Health inspection·December 31, 2025

F600 42 C.F.R. §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— (a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 22 CCR 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. 22 CCR 72311. Nursing Service-General. (a) Nursing service shall include, but not be limited to, the following: (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. 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. On 11/14/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a Facility-Reported Incident (FRI) and a complaint regarding resident abuse. The facility failed to protect Resident 1’s and Resident 2’s right to be free from physical abuse when, on 10/30/2025, at approximately 8:45 p.m., Resident 1 hit Resident 2 in the face with a closed right fist, and Resident 2 hit Resident 1 in the face with a wheelchair footrest. The facility failed to: 1. Implement its policy and procedure (P&P) titled “Abuse, Neglect, Exploitation and Misappropriation Prevention Program”, last reviewed on 5/28/2025, which indicated “residents have the right to be free from abuse…The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment… to protect residents from abuse, neglect, exploitation or misappropriation of property, by anyone, including, but not necessarily limited to other residents and any other individuals.”  2. Develop a comprehensive person-centered care plan and implement interventions for Resident 2’s documented history of sensitivity to noise and roommate incompatibility. 3. Ensure the residents’ rights to be free from abuse with appropriate interventions in place and implemented to prevent the physical altercation between Resident 1 and Resident 2 from occurring, including when nursing staff failed to intervene in response to Resident 2’s complaint to nursing staff about the noise from Resident 1’s television right before the altercation. As a result, Resident 1 and Resident 2 were subjected to physical abuse while under the care of the facility. On 10/30/2025, Resident 1 sustained scratches on the bridge of the nose, the right side of nose, and the right thumb that needed first aid. On 10/30/2025, Resident 2 sustained a cut to the bottom lip and complained of moderate pain on the right side of the head, face and left hand with recommended transfer to a general acute care hospital (GACH) for evaluation. In addition, the facility’s failure to develop a comprehensive person-centered care plan for Resident 2 had the potential to result in the resident’s behavioral needs not being properly addressed. A review of Resident 1’s Admission Record indicated the facility admitted Resident 1 on 10/23/2025, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD – a lung disease that block airflow, making it hard to breathe), muscle wasting and atrophy (refers to the loss or thinning of muscle tissue, causing decreased mass and strength), abnormalities of gait and mobility and Schizophrenia. A review of Resident 1’s History and Physical (H&P – a comprehensive assessment of a resident’s medical condition) dated 10/24/2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool) dated 10/27/2025, indicated Resident 1’s cognition was moderately impaired. The MDS indicated that Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity) with eating and required substantial/maximal (helper does more than half the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) assistance from staff with oral hygiene, upper body dressing and personal hygiene. A review of Resident 1’s Change in Condition (COC- a significant change in resident’s health status) Evaluation Form, dated 10/30/2025, timed at 8:45 p.m., documented by Licensed Vocational Nurse 1 (LVN 1), indicated that Resident 1’s roommate (Resident 2) was standing next to Resident 1 while Resident 1 was seated on his (Resident 1) bed. LVN 1 observed Resident 2 attacking Resident 1 with a wheelchair footrest. A review of Resident 1’s Nursing Note dated 10/30/2025, timed at 8:45 p.m., indicated that Resident 1 reported Resident 2 swung Resident 2’s wheelchair footrest and hit Resident 1 in the face. The Nursing Note indicated that Registered Nurse 1 (RN 1) assessed Resident 1 and observed scratches measuring approximately 1.5 centimeters (cm- unit of measurement) on the bridge of nose, 0.5 cm on the right side of the nose, and approximately 0.5 cm on the right thumb. The Nursing Note indicated that RN 1 provided first aid treatment to Resident 1. A review of Resident 2’s Admission Record indicated the facility originally admitted Resident 2 on 6/27/2021 and readmitted Resident 2 on 10/16/2024 with diagnoses including unspecified dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with psychotic disturbance (a mental health state characterized by a loss of contact with reality, leading to hallucinations [seeing or hearing things that are not there] and delusions [firmly held false beliefs]) and unspecified psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality). A review of Resident 2’s MDS dated 6/27/2025, indicated Resident 2’s cognition was severely impaired. The MDS indicated Resident 2 had clear speech, usually had the ability to make self-understood, and usually had the ability to understand others. The MDS indicated Resident 2 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity and helper assists only prior to or following the activity) with eating, supervision or touching assistance with oral hygiene, and required substantial/maximal assistance from staff with toileting, lower body dressing and personal hygiene. A review of Resident 2’s COC Evaluation Form, dated 10/30/2025, timed at 8:45 p.m., documented by LVN 1, indicated that LVN 1 observed Resident 2 standing next to Resident 1, holding his (Resident 2) wheelchair footrest, and hitting Resident 1 in the face with it. The COC Evaluation Form indicated that Resident 1 and Resident 2 were separated, and upon assessment, Resident 2 was noted to have a small (specific measurement not indicated) cut at the bottom of the lip and complained of moderate pain on the right side of the face, head and left hand. A review of Resident 2’s Nursing Note dated 10/30/2025, timed at 8:45 p.m., indicated that Resident 2 reported that at unknown time, when he (Resident 2) went to turn off the television (TV) in the room, Resident 1 hit him. Resident 2 reported his pain to staff and agreed to go to the GACH for further evaluation.  A review of Resident 2’s Care Plan (CP) initiated on 10/30/2025, indicated Resident 2 had swelling of the upper lip and right lower lip, with a 1.0 cm by 1.0 cm cut and purplish discoloration (any change in the skin’s normal color).  The CP’s interventions included providing first aid treatment, monitoring for pain, administering medication as ordered and observing for signs and symptoms of infection. A review of Resident 2’s Physician’s Order Summary Report with an order date of 10/30/2025 indicated to transfer Resident 2 to GACH related to physical aggression initiated towards roommate.  During an interview on 11/14/2025 at 11:42 a.m., with Resident 1, Resident 1 stated that he and Resident 2 were roommates. Resident 1 stated that on 10/30/2025 (does not recall the exact time), after dinner, while he was seated on his bed watching TV, Resident 2 stood up from his wheelchair, came to Resident 1’s side of the room, and turned off his (Resident 1’s) TV. Resident 1 stated that he grabbed Resident 2’s hat and told Resident 2 to stop touching his TV. Resident 1 stated Resident 2 turned around and hit (Resident 1) with a closed fist on his chest and in turn he (Resident 1) punched Resident 2 with a closed fist in the face. Resident 1 stated that after he punched Resident 2, Resident 2 left the room. Resident 1 stated when Resident 2 returned, he (Resident 2) wheeled himself to his (Resident 1‘s) side of the room, stood up, walked over to him (Resident 1) and swung the wheelchair footrest at him, hitting him (Resident 1) in the face, resulting in bleeding to the nose and thumb.  During an interview on 11/14/2025 at 11:48 a.m., with LVN 1, LVN 1 stated that a resident-to-resident altercation between Resident 1 and Resident 2 occurred on 10/30/2025 after dinner (does not recall exact time) during the 3 p.m. to 11 p.m. shift (an eight hour work schedule from 3 p.m. to 11 p.m.). LVN 1 stated that prior to the incident, Resident 2 approached LVN 1 and stated that his roommate’s (Resident 1) TV was on and that he wanted it turned off. LVN 1 stated that she (LVN 1) explained to Resident 2 that Resident 1 had the right to keep his TV on. LVN 1 stated that shortly thereafter, Certified Nursing Assistant 2 (CNA 2) ran toward her (LVN 1) and reported that Resident 1 and Resident 2 were yelling at each other. LVN 1 stated that when she (LVN 1) arrived at the residents’ (Resident 1 and Resident 2) room, she witnessed Resident 2 holding his wheelchair footrest and hitting Resident 1 with it. LVN 1 stated that Resident 2 was swinging the wheelchair footrest while Resident 1 was holding onto it in an attempt to protect himself, with both residents pushing and pulling the wheelchair footrest toward one another. LVN 1 stated that she (LVN 1) and CNA 2 separated Resident 1 and Resident 2 when it was safe to do so.  