Other·May 6, 2026

California Code of Regulations, Title 22, 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 Patient’s 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. (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. H&S § 1418.91 (a)A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class “B” violation. 22 CCR §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 3/31/2026, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident (FRI) regarding resident-to resident altercation (a noisy, heated, or angry argument and dispute between people that can occasionally turn physical). The facility failed to do the following when on 3/22/2026, at approximately 12 p.m., Certified Nursing Assistant (CNA) 1 and Counselor (C)1 observed that Resident 3 and Resident 4 had a physical altercation (a confrontation or struggle that involves physical aggression between individuals): 1. Protect Resident 3 and Resident 4`s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another). As a result, Resident 3 and Resident 4 were subject to physical abuse while under the care of the facility. 2. Implement its Policy and Procedures (P&P) titled, “Abuse Reporting Dependent Adults” by failing to report the allegation of resident-to resident physical abuse to the State Survey Agency (SSA), the Ombudsman (OMB-an advocate who supports residents by resolving issues related to their health, safety and well-being), and Local Law Enforcement (LLE). As a result, Resident 3 and Resident 4 were placed at an increased risk for further abuse, which could have led to additional unreported incidents and failure to protect other residents from potential harm. A review of Resident 3’s Admission Record (AR) indicated the facility admitted Resident 3 on 7/11/2024, with diagnosis including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), depression (a common, serious mental health condition characterized by a persistent feeling of deep sadness, hopelessness, and a loss of interest in activities that lasts for at least two weeks), and anxiety (a feeling of fear, dread, or uneasiness, often accompanied by physical tension such as a rapid heart rate or restlessness). A review of Resident 3’s Minimum Data Set (MDS – a resident assessment tool) dated 1/20/2026, indicated that the resident`s cognitive skills (brain’s ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated that Resident 3 required set up or clean up assistance ( helper sets up or cleans up, helper assists only prior to or following the activity) with oral hygiene and personal hygiene, showering, and was independent (resident completes the activity by themselves with no assistance from helper) with eating, toileting, upper and lower body dressing, and putting on and taking off footwear. A review of Resident 3’s Nursing Change of Condition (COC-a significant change in a resident`s health status), dated 3/22/2026 at 1:41 p.m., indicated at approximately 12 p.m. Resident 3 was engaged in interpersonal behavioral conflict with peers (a temporary disagreement or clash between individuals of similar power). The COC indicated that Resident 3 was placed on monitoring for 72 hours, neurological check (a series of simple, painless tests performed by a healthcare professional to evaluate how well your brain, spinal cord, and nerves are functioning) every two (2) hours for 24 hours, and a radiograph (x-ray: a quick, painless medical test that uses a small amount of radiation to take pictures of the inside of your body, primarily to look at bones) of skull (the bony framework of the head that forms the skeleton of the face and encloses the brain to protect it) was ordered. A review of Resident 3’s Order Summary Report (OSR-physician orders) dated 3/22/2026, indicated: - X-ray related to trauma to back of head. - X-ray due to participating in grappling (a form of unarmed fighting focused on holding, controlling, or throwing an opponent rather than hitting them, usually at close range or on the ground) like behavior. A review of Resident 3’s Radiology Report dated 3/23/2026 at 12 a.m., indicated that Resident 3 sustained a fracture of the nasal bone. The Radiology report further indicated that the age of the fracture is likely acute (new). A review of Resident 3’s OSR dated 3/23/2026, indicated to transfer the resident to General Acute Hospital (GACH) 1 Emergency Room (ER) on 3/23/2026 at 5 p.m., for evaluation and treatment of nose, related to the abnormal x-ray result. A review of Resident 3’s GACH 1 note dated 3/23/2026, with no documented time, indicated that Resident 3 had a likely chronic (old) nasal bone fracture that was not considered dangerous. A review of Resident 4’s AR indicated that the facility admitted the resident on 2/25/2021, and readmitted on 10/9/2025, with diagnosis including anxiety, psychosis (a mental health symptom where a person loses touch with reality, making it hard to