Health inspection·March 25, 2026

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. §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion CCR§ 72523(a) 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. CCR§ 72311 - Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. During an annual recertification survey conducted from 02/09/2026 to 02/12/2026, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) while onsite and initiated an onsite investigation into Resident 44’s reported allegation of abuse. The facility failed to: Protect the resident’s right to be free from physical abuse when Resident 96 pushed Resident 44 on 2/11/2026 at 5:45 a.m. inside their shared room, causing Resident 44 to fall to the ground. As a result of this failure, Resident 44 sustained a traumatic skin tear measuring 1 centimeter (cm, unit of measure of length) long by x 0.1 cm wide on the right eyebrow, requiring an emergency visit to a General Acute Care Hospital (GACH) for treatment and management.  A review of Resident 96’s Admission record indicated the facility admitted Resident 96, a 77-year-old female, on 8/21/2025 with diagnoses including dementia, anxiety (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one’s daily activities), restlessness, and agitation.   A review of Resident 96’s care plan titled, “Ineffective coping as evidenced by episodes of anger or hostility towards other residents,” initiated on 10/1/2025, indicated the care plan goals for Resident 96 included, resident needs to be met until the next assessment. The care plan intervention was to respect resident’s preferences. A review of Resident 96’s COC assessment form dated 2/11/2026 and timed at 7:19 a.m., indicated on 2/11/2026 at 5:45 a.m., Resident 96 stated she pushed her roommate (Resident 44) for being in her closet. A review of Resident 44’s Admission record indicated the facility admitted Resident 44, a 74-year-old- female, on 12/20/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), depression (constant feelings of sadness, and  irritability that lasts more than two weeks) and Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities).  A review of Residents 44’s Minimum Data ([MDS)], a resident assessment tool), dated 12/26/2025, indicated Resident 44’s cognition (ability to make decisions of daily living) was severely impaired. The MDS indicated Resident 44 needed partial/moderate assistance with personal hygiene, putting on/taking off footwear, lower body dressing, shower, toileting, and oral hygiene.   A review of Resident 44’s Change of Condition (COC- a sudden clinically important deviation from a patient’s baseline in physical, cognitive, behavioral, or functional condition) assessment form, dated 2/11/2026 and timed 5:45 a.m., indicated Resident 44 had a cut on the right side of her forehead. The COC assessment form indicated on 2/11/2026 5:45 a.m., Resident 44 was found on the floor, bleeding from a cut on right side of her forehead. The COC assessment form indicated unknown staff applied pressure to Resident 44’s cut to minimize bleeding. The COC assessment form indicated Resident 44 was transferred to GACH emergency department. A review of Resident 44’s “Licensed Nursing Note,” dated on 2:05 p.m. indicated that Resident 44 came back from GACH, was assessed by treatment nurse and noted right eyebrow skin tear with discoloration measuring 1 cm long by x 0.1 cm wide. A review of Resident 44’s GACH Emergency Documentation (ED) titled “ED physician notes” dated 2/11/2026 timed at 6:23 a.m. indicated “complaint of head pain with laceration to frontal head and left knee pain after assaulted by another resident.” The ED notes indicated that Resident 44 laceration to right eyebrow was closed using dermabond (surgical glue). Resident 44 was discharge with diagnosis of assault (physical attack) and facial laceration. During an observation on 2/9/2026 at 9:25 a.m., Resident 44 was walking in the hallway and using paper towels to clean the handrails adjacent to Resident 44 and Resident 96’s shared room. During an observation on 2/9/2026 at 9:27 a.m., Resident 96 was lying in bed with bilateral (both) side rails up. The door of the closet in Resident 96’s room was slightly ajar. During a concurrent observation and interview on 2/10/2026 at 12:54 p.m., with Certified Nurse Assistance (CNA) 1, CNA 1 stated that the closets in the room were not locked because the locks did not work. CNA 1 stated that the closets in the residents’ rooms must remained locked at all times. CNA 1 stated they would notify the maintenance department about the broken lock. During an interview on 2/11/2026 at 10:13 a.m., with CNA 2, CNA 2 stated that Resident 44 often wandered into other residents’ rooms and attempted to clean. CNA 2 stated that it was important to keep closets locked to prevent residents from accessing each other’s belongings. CNA 2 stated that Resident 96 always wanted her closet locked at all times. During an interview on 2/11/2026 at 10:31 a.m., with Resident 96, Resident 96 stated earlier that morning (prior to the altercation with Resident 44), there was urine on the floor in their room. Resident 96 stated facility staff (unknown) instructed her (Resident 96) to return to bed. Resident 96 stated the urine was still on the floor. Resident 96 stated she went to bed, but later around 3 a.m., Resident 44 got out of bed and began cleaning inside their shared room and looking at things inside her (Resident 96’s) unlocked closet. Resident 96 stated Resident 44 searched through her (Resident 96)’s closet and was speaking in Spanish. Resident 96 stated she did not understand Spanish. Resident 96 stated she observed Resident 44 going through her belongings in her closet. Resident 96 stated she got out of bed and pushed Resident 44 