Health inspection·August 22, 2025

CFR §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- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. CCR§ 72311. Nursing Service - General. (a) Each facility shall employ sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. On 7/9/2025, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) regarding an allegation of abuse. On 7/10/2025, CDPH conducted an unannounced visit at the Facility to investigate the FRI. Upon investigation, CDPH determined the facility failed to: 1. Protect Resident 1 from Certified Cursing Assistant (CNA) 1’s neglect when CNA 1 was not responding to Resident 1’s call light to change his soiled adult brief making Resident 1 call the nursing station to look for CNA 1. 2. Protect Resident 1 from CNA 1’s verbal abuse by telling Resident 1 that he was “rude” for calling the nursing station looking for her to get her to come to change his soiled adult brief on 7/8/2025. 3. Protect Resident 2 from CNA 1’s neglect when on 7/3/2025 CNA 1 responded to the resident’s call light by rudely and loudly stating she was ‘busy’ and the resident had to wait for her to come back and change his soiled adult briefs. Resident 2 had to wait for CNA 1 to return from 9 a.m. to 11 a.m. 4. Implement the facility policy and procedure (P/P) titled “Abuse Prohibition Policy and Procedure” dated 2/23/2021, which indicated the facility prohibited abuse, mistreatment, and neglect. 5. Implement the facility P/P titled “Answering the Call Light” dated 10/24/2025, which indicated facility staff were to answer the call system request for assistance, identify themselves, and politely respond to the resident. The P/P indicated facility staff were to inform the residents how long it would take staff to respond to the request and if the staff was unable to fulfill the request, ask the nurse supervisor for assistance. As a result of these deficient practices Resident 1 felt “upset” and Resident 2 felt “bad,” like a “burden”, and “upset” due to the neglect and verbal abuse from CNA 1. Resident 1 and Resident 2 requested CNA 1 not to be assigned to them anymore. A review of Resident 1’s Admission Record, indicated Resident 1, a 72-year-old man, was admitted to the facility on 6/8/2018 with diagnoses including left side hemiplegia (unable to move one side of the body), contractures of multiple sites, and major depressive disorder. A review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool) dated 6/18/2025, indicated Resident 1 was cognitively intact. The MDS indicated Resident 1 was dependent on staff for toileting, getting dressed, showering, rolling left to right, and personal hygiene. A review of Resident 2’s Admission Record indicated Resident 2 was admitted to the facility on 2/3/2024 with diagnoses including cervical spine (uppermost segment of the spine that's located in the neck) injury, lack of coordination, and neuromuscular dysfunction of bladder (refers to what happens when an injury or disease interrupts the electrical signals between your nervous system and bladder function). A review of Resident 2’s MDS dated 5/28/2025, indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 used a wheelchair for mobility. The MDS indicated Resident 2 was dependent on staff for showering and lower body dressing. The MDS indicated Resident 2 required substantial/ maximum assistance for toileting, oral hygiene, upper body dressing, and to move from lying to sitting. The MDS indicated Resident 2 required partial/ moderate assistance to transfer from the bed to the chair. A review of CNA 1’s Employee Corrective Action notice dated 6/5/2025, indicated CNA 1 performed unsatisfactory customer service and failed to follow instructions when CNA 1 was observed standing right across two resident rooms (unknown) that had call lights on and did not answer the call s for either room. A review of the facility’s Nursing Assignment for the 7 a.m.- 3 p.m., Shift dated 7/3/2025, indicated CNA 1 was assigned to Resident 2. A review of the facility’s Nursing Assignment 7a.m.