tell what is real and what is not), and mood disorder (a serious mental health condition that causes extreme, lasting shifts in emotion, such as intense sadness [depression] or high energy [mania], that disrupt daily life, work, and relationships). A review of Resident 4’s MDS dated 2/2/2026, indicated that the resident`s cognitive skills for daily decision making was intact. The MDS indicated that Resident 4 required supervision (helper provides verbal cues and touching, steadying and contact guard assistance as resident completes activities) with eating, and personal hygiene, and required setup or clean-up assistance with oral hygiene, showering, and was independent with toileting, upper body and lower body dressing, and putting on and taking off footwear. A review of Resident 4’s Nursing COC dated 3/22/2026 at 2:04 p.m., indicated at 12 p.m. Resident 4 was engaged in interpersonal behavioral conflicts with peers. A review of Resident 4’s OSR dated 3/22/2026, indicated to place the resident on one-to-one monitoring (a high-level safety intervention where a designated staff member is assigned to remain in direct, continuous supervision of a single patient 24/7) related to involvement in interpersonal behavioral conflict event for 72 hours. A review of Resident 4’s OSR dated 3/23/2026, indicated transferring the resident to GACH 2 on 3/23/2026 at 6:15 p.m., for psychiatric evaluation (a comprehensive assessment conducted by a mental health professional to evaluate an individual's mental health status, personality, behavior, and cognitive functioning). During an interview on 3/31/2026 at 11:08 a.m. with Resident 3, Resident 3 stated that maybe a week ago around lunch time, she (Resident 3) was standing in line to receive medication, and was not paying attention, when someone began striking her (Resident 3) on the back of the head. Resident 3 stated that Resident 4 began striking her (Resident 3) on the back and top of the head with a closed fist in a “hammering/pounding motion.” During an interview on 3/31/2026 at 1:27 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated that on 3/22/2026 at around noon, she (RNS 1) was in the medication room located in the Nurses Station 1 when the alleged resident-to resident physical altercation was reported to her (RNS 1) by a staff member. RNS 1 stated that she (RNS 1) was unsure who reported the allegation but was informed an incident involving Resident 3 and Resident 4 had occurred. RNS 1 stated a code green indicating a resident-to-resident interaction, was announced. RNS 1 stated that she (RNS 1) was informed that Resident 3 and Resident 4 were attempting to grab and hold each other while standing in line during the medication pass. RNS 1 stated that Resident 3 and Resident 4 were trying to fight. RNS 1 stated that Resident 3 and Resident 4 grappling and putting hands on each other would be considered physical abuse. RNS 1 stated that on 3/22/2026, shortly after the incident between Resident 3 and Resident 4, she (RNS 1) reported the incident to the residents` doctor, Resident 3 and Resident 4`s conservators (a person appointed by a judge to act or make decisions for the person who needs help), the Director of Nursing (DON) and the Incident Report Coordinator (IRC). RNS 1 stated that the DON instructed her (RNS 1) to ensure the physicians were notified and that the residents were separated. RNS 1 stated that Resident 3 and Resident 4 grappling and putting hands on each other would be considered physical abuse. RNS 1 stated that abuse reporting must be completed within two hours and that all staff are mandated reporters. RNS 1 stated abuse must be reported to the facility Administrator, the police, SSA, and the ombudsmen (OMB). RNS1 stated she (RNS1) did her part she reported the incident to the DON and IRC. RNS 1 stated she (RNS1) did not report to SSA, OMB and the police. RNS 1 stated that abuse be reported within two hours so it can be investigated and, if confirmed, appropriately addressed to ensure resident safety. RNS 1 stated that there is potential for neglect if abuse is not reported. During an interview on 3/31/2026 at 2:03 p.m. with Counselor 1 (C1), C1 stated on 3/22/2026 around 12:00 p.m., she (C1) was near Nurses Station 1 and Resident 3 and Resident 4 were in line to receive medication. C 1 stated that Resident 3 was in front of Resident 4. C1 stated that Resident 3 started speaking loudly to the nurses. C1 stated that she (C1) observed Resident 4 from behind pulling on Resident 3. C1 stated that Resident 4 was grabbing Resident 3’s arms. During an interview on 3/31/2026 at 2:22 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated that she (CNA 1) was working in the facility on 3/22/2026 and around 12 p.m. during the medication pass, CNA 1 observed Resident 3 standing in front of Resident 4 in the medication line. CNA 1 stated that Resident 3 was heard yelling. CNA 