away from the closet (Resident 96’s closet), but Resident 44 attempted to continue to look through the closet again. Resident 96 stated she pushed Resident 44 a second time, causing Resident 44 to fall to the floor. Resident 96 stated that staff (unknown) were aware of Resident 44’s behavior and that both residents had been arguing since early morning (over the liquid on the floor, which Resident 96 assumed as Resident 44’s urine). During a concurrent interview and record review of Resident 44’s care plan report and active physician orders for 2/2026, on 2/11/2026 at 12:14 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated that Resident 44 likes to clean and fix things in her and other residents’ rooms. LVN 4 stated that staff had consistently observed Resident 44’s behavior of cleaning and fixing things in other residents’ room, since Resident 44 was admitted. LVN 4 stated facility staff did not monitor this behavior and there was no care plan for this behavior. LVN 4 stated the facility did not consider Resident 44’s behavior of going into other residents’ rooms cleaning and fixing things as a problem behavior. LVN 4 stated that Resident 44’s care plan should have included monitoring this behavior of cleaning and fixing other resident’s belongings. LVN 4 stated staff should have been monitoring Residents 44 behavior and potentially prevented the altercation with Resident 96 on 2/11/2026 at 5:45 a.m. During an interview on 2/11/2026 at 3:56 p.m. with Social Worker (SW) 1, SW 1 stated that all the closets must be locked because residents in this unit are confused and can grab belongings from other residents since the residents wandering into other’s rooms. SW 1 stated that CNAs are aware that all the closets must be locked to prevent items from going missing. SW stated that the altercation between Resident 44 and Resident 96 could have been avoided if the closet in Resident 96’s room was locked. During an observation on 2/11/2026 at 4:08 p.m. in Resident 44’s room, the resident was lying in bed with bilateral side rails up. Three of three closet doors were open, and accessible to all residents. During an interview on 2/12/2026 at 7:13 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that approximately around 3 a.m. (on 2/11/2026), Resident 44 and Resident 96 were yelling at each other over water on the floor, which Resident 96 mistook for urine from Resident 44. LVN 2 stated a CNA (not identified) and herself cleaned the floor and reassured Resident 96 that it was water. LVN 2 stated she put Resident 44 back to bed and did not notice whether the closet was unlocked. LVN 2 stated that she left Resident 44 and Resident 96 in the same room. During a subsequent interview on 2/12/2026 at 7:15 a.m., with LVN 2, LVN 2 stated at approximately around 5 a.m. (on 2/11/2026) while she was standing near the shared room of Resident 44 and Resident 96, LVN 2 heard a loud noise, turned around and found Resident 44 on the floor bleeding from her (Resident 44) head. LVN 2 stated she separated Resident 44 and Resident 96. LVN 2 stated Resident 96’s closet remaining open was a major factor in the altercation. LVN 2 stated Resident 96 pushed Resident 44, because Resident 44 went into her closet. LVN 2 stated it was preventable if Resident 96’s closet would have been closed and locked. During an interview on 2/12/2026 at 10:45 a.m. with the Assistant Director of Nursing (ADON), the ADON stated that residents must be free from physical abuse because they are frail and rely on staff for safety. The ADON explained that closet locks should always be used, especially in secured units (exit and entrance to the unit are managed by facility staff), since residents wander and open closets. During interview on 2/12/2026 at 1:48 p.m. with the Administrator(Admin), the Admin stated that Resident 44 and Resident 96 should have been separated when the first altercation occurred regarding the water on the floor (on 2/11/2026). Admin stated that it could have been prevented since there is already a verbal altercation prior before the physical altercation about the closet. Admin stated that this would be intentional for Resident 96 since it was triggered with the water droppings on the floor prior to the closet incident. A record review of the facility’s policy and procedure (P&P) titled, “Abuse & Mistreatment of Residents,” revised on 5/3/2023, indicated “involved resident(s) shall be removed from the environment that threatens residents' health or safety....if the suspect is another resident the residents shall be separated to avoid any further contact.” A record review of the facility’s policy and procedures (P&P) P&P titled, “Abuse & Mistreatment of Residents,” revised on 5/3/2023, indicated “resident with possible needs and potential for behavioral symptoms and manifestation that may lead to conflict, and anger shall be identified through comprehensive assessment, initially upon resident admission and continually thereafter.” A record review of the facility’s P&P titled, “Secured Unit” revised (unknown date) indicated “may keep resident closets locked unless resident/responsible party prefers otherwise.” The facility failed to: Protect the resident’s right to be free from physical abuse when Resident 96 pushed Resident 44 on 2/11/2026 at 5:45 a.m. inside their shared room, causing Resident 44 to fall to the ground. As a result of this failure, Resident 44 sustained a traumatic skin tear measuring 1 centimeter (cm, unit of measure of length) long by x 0.1 cm wide on the right eyebrow, requiring an emergency visit to a General Acute Care Hospital (GACH) for treatment and management.  This violation presented a direct or immediate relationship to the health, safety, security, or welfare of Resident 44 and Resident 96.