Health inspection·September 26, 2025

F557 §483.10(e) Respect and Dignity. The Resident has a right to be treated with respect and dignity, including: §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other Residents.

F656 §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. The comprehensive care plan must describe the following — (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and

F745 §483.40(d) Medically Related Social Services The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. On 8/14/2025 at 1:20 PM, California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint, and a facility reported incident regarding resident’s rights and an incident of alleged resident abuse. CDPH determined the facility failed to implement its policy and procedure (P&P) on “Dignity” and failed to honor Resident 1’s preferences for privacy and comfort by not obtaining permission before entering her room on 8/12/2025, as indicated in the resident’s written care plan. HK 1 entered the resident's room without consent of the resident, opened the privacy curtain and observed the resident undressed. Despite Resident 1’s complaint about HK 1, the same housekeeper was reassigned to clean the resident’s room on 8/13/2025 and 8/14/2025, further compromising Resident 1’s dignity and emotional well-being. This deficient practice had the potential to negatively affect Resident 1’s psychosocial and psychological well-being by causing Resident 1 to become very upset, yelling out, crying. Resident 1 verbalized feeling isolated, mistreated, and discriminated against on 8/12/2025 and 8/13/2025. A review of Resident 1's Admission Record (AR) indicated a 58 year old, female resident, was admitted to the facility on 12/27/2024 with diagnoses including Diabetes Mellitus ( high blood sugar), major depressive disorder (a mental illness constant feeling of sadness), and acute respiratory disorder (a sudden, life-threatening condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to dangerously low oxygen levels in the blood or excessive carbon dioxide buildup, require medical intervention).   A review of Resident 1’s care plan, initiated on 3/18/2025 indicated that Resident 1 prefers to keep the curtain closed at all times. The care plan included a goal that Resident 1’s preferences will be honored, and her privacy and comfort will be respected. The environment will be conducive to her emotional and physical well-being. The care plan intervention indicated that if the room needs to be entered for emergency purposes, the resident should be informed, and any necessary adjustments to the environment should be made easily.   A review of Resident 1's History and Physical (H&P) dated 5/14/2025 indicated Resident 1 had the capacity to make medical decisions. A review of Resident 1's Minimum Data Set (MDS), a resident assessment tool, dated 7/3/2025, indicated Resident 1 was cognitively intact.   A review of Resident 1’s progress note dated 8/12/2025 at 10:03 AM, indicated the following information: -The SSD was made aware by Certified Nurse Assistant (CNA) 1 that the resident was very upset and yelling out. The SSD went to the resident’s room and asked to speak with her, and the resident agreed. Upon entering the room, the resident was sitting at the edge of the bed, staring out the window—not yelling or appearing in distress. The SSD explained that she had been informed the resident was upset and wanted to follow up and offer assistance. At that moment, [Resident 1] turned and began yelling, ‘I'm so fucking tired of this! I'm done! I need to be respected!’ -The note indicated [Resident 1] explained that she had just showered and was about to get dress when she heard a knock on the door. [Resident 1] stated that she said out loud, ‘I'm changing,’ but then heard the housekeeper enter the room. [Resident 1] noted that her curtain was fully drawn, covering her. The note indicated [Resident 1] said, ‘Why do they need to come into the room when they see the curtain drawn? I'm fed up. I can't take this anymore.’ -The note indicated [Resident 1] continued to express her frustration by yelling, repeating herself multiple times, and not responding to redirection attempts. The SSD encouraged the resident to verbalize her feelings and provided emotional support but was unsuccessful in calming her down. The SSD apologized for the incident, assured the resident that her concerns would be followed up on, and asked if she was okay at that moment. The resident, still visibly upset, did not respond to SSD. Instead, she called someone on her phone and began yelling again, repeating the same complaint. When asked again, the Resident stated she was ‘fine’ and continued yelling on the phone. The SSD exited the room to give her privacy and indicated follow-up is pending.   A review of Resident 1’s Progress Note dated 8/12/2025, at 11:16 AM, indicated: “Resident is still on a phone call, yelling and stating, ‘I'm fucking tired.’”* The note further indicated that the SSD provided the resident [Resident 1] with space and privacy to continue her phone call and would continue to follow up.   A review of Resident 1’s Progress Note dated 8/12/2025, at 3:34 PM, indicated that the SSD attempted to discuss the earlier incident and provide a follow up, but [Resident 1] declined at the moment and stated she was upset about missing a doctor’s appointment. The Note indicated “SSD to follow up.” A review of Resident 1’s grievance dated 8/12/2025 (time not specified), indicated that Resident 1 had a complaint regarding housekeeping [HK 1]. [Resident 1] explained that she was in her room after showering when she heard a knock on the door. [Resident 1] stated that she said aloud, “I am changing,” but still heard [HK 1] enter her room. The grievance form indicated that the DON, Social Services Director (SSD), and Housekeeping Supervisor were the department heads designated to take action on the concern. The grievance form indicated under Action Taken: “The Housekeeping Supervisor was made aware of the incident, and a one-on-one in-service training was requested.”   