1 then turned and observed Resident 3 and Resident 4 attempting to slap each other with open hands. CNA 1 stated Resident 3 was observed hitting Resident 4 while Resident 3 was slightly turned, and Resident 4 was observed hitting Resident 3 from behind. CNA 1 stated what he (CNA 1) observed would be considered abuse, as the residents were hitting each other. During an interview on 3/31/2026 at 4:41 p.m. with the IRC, the IRC stated that she (IRC) was notified about Resident 3’s and Resident 4’s incident on 3/23/2026, however, the incident occurred on 3/22/2026. The IRC stated she (IRC) was informed that Resident 3 and Resident 4 were grappling, tugging (pulling) at each other, and were yelling at one another. The IRC stated initially she (IRC) did not consider this to be abuse, as there was no contact, only residents tugging at each other. IRC stated she (IRC) spoke to Resident 4 and the resident stated that she (Resident 4) was mad, because Resident 3 was yelling. IRC stated she (IRC) did not speak to Resident 3 because Resident 3 refused to speak to her (IRC). The IRC stated that she (IRC) did not document Resident 3’s refusal to speak to her (IRC). The IRC stated that RNS 1 did not call her (IRC) on 3/22/2026 reporting the incident. The IRC stated she (IRC) received the report of the incident on 3/23/2026. The IRC stated that on 3/23/2026 Resident 3`s x-ray report indicated that Resident 3 had a nasal fracture. The IRC stated that Resident 3 stated that she (Resident 3) had a history of nasal fracture. The IRC stated that there is no documented evidence of Resident 3 having a history of nasal fracture. The IRC stated that she (IRC) reported to allegation of resident-to-resident incident to SSA and the OMB on 3/24/2026 at around 4 p.m. The IRC stated that Resident 3 and Resident 4 were tugging and pulling each other so we can classify it as abuse. The IRC stated this is considered physical abuse. The IRC stated that the allegations of physical abuse should be reported within two hours of the event if bodily injury is involved, and within 24 hours if no bodily injury is present. The IRC stated the allegation of physical abuse between Resident 3 and Resident 4 should have been reported within two hours because of the tugging and being interlocked. The IRC stated potential outcome is that residents may not feel safe. During an interview on 3/31/2026 at 4:50 p.m. with the DON, the DON stated on 3/22/2026, he (DON) was notified of the incident involving Resident 3 and Resident 4’s via phone call and was informed that there was some contact between the residents. The DON stated that the facility should have reported the alleged abuse within 24 hours, because there was no apparent bodily harm. The DON stated Resident 3`s x-ray result dated 3/23/2026 indicated that there was a nasal fracture, however, GACH 1 records indicated the nasal fracture was chronic. The DON stated that there is no prior history of bone fractures for Resident. The DON stated the incident should have been reported within 24 hours due to presumed bodily harm from nasal fracture and potential for further harm. The DON stated the potential outcome of not reporting an allegation of abuse is that it may go uninvestigated, unaddressed, increasing the risk of recurrence. A review of the facility’s policy and procedure (P&P) titled, “Abuse Reporting, Dependent Adults,” last reviewed on 2/2/2026, indicated the DON, Program Director, or IRC will be responsible for reporting all suspected incidents of dependent adult abuse as soon as is possible by phone to Department of Public Social Services and follow it up with a completed SOC341 (Report of Suspected Dependent Adult/Elder Abuse). 4. If the reportable event results in serious bodily injury, a telephone report shall be made to the local law enforcement agency immediately and no later than two (2) hours of observation, knowledge or suspicion of physical abuse. In addition, a writer report shall be made to the local OMB, the SSA, and the local law enforcement agency within two (2) hours of observation, knowledge, or suspicion of physical abuse. 5. If the reportable event does not result in serious bodily injury, the Administrator, or his/her designees, will make a telephone report to the local law enforcement agency within twenty-four (24) hours of the observation, knowledge, or suspicion of physical abuse. In addition, a written report shall be made to the local OMB, SSA, and the local law enforcement agency within twenty-four (24) hours of the observation, knowledge, or suspicion of physical abuse. A review of the facility’s P&P titled, “Abuse Definitions,” last reviewed on 2/2/2026 the P&P indicated abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, pinching, and kicking. During a review of the facility’s P&P titled, “Abuse Prevention Program,” last reviewed on 2/2/2026 the P&P indicated our residents have the rig