Health inspection·February 12, 2026

§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. §483.12(a) The facility must §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 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. 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 § 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 12/30/2025 the Department of Public Health (DPH) received a facility reported incident (FRI) alleging Resident 4 made physical contact with Resident 3 by holding him down on the couch preventing Resident 3 from getting up and preventing Resident 3 from trying to kick and hit Resident 4. On 12/30/2025, the CDPH conducted an unannounced visit at the facility to investigate the FRI. The facility failed to follow its undated policy and procedure (P&P), titled "Abuse Prevention and Reporting," which indicated it will protect residents from any form of abuse, by not ensuring: 1. Resident 4 did not push Resident 3 and Resident 3 did not strike Resident 4. As a result, Resident 4 pushed Resident 3 who was trying to get up from the couch and placed other residents at risk for abuse. A. Resident 3 was an 69-year-old male admitted to the facility on 8/18/2023 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), cerebral ischemia (insufficient blood flow to the brain), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). A review of Resident 3's Minimum Data set (MDS-a resident assessment tool), dated 11/25/2025, indicated Resident 3 was cognitively intact (able to make decisions). The MDS indicated Resident 3 required supervision or touching assistance when transferring to the shower. The MDS indicated Resident 3 required setup assistance (helper sets up only) from nursing staff with showering, eating and personal hygiene. B. Resident 4 was a 61-year-old male admitted to the facility on 4/09/2025 with diagnoses including schizophrenia (a mental disorder that is characterized by disturbances in thought), major depressive disorder, insomnia (difficulty sleeping), and anxiety (emotion characterized by feelings of tension, worried thoughts). A review of Resident 4's MDS, dated 11/27/2025, indicated Resident 4 had the ability to express ideas and wants. The MDS indicated Resident 4 had the ability to understand others. The MDS indicated Resident 4 required setup or clean-up assistance from nursing staff with eating, showering and personal hygiene. A review of Resident 4's Care Plan titled "Living in Focus," dated 8/11/2025 indicated Resident 4 had been demonstrating psychotic behavior, verbally aggressive, intrusiveness, and inappropriate behavior toward others. The care plan interventions indicated if Resident 4 became agitated staff will intervene before the agitation escalated, guide the resident away from the source of distress, and engage the resident in a calm conversation. A review of Resident 4's Post-Event Assessment Form dated 12/29/2025, indicated at approximately 5:30 p.m. Residents 3 and 4 were seated next to each other in the living room. Resident 3 blew his nose, prompting Resident 4 to express discomfort, stating, "Why did you blow your nose here in front of me?" Resident 3, who primarily communicated in a language other than English, responded in his native language. Resident 4 stood up to leave, and Resident 3 also began to rise from his seat. Resident 4 then made physical contact with Resident 3 and held him down onto the couch while verbally instructing him to "stop." Resident 4 continued to hold Resident 3 down briefly, stating, "Stop, stop. I can't let you go if you keep trying to kick or hit me." Staff immediately initiated Code Green (signal for a behavioral emergency, such as an agitated, combative, or violent resident requiring immediate intervention) and intervened to separate both residents. A review of Resident 4's Medication Administration Record (MAR), dated 12/2025, indicated on 12/29/2025 3 p.m. to 11 p.m. shift, Resident 4 had anxiety (feeling of fear, worry, or unease) manifested by (m/b) irritability, depressed mood (feeling of sadness, emptiness, or hopelessness) verbal aggression (use of words or language to threaten, insult, humiliate), labile mood (state in which a person's emotional expression changes rapidly and unpredictably), and paranoid delusions (type of false, fixed belief characterized by irrational suspicion or mistrust of others). During an interview on 12/30/2025 at 2:32 p.m., Resident 4 stated Resident 3 attacked him. Resident 4 stated he believed Resident 3 had a weapon in his bag, so when Resident 3 attempted to get up, he pushed Resident 3 back down onto the couch until staff arrived and separated them. During an interview on 12/31/2025 at 12:31 p.m., the Rehabilitation Activity leader (RAL), stated on 12/29/2025 at 5:30 p.m., Resident 4 was seated on a couch in the living room, and Resident 3 sat down next to him and blew his nose. The RAL stated Resident 4 said, "Why did you blow your nose in my face?" Resident 3 then responded in his own language. The RAL approached both residents and explained to Resident 4 that Resident 3 was simply blowing his nose. Resident 4 then stood up, and when Resident 3 attempted to stand, Resident 4 pushed him back down onto the couch. Resident 3 became upset, and both residents began pushing and shoving each other. The RAL stated she left the residents to get help and called a Code Green (response to a combative/violent resident) The RAL stated she observed Resident 4 holding onto Resident 3's arm while the Director of Nursing (DON) and Rehabilitation Therapist (RHT) 1 repeatedly instructed Resident 4 to let go. Resident 3 eventually stood up, and Resident 4 walked out of the room to the dining area while Resident 3 remained in the living room. The RAL she stated she asked Resident 3 how he was feeling, and he replied that he was okay. The RAL stated the group meeting was then closed, and both residents were placed on 15-minute monitoring. During an interview on 12/31/2025 at 1:00 p.m., RHT 1 stated he heard yelling and commotion coming from the living room. When he arrived, he observed the RAL attempting to separate Resident 4 and Resident 3. RHT 1 stated Resident 4 was standing over Resident 3, who was seated on a couch. RHT 1 stated Resident 4 stood up, and when Resident 3 attempted to stand, Resident 4 struck Resident 3 on the head. Both residents then began hitting each other. Resident 4 held Resident 3's arms down while Resident 3 held onto Resident 4's arms and kicked in an attempt to get up. Resident 4 stated he did not want to release Resident 3's arms because he believed Resident 3 would kick or hit him if he did. Staff instructed both residents to let go of each other. Resident 4 released Resident 3's arms first, followed by Resident 3 releasing Resident 4's arms. RHT 1 stated he then escorted Resident 4 to his room, and a Code Green was called. RHT 1 stated Resident 4 has a history of becoming aggressive toward other residents by yelling and threatening to hit them. During an interview on 12/31/2025 at 1:19 p.m. the Director of Nursing (DON), stated this incident between Resident 4 and Resident 3 was abused as Resident 4 pushed down Resident 3 and Resident 3 was hitting Resident 4. A review of the facility's policy and procedure (P&P), titled "Abuse Prevention and Reporting," undated, the P&P indicated "The facility is committed to protecting the physical and emotional well-being and personal possessions of every resident...Any form of mistreatment of residents including but not limited to abuse, neglect, exploitation, involuntary seclusion, misappropriation of property or any crime are strictly prohibited...All allegations as mentioned shall be investigated. Reports will be made in a timely manner based on State statutes." The facility failed to follow its undated P&P, titled "Abuse Prevention and Reporting," which indicated it will protect residents from any form of abuse, by not ensuring: 1. Resident 4 did not push Resident 3 and Resident 3 did not strike Resident 4. As a result, Resident 4 pushed Resident 3 who was trying to get up from the couch and placed other residents at risk for abuse. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.