A review of Resident 1’s Progress Note dated 8/13/2025, at 1:13PM, indicated the following information: “[The] SSD met with the Resident in her room and inquired about the earlier incident. The Resident verbalized, feeling upset with the housekeeper [HK 1] that day. She [Resident 1] stated that she went out for a walk with [RNA 1] and, upon returning, asked for the floor to be dried before entering. She [Resident 1] reported that CNA 4 dried the floor for her and expressed frustration that the housekeeper [HK 1] did not do it instead.” The SSD encouraged [Resident 1] to express her feelings and provided emotional support. The SSD explained that the concerns had been reported to the Housekeeping Supervisor, and [HK 1] would receive one-on-one training on resident rights and customer service. Additionally, since [Resident 1] had verbalized that she “does not want to see him [HK 1],” [HK 1] would be reassigned and would no longer be present around [Resident 1’s] room or area. [Resident 1] verbalized understanding and agreed with the plan, although she remained visibly upset and angry. When asked if there was anything else that could be done to assist her or make her feel better, the Resident did not respond directly but stated, “I’m just done with all this shit! I don’t know who he thinks he is. I’m done with this place.” The SSD encouraged [Resident 1] to continue expressing her feelings and suggested breathing exercises to help her calm down. The SSD also discussed available options and resources for returning to the community. The SSD noted that one-on-one visits would be provided as needed to support Resident 1’s emotional and psychosocial well-being.   During an interview on 8/14/2025, at 1:52 PM, Resident 1 reported that on 8/12/2025, around 10 AM, while changing after a shower, she heard a knock on the door but told the housekeeper (HK 1) not to enter. Despite this, HK 1 entered, opened the curtain, and looked at her while she was undressed. Resident 1 stated she yelled at HK 1 to leave, but he returned minutes later, again opened the curtain, and stared at her, claiming he needed an extension cord near her bed. Resident 1 immediately reported the incident to the social worker and filed a grievance. Resident 1 stated that on 8/13/2025, she saw HK 1 cleaning her room again, which made her feel uncomfortable and unable to enter her room. Resident 1 expressed feeling violated, humiliated, and ignored, especially after being told she would be transferred instead of having her concerns addressed. Resident 1 stated felt isolated, mistreated, and discriminated against, and became emotional during the interview.   During an interview on 8/14/2025 at 2:14 PM, the SSD stated that on 8/12/2025, Resident 1 was visibly angry and yelling after HK 1 entered her room without permission while she was changing. The SSD attempted to provide emotional support but was unsuccessful. She reported the incident the same day to the DON and Housekeeping Supervisor. The SSD noted Resident 1 remained upset and emphasized that staff must not enter residents’ rooms without permission to uphold their rights and dignity.     During an interview on 8/14/2025, at 3 PM, RNA 1 stated that on 8/12/2025 around 10 AM, she heard Resident 1 yelling and was told by the resident that a housekeeper (HK 1) had entered her room without permission while she was changing. Resident 1 remained upset throughout RNA 1’s shift. RNA 1 did not intervene, noting that SSD and LVN 1 were already present. On 8/13/2025, Resident 1 saw HK 1 mopping her room and asked him to dry the floor. HK 1 did not respond, and CNA 4 dried the floor instead. RNA 1 stated Resident 1 became very upset upon seeing HK 1 again.    During an interview on 8/15/2025 at 3:49 PM, HK 1 stated he does not understand or speak English and did not understand the phrase “I am changing, do not enter.” On 8/12/2025, he knocked on Resident 1’s door, the curtains were closed, heard no response, and entered while she was changing. HK 1 stated he left after hearing Resident 1 yell but did not understand what Resident 1 said. HK 1 was unaware of the facility’s policy on entering resident’s rooms without permission. On 8/13/2025, while mopping Resident 1’s room, HK 1 stated he did not respond to Resident 1’s request, and CNA 4 dried the floor instead. HK 1 confirmed he received in-service training on 8/13/2025 about not entering resident rooms without permission but was still assigned to clean Resident 1’s room right after. During an interview on 8/14/2025, at 4:38 PM, the DON stated she was informed on 8/12/2025 that Resident 1 was upset after a housekeeper entered her room without permission while she was changing. Although she heard Resident 1 yelling throughout the day, the DON did not follow up directly, waiting for the resident to calm down. She acknowledged that the incident reflected a change in condition but admitted no care plan, SBAR, emotional monitoring, or psychiatric referral was initiated. The physician was not notified, and in-service training for housekeeping was delayed until the following day. The DON was unsure if the housekeeper’s assignment had been changed and emphasized the importance of respecting residents’ rights and dignity. During an interview on 8/15/2025, at 10:03 AM, LVN 1 stated she was assigned to Resident 1 on 8/12/2025 and was informed by the DON that a housekeeper had entered the resident’s room without permission. Although LVN 1 observed Resident 1 was upset during her shift, LVN 1 stated she did not ask about it or initiate a care plan or Change of Condition (COC), assuming the DON had addressed it. LVN 1 confirmed no psychiatric evaluation was scheduled and acknowledged that per facility protocol, a COC, care plan, and 72-hour emotional monitoring should have been initiated for emotional distress.   During an interview on 8/15/2025, at 11:05 AM, the Housekeeping Supervisor stated he was informed by the SSD on 8/12/2025 that HK 1 entered Resident 1’s room without permission while she was changing. He provided in-service training to HK 1 on 8/13/2025, but HK 1 was still assigned to Resident 1’s room on both 8/13 and the afternoon of 8/14.   During an interview on 8/15/2025, at 12:28 PM, CNA 2 stated that she was assigned to Resident 1 on 8/12/2025, from 7 AM to 3 PM. Around 9:30 AM to 10 AM, CNA 2 assisted Resident 1 with a shower and helped her return to her room. Later, between 10 AM and 10:30 AM, CNA 2 stated she heard Resident 1 yelling and noticed that she appeared upset. CNA 2 stated that Resident 1 reported to her that housekeeping had entered the room without permission while she was changing. CNA 2 added that Resident 1 remained very upset and angry for the rest of the day, from 10 AM to 3 PM on 8/12/2025.    A review of the facility’s Policy and Procedure titled “Dignity,” revised February 2021, the P&P indicated that: Each Resident shall be cared for in a manner that promotes and enhances their sense of well-being, satisfaction with life, and feelings of self-worth and self-esteem. Residents are to be treated with dignity and respect a