LVN 1 stated that she (LVN 1) observed blood all over Resident 1’s face. LVN 1 stated that when she asked Resident 2 why he hit Resident 1 with the footrest, Resident 2 stated it was because of the TV. LVN 1 stated that the altercation between Resident 1 and Resident 2 was physical abuse because residents should not physically hit one another for any reason. LVN 1 further stated that the resident-to-resident altercation was avoidable, such as through redirection and that the facility should have provided a safe environment for both residents. During an interview on 11/14/2025 at 2:21 p.m., with RN 1, RN 1 stated that on 10/30/2025, after dinner, during the 3 p.m. to 11 p.m. shift, LVN 1 called him (RN 1) and asked him (RN 1) to come to Resident 1 and Resident 2’s room. RN 1 stated that upon arrival, LVN 1 informed him that Resident 1 and Resident 2 had been fighting. Resident 1 reported to RN 1 that Resident 2 had hit him (Resident 1) with a wheelchair footrest. RN 1 stated that he assessed Resident 1 and noted injuries, including a cut on the bridge of the nose and on the right thumb. RN 1 stated that he then assessed Resident 2 and noted that Resident 2 had a cut on the lower lip. During an interview on 11/17/2025 at 10:40 a.m. with the Director of Nursing (DON), the DON stated that the facility was aware that Resident 2 has behavioral triggers. The DON stated that Resident 2 becomes angry when his roommates’ TVs are on or when he (Resident 2) hears other residents screaming. The DON stated that these stimuli – loud noises and the sound of the TVs – trigger behaviors that result in Resident 2’s anger. During a concurrent interview and record review on 11/17/2025 at 11:00 a.m., with the Director of Nursing (DON), Resident 2’s Care Plans from 10/16/2024 were reviewed. The DON stated that Resident 2 does not have a care plan specific to Resident 2’s behavioral triggers.  The DON stated that a care plan should have been developed to address Resident 2’s triggers so that specific interventions could have been implemented to prevent behavioral outbursts. During an interview on 11/17/2025 at 3:35 p.m., with the Administrator (ADM), the ADM stated that the physical altercation between Resident 1 and Resident 2 constituted physical abuse as it involved one resident hitting another. The ADM further stated that the physical altercation between Resident 1 and Resident 2 was avoidable based on Resident 2’s history of not liking noises and roommate incompatibility, and that interventions should have been put in place to prevent the incident from occurring.  A review of the facility P&P titled “Abuse, Neglect, Exploitation and Misappropriation Prevention Program”, last reviewed on 5/28/2025, indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse.... The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property, anyone including, but not necessarily limited to: b. other residents; j. any other individuals. 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents. 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. The facility failed to protect Resident 1’s and Resident 2’s right to be free from physical abuse when, on 10/30/2025, at approximately 8:45 p.m., Resident 1 hit Resident 2 in the face with a closed right fist, and Resident 2 hit Resident 1 in the face with a wheelchair footrest. The facility failed to: 1. Implement its P&P titled “Abuse, Neglect, Exploitation and Misappropriation Prevention Program”, last reviewed on 5/28/2025, which indicated “residents have the right to be free from abuse…The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment… to protect residents from abuse, neglect, exploitation or misappropriation of property, by anyone, including, but not necessarily limited to other residents and any other individuals.”  2. Develop a comprehensive person-centered care plan and implement interventions for Resident 2’s documented history of sensitivity to noise and roommate incompatibility. 3. Ensure the residents’ rights to be free from abuse with appropriate interventions in place and implemented to prevent the physical altercation between Resident 1 and Resident 2 from occurring, including when nursing staff failed to intervene in response to Resident 2’s complaint to nursing staff about the noise from Resident 1’s television right before the altercation. As a result, Resident 1 and Resident 2 were subjected to physical abuse while under the care of the facility. On 10/30/2025, Resident 1 sustained scratches on the bridge of the nose, the right side of nose, and the right thumb that needed first aid. On 10/30/2025, Resident 2 sustained a cut to the bottom lip and complained of mode