- 3 p.m. shift, dated 7/8/2025, CNA 1 was assigned to Resident 1. A review of Resident 1’s Complaint/ Grievance Report filed on 7/8/2025 indicated Resident 1 complained CNA 1 had “poor customer service” and he did not want CNA 1 assigned to him anymore. A review of Resident 2’s Complaint/ Grievance Report filed 7/8/2025, indicated Resident 2 complained CNA 1 had “poor customer service” and Resident 2 stated he had to wait “awhile” to get changed. During an interview on 7/10/2025 at 2:01 p.m., CNA 2 stated she felt as though CNA 1 was just coming to work to collect a paycheck and it did not seem as though she wanted to be at work. CNA 2 stated a few days prior (7/8/2025), Resident 1 complained about CNA 1’s “attitude.” During an interview on 7/10/2025 at 3:23 p.m., Resident 1 stated CNA 1 was mean, always seemed angry, and made it seem as though she did not want to be at work. Resident 1 stated on 7/8/2025 (time unspecified) he needed help getting changed because his adult incontinence brief was wet and CNA 1 did not respond when he pressed his call light button. Resident 1 stated he called the nurses station with his cell phone because CNA 1 was not answering his call light, and the staff at the nurse’s station paged CNA 1 to go to his (Resident 1’s) room. Resident 1 stated CNA 1 then came into his room and in a loud voice told him he (Resident 1) was “rude” for calling the nurses’ station asking for her and then CNA 1 stated in a loud voice, “why did you press the call light button, what do you want?” Resident 1 stated the interaction with CNA 1 made him upset because he needed help from CNA 1, she was angry he pressed the call light button. Resident 1 stated he felt CNA 1 did not want to do her job and performed the care hurriedly. Resident 1 stated every time CNA 1 responded to the call light for his roommate (Resident 3) or himself, CNA 1 was loud, and Resident 1 did not like how CNA 1 spoke to himself or Resident 3. Resident 1 stated his roommate had trouble communicating and every time CNA 1 answered Resident 3’s call light she seemed angry towards Resident 3. Resident 1 stated CNA 1’s behavior towards Resident 3 was “the last straw” for him, so he reported CNA 1 to the Director of Staff Development (DSD) on the same day. During an interview on 7/11/2025 at 9:35 a.m., Resident 2 stated on 7/3/2025, CNA 1 was assigned to him. Resident 2 stated his daily routine was to get changed and up in his wheelchair at 9 a.m. so he could participate in physical therapy. Resident 2 stated on 7/3/2025 he pressed the call light button at 9 a.m., because he was wet and wanted to be changed and to get up in the wheelchair. Resident 2 stated CNA 1 came into his room, turned off the call light and stated she was busy and would be back. Resident 2 stated CNA 1 did not come back until 11 a.m. to change him (two hours later) and when she came back CNA 1 looked angry and performed the care hurriedly. Resident 2 stated he was upset because the last time he was changed that morning was at 6 a.m. Resident 2 stated having to wait for CNA 1 for two hours in wet briefs and missing physical therapy made him feel bad. Resident 2 stated he felt like a “burden” that he was not able to perform the care himself and had to depend on other people to take care of his needs. Resident 2 stated that incident with CNA 1 “threw off” his whole day. Resident 2 stated he asked the facility not to assign CNA 1 to him anymore because she seems angry, upset about something, and does not want to be at work. During an interview on 7/11/2025 at 9:51 a.m., CNA 3 stated she works the 7 a.m. to 3 p.m. shift with CNA 1 and sometimes they buddy up to deliver care to residents. CNA 3 stated she felt as though CNA 1’s “tone was off” when speaking to residents. CNA 3 stated, on 7/3/2025 around 2 p.m., Resident 2 pressed the call light button and asked CNA 3 to inform CNA 1 he (Resident 2) needed to be changed. CNA 3 stated she witnessed CNA 1 responding to Resident 1 by saying, “I will be right there!” CNA 3 stated CNA 2’s tone of voice towards Resident 2 made her (CNA 3) feel bad. CNA 3 stated when CNA 1 was ready to change Resident 2, CNA 1 told Resident 2, “okay I am ready to change you now!” but Resident 2 was “shut down” and refused CNA 1’s care. CNA 3 stated Resident 2 even started “faking like he was sleeping” so he did not have to talk to CNA 1 anymore. CNA 3 stated she felt bad for Resident 2 because this was out of character for him. CNA 3 stated she waited in Resident 2’s room for CNA 1 to leave and asked Resident 2 if he was okay and the resident responded he was “upset” and did not want to be changed anymore. During an interview on 7/11/2025 at 10:32 a.m., the Social Services Director (SSD) stated the facility received two grievances about CNA 1 (from Resident 1 and Resident 2) on 7/8/2025 and then they received a separate complaint from their Compliance Hotline on 7/9/2025 from an anonymous caller that identified CNA 1 as mistreating their family member. CNA 1 was suspended on 7/9/2025 pending investigation. During an interview on 7/11/2025 at 10:53 a.m., the Director of Nursing (DON) stated insulting or mocking a resident could be considered verbal abuse, and not addressing the resident’s