025, indicated the resident had a behavioral problem of being physically aggressive related to pushing staff and throwing trash when entering her room. The care plan indicated that staff must intervene to protect the rights and safety of others, divert attention and remove Resident 1 from the situation and/or take the resident to an alternate location.   A review of Resident 1’s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 8/26/2025, indicated the resident had severe cognitive impairment (problems with a person’s ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 1 was assessed requiring partial/moderate assistance for activities of daily living (ADLs - basic self-care tasks). The MDS further indicated Resident 1 was assessed walking with partial/moderate staff assistance. The MDS further indicated Resident 1 manifested wandering behavior (a disturbance of motor activity that involves directionless, disoriented movement) and behavioral symptoms not directed towards others (MDS examples indicated physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming, disruptive sounds).   A review of Resident 1’s previous Change of Condition (COC) form dated 9/10/2025, authored by Registered Nurse (RN) 2, indicated Resident 1’s previous history of agitation observed by staff with escalating agitation. The COC further indicated that at 5:09 PM on 9/10/2025, Resident 1 was yelling profanities (offensive language) at staff when staff entered her room. The COC indicated that Resident 1 threw water at the CNA and other staff passing her doorway. The COC indicated verbal redirection was attempted without success. The COC indicated the physician was notified and that Resident 1 was medicated with Haldol (a medication used to treat aggressive behavior) 5 milligrams (mg – unit of measure) intramuscularly (IM – injection under the muscle) and Benadryl (medication used to cause drowsiness) 25 mg IM one time. A review of Resident 1’s Nursing Progress Notes dated 11/13/2025 timed at 4:31 PM, indicated another previous episode of agitation where Resident 1 was in an agitated state, had thrown water at staff and attempted to elope (a patient leaving a facility or designated safe area without authorization, often due to confusion). The Note indicated that the staff left her alone pacing up and down the hallway so as to not trigger her anger. A review of Resident 1’s psychology (the scientific study of the human mind and its functions, especially those affecting behavior) note titled “Behavioral Health” documented on 11/24/2025 at 5:31 PM, indicated that Resident 1 reported to the psychologist that she was experiencing anxiety, frustration, and negative thinking patterns. The Note did not provide details regarding the specific situations or triggers that contributed to these symptoms. In addition, the Note did not include any recommendations or modifications to the treatment plan to address these concerns. The psychology note documented the following statements: *      “Were there any treatment modifications needed in today's session due to cognitive impairment? No cognitive impairment noted.” *     “Medical Necessity for Ongoing Treatment: Symptoms Require More Attention, Risk of Significant Decline.”   A review of Resident 1’s Progress Notes dated 11/24/2025 documented at 10:40 PM, indicated an incident happened around 10:30 PM when the [CNA 1] informed [Registered Nurse (RN) 1] that Resident 1 was “playing” with a wheelchair’s metal footrests. The Notes indicated [CNA 1] tried to calm [Resident 1] down and get the wheelchair footrests from [Resident 1], but the resident was swinging it [at] CNA 1.”  The Note indicated CNA 1 went to ask for help from RN 1 but while walking back to Resident 1’s room, a scream was heard from the roommate, [Resident 2]. The Note indicated that Resident 1’s physician (MD 1) was notified and ordered to administer Haldol 5 mg and Benadryl 25 mg IM to [Resident 1]. The Note indicated that RN 1 entered [Resident 1's] room and the roommate, [Resident 2] was observed with multiple lacerations to her face. The Note indicated the Police Department was notified and a police report was filed with the local police department.   A review of Resident 1’s physician’s telephone order dated 11/25/2025, indicated to transfer Resident 1 to GACH 2 to rule out (r/t) agitation.   