Health inspection·January 30, 2026

Freedom from Abuse, Neglect, and Exploitation 42 CFR §483.12(a) The facility must: 42 CFR §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 22 CFR § 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. 22 CFR § 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. 22 CFR § 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. On 12/15/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility-reported incident (FRI) related to allegations of resident-to-resident abuse. The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 5 provided one-to-one supervision (1:1, close monitoring) to Resident 45, as ordered. 2. Follow its Policy and Procedure (P&P), titled, "Resident Safety", which indicated the facility will provide a safe and hazard free environment. As a result, on 12/5/2025, at approximately 2:00 a.m., Resident 45 punched Resident 110 on the right side of his nose while he slept, unprovoked after being left unsupervised. Resident 45 was a 66-year-old male, recently readmitted to the facility on 12/3/2025. Resident 45's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), anxiety (a feeling of uneasiness), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and hypertensive heart disease (high blood pressure). A review of Resident 45's Minimum Data Set ([MDS], a resident assessment tool), dated 9/11/2025, indicated Resident 45's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 45 required supervision or touching assistance for the performance of activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 45's History and Physical (H&P), dated 12/4/2025, indicated Resident 45 did not have the capacity to understand and make decisions. Resident 110 was a 67-year-old male, initially admitted to the facility on 1/9/2023 and readmitted on 6/18/2024. Resident 67's diagnoses included schizoaffective disorder, bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), COPD, and abnormalities of gait and mobility. A review of Resident 110's MDS, dated 11/25/2025, indicated Resident 110's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 110 required set up assistance for toileting, oral hygiene, eating and taking off footwear. A review of Resident 45's care plan titled "Behavior Problem," dated 12/4/2025, indicated Resident 45 exhibited behavior problems related to schizophrenia (a mental illness that is characterized by disturbances in thought) manifested by delusions (false beliefs that persist despite evidence to the contrary) that somebody was out to get him and sudden angry outbursts, intrusive behaviors, and sudden changes in mood from pleasant to extreme anger. The interventions were to ensure 1:1 monitoring for safety every shift and to intervene as necessary to protect the rights and safety of others. A review of Resident 45's Order Summary Report, dated 12/4/2025, indicated 1:1 supervision. A review of Resident 45's Incident Report, dated 12/5/2025, indicated Resident 45 hit his roommate, Resident 110, on the right side of his nose, while he was asleep. The Incident Report indicated the incident was unwitnessed. A review of CNA 5's Corrective Action Memo, dated 12/5/2025, indicated CNA 5 violated policy or procedure, failed to follow instructions, and was careless. The Corrective Action Memo indicated CNA 5 left Resident 45 "alone" during 1:1 supervision duties without proper staff or supervisory notification, which resulted in an incident. A review of Registered Nurse (RN) 2's Written Statement, dated 12/18/2025, indicated on 12/15/2025 at approximately 2:55 a.m., Licensed Vocational Nurse (LVN) 7 notified her of an altercation that occurred on Unit A between Residents 45 and 110. The statement indicated RN 2 immediately reported to Unit A and separated the residents. The statement indicated Resident 45 had been placed on 1:1 supervision prior to the incident for the safety of the residents and others. The statement indicated the assigned 1:1 CNA, CNA 5, left Resident 45 unattended to use a restroom located outside of the unit and failed to notify or arrange for another staff to cover the 1:1 assignment. The statement indicated CNA 12, who was present in the hallway, heard commotion in the resident's room and observed Resident 45 standing in front of Resident 110, who had been bleeding from his nose. The statement indicated Resident 110 reported he was sleeping when he was hit on the right side of his face by Resident 45. The statement indicated upon returning to the unit, CNA 5 stated he used the restroom located outside of the unit. During an interview on 12/18/2025 at 9:22 a.m., RN 2 stated she recalled being notified of the incident (12/5/2025) involving Resident 45 and Resident 110. RN 2 stated upon arrival to Unit A, CNA 5 could not be located. RN 2 stated she proceeded to call his personal cell phone multiple times. RN 2 stated upon assessment of Resident 110, his nose was bleeding. RN 2 stated CNA 5 returned to Unit A approximately 15 to 30 minutes later. RN 2 stated CNA 5 informed her he went to use the restroom located outside of the unit. RN 2 stated the expectations of the CNA assigned to 1:1 monitoring was to stay within arm's distance of Resident 45 in order be able to attempt to intervene prior to any accidents or physical altercations. RN 2 stated the lack of 1:1 supervision led to Resident 110 being physically abused by Resident 45. During an interview on 12/18/2025 at 11:54 a.m., the Director of Nursing (DON) stated the facility's expectations for CNAs assigned to provide 1:1 supervision included remaining within arm's length of the resident, maintaining continuous visual supervision, and ensuring any required breaks were communicated to and covered by other staff. The DON stated staff failed to minimize the risk of physical abuse by not rendering adequate 1:1 supervision, which resulted in physical abuse by Resident 45. A review of the facility's Policy and Procedure (P&P) titled, "Resident Safety", dated 4/15/2021, indicated the facility was to provide a safe and hazard free environment and the IDT would establish a person-centered observation or monitoring system for the resident to address the identified risk factors. The P&P indicated the person-centered care plan may require more frequent safety checks. A review of the facility's P&P titled, "Abuse Prevention and Management", dated 5/30/2024, indicated the facility did not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. The P&P indicated the facility developed policies, procedures, training, programs, and screening and prevention systems. The facility failed to: 1. Ensure CNA 5 provided 1:1 supervision to Resident 45, as ordered. 2. Follow its P&P, titled, "Resident Safety", which indicated the facility will provide a safe and hazard free environment. As a result, on 12/5/2025, at approximately 2:00 a.m., Resident 45 punched Resident 110 on the right side of his nose while he slept, unprovoked after being left unsupervised. This violation had a direct or immediate relationship to the health, safety, or security of all residents.