needs would be considered as neglect. The DON stated that any resident having to wait for two hours with wet/soiled incontinence briefs was too long and CNA 1 should have asked for help with her workload if she needed it so Resident 2 did not have to wait so long. The DON stated the potential outcome of a resident waiting for two hours for care included a urinary tract infection, skin issues such as maceration (skin becomes soft and fragile due to prolonged soaking), the risk of falls (due to resident trying to get up unassisted to get out of wet/soiled briefs), and psychosocial harm because residents could feel unimportant. The DON stated the facility was the resident’s home and they should be treated with dignity and respect. The DON stated talking to residents in a loud manner had the potential to affect residents’ dignity negatively and they should not be talked to in that way. The DON stated the residents in the facility were dependent on staff for daily care, so she felt bad if residents were being treated this way (waiting for help for extended periods and talking to them in a loud manner). The DON stated they did not tolerate abuse or neglect by facility employees. During an interview on 7/11/2025 at 12:19 p.m., the DSD denied knowing the extent of the allegations from Resident 1 and Resident 2 and stated she was only aware of CNA 1’s “bad customer service issue,” and not being friendly, and being rude. The DSD stated there was no reason staff should talk to patients “out of line” and staff needed to ensure they were providing all necessary care for the residents. The DSD stated she expected her staff to be professional and treat their residents with dignity and respect. The DSD stated there was potential for residents to feel discouraged by staff if they were not talked to appropriately. During a review of the facility’s policy and procedure (P/P) titled “Abuse Prohibition Policy and Procedure” dated 2/23/2021, the P/P indicated the facility prohibited abuse, mistreatment, and neglect. Instances of abuse of all patients, irrespective of any mental or physical condition, cause harm, pain, or mental anguish and included verbal abuse. Neglect was defined as the failure of the facility and its employees to provide goods and services to a patent that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The P/P indicated the facility was to identify, correct, and intervene in situations in which abuse, or neglect was more likely to occur. During a review of the facility’s P/P titled “Answering the Call Light” dated 10/24/2025, the P/P indicated facility staff were to answer the call system request for assistance, identify themselves, and politely respond to the resident. The P/P indicated facility staff were to inform the residents how long it would take staff to respond to the request and if the staff was unable to fulfill the request, ask the nurse supervisor for assistance. The facility failed to: 1. Protect Resident 1 from Certified Cursing Assistant (CNA) 1’s neglect when CNA 1 was not responding to Resident 1’s call light to change his soiled adult brief making Resident 1 call the nursing station to look for CNA 1. 2. Protect Resident 1 from CNA 1’s verbal abuse by telling Resident 1 that he was “rude” for calling the nursing station looking for her to get her to come to change his soiled adult brief on 7/8/2025. 3. Protect Resident 2 from CNA 1’s neglect when on 7/3/2025 CNA 1 responded to the resident’s call light by rudely and loudly stating she was ‘busy’ and the resident had to wait for her to come back and change his soiled adult briefs. Resident 2 had to wait for CNA 1 to return from 9 a.m. to 11 a.m. 4. Implement the facility P/P titled “Abuse Prohibition Policy and Procedure” dated 2/23/2021, which indicated the facility prohibited abuse, mistreatment, and neglect. 5. Implement the facility P/P titled “Answering the Call Light” dated 10/24/2025, which indicated facility staff were to answer the call system request for assistance, identify themselves, and politely respond to the resident. The P/P indicated facility staff were to inform the residents how long it would take staff to respond to the request and if the staff was unable to fulfill the request, ask the nurse supervisor for assistance. As a result of these deficient practices Resident 1 felt “upset” and Resident 2 felt “bad,” like a “burden”, and “upset” due to the neglect and verbal abuse from CNA 1. Resident 1 and Resident 2 requested CNA 1 not to be assigned to them anymore. These violations presented a direct or immediate relationship to the health, safety, security, or welfare of the residents.