A review of Resident 1’s Nursing Progress Note dated 11/25/2025 documented at 2:35 AM, the Note indicated that Resident 1 was taken to GACH 2 on 11/25/2025 at 12:52 AM for further behavioral evaluations related to agitation.   A review of Resident 1’s Change of Condition (COC) dated 11/25/2025, indicated that an incident occurred around 10:30 PM when [CNA 1] informed [RN 1] that Resident 1 was “playing [with] the footrest of the wheelchair. She [CNA 1] tried to calm her (Resident 1) down to get the footrests from her, but she was swinging it [at] her.”  The Note indicated CNA 1 left the room and went to ask for help from RN 1, but while walking back to Resident 1’s room, a scream was heard from the roommate, Resident 1.   2. A review of Resident 2’s AR, indicated the facility admitted the resident on 9/15/2023, with a diagnosis of dementia with behavioral disturbance and anxiety disorder (experiencing excessive worry and fear).   A review of Resident 2’s H&P dated 11/27/2025, indicated Resident 2 did not have the capacity to understand and make decisions.   A review of Resident 2’s MDS dated 11/11/2025, indicated that Resident 2 had severe cognitive impairment. The MDS indicated that Resident 2 required partial/moderate assistance for ADLs.  The MDS further indicated that Resident 2 required partial/moderate assistance to move from sitting on the side of the bed to lying flat on the bed, to come to a standing position from sitting in a chair, wheelchair or on the side of the bed, and the ability to transfer to and from the bed to a chair.   A review of Resident 2’s Nursing Progress Notes Type: Situation Background Assessment Recommendations [SBAR] dated 11/24/2025 timed at 11:14 PM, indicated an incident occurred around 10:30 PM when [CNA 1] informed [RN 1] that Resident 1 was “playing the footrest of the wheelchair. The Note indicated [CNA 1] tried to calm her (Resident 1) down and get the footrests from her, but [Resident 1] was swinging it [at] [CNA 1].”  The Note indicated CNA 1 went to ask help from RN 1 but while walking back to Resident 1’s room, a scream was heard from the roommate, [Resident 1]. The Note indicated that [Resident 2] was found with lacerations on her face and treatment was applied.   A review of Resident 2’s Nursing Progress Notes dated 11/24/2025 timed at 11:14 PM, indicated that Resident 2 was medicated with Acetaminophen (pain medication) 325 mg two tablets for 7 out of 10 (a severe level of pain on the standard 0 to 10 pain rating scale used by medical professionals to quantify subjective pain experiences) facial pain.   A review of Resident 1’s Police Report dated 11/24/2025, documented by Police Officer (PO) 1 on 11/24/20925 at 11:58 PM, indicated that at approximately 11:57 PM, PO 1 responded to a call at the facility regarding a resident who struck another resident with a wheelchair footrest. The report indicated that Resident 1 was the individual who struck Resident 2. RN 1 stated that the incident occurred at approximately 10:40 PM, when CNA 1 was in Resident 1’s shared bedroom and observed Resident 1 swinging wheelchair footrests she had removed from her wheelchair, attempting to strike CNA 1. PO 1 further indicated in the report that CNA 1 left the room to seek assistance, and shortly afterward, nursing staff heard screams coming from the shared bedroom. Staff entered the room and observed Resident 2 with severe laceration on her forehead. According to the report, LVN 1 called 911, and Resident 2 was transported to GACH 3 for treatment.    A review of Resident 2’s COC Evaluation dated 11/25/2025, indicated Resident 2 manifested acute pain (pain that comes on suddenly and is caused by something specific) to the face. The Pain Status Evaluation indicated Resident 2 was unable to rate the pain but noted with facial grimacing (distorted facial expression) with body language noted as rigid, fists clenched, knees pulled up.   A review of Resident 2’s Nursing Progress Notes at the facility dated 11/25/2025, indicated Resident 2 was transferred to GACH 3 on 11/25/2025 at 12:08 AM via ambulance assisted by two emergency medical technicians (EMT) for further evaluation of facial lacerations.   A review of Resident 2’s GACH 3 records titled ‘E