Health inspection·October 17, 2025

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 8/25/2025, the California Department of Public Health (CDPH) received a facility reported incident (FRI) regarding a staff-to-resident abuse allegation. On 9/3/2025, the CDPH conducted an unannounced visit at the facility to investigate the FRI. The facility failed to: 1. Follow its Policy and Procedure (P&P) titled “Abuse and Neglect Prohibition Policy,” which indicated the facility would identify, correct, and intervene in situations in which abuse was more likely to occur. As a result, Resident 1 was subjected to Certified Nursing Assistant (CNA) 1’s verbal abuse. a. Resident 1 was a 55-year-old male, admitted to the facility on 6/25/2021 and readmitted on 9/1/2021 with diagnoses which included cataracts, legal blindness, and major depressive disorder. A review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool), dated 6/12/2025, indicated Resident 1 had intact cognitive skills for daily decision making. The MDS indicated Resident 1 required setup assistance with eating. The MDS indicated Resident 1 required supervision with oral hygiene, toileting hygiene, showering/bathing, personal hygiene, bed-to-chair transferring, and walking. The MDS indicated Resident 1 had adequate hearing and impaired vision. A review of Resident 1’s History and Physical (H&P), dated 9/14/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1’s Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there was a change of condition among the residents) form, dated 8/25/2025 at 5:55 a.m., indicated on 8/25/2025 at 4:30 a.m., Resident 1 accused CNA 1 of violating his patient rights. The SBAR indicated Resident 1 requested CNA 1 to pull his curtain back, turn off the light, and close the door. The SBAR indicated Resident 1 stated CNA 1 left the room without doing so and called Resident 1 names which escalated into a verbal altercation. A review of Resident 1’s care plan titled “He wanted to also control who can enter his room for example CNA and LVN (licensed vocational nurse),” initiated on 3/22/2025, indicated staff were to assess and anticipate Resident 1’s needs, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, staff to walk away calmly and approach later. During an interview on 9/4/2025 at 9:51 a.m., Resident 1 stated on 8/25/2025, CNA 1 left the bathroom light on after providing care to his roommate. Resident 1 stated he walked to the hallway and asked CNA 1 to “put everything back” the way it should be in the room. Resident 1 stated CNA 1 became verbally and physically aggressive toward him. Resident 1 stated he did not remember exactly what CNA 1 said but he cursed and called the resident names. Resident 1 stated CNA 1 was coming at him like a “gang member.” Resident 1 stated Registered Nurse (RN) 1 stepped in between him and CNA 1 to stop CNA 1 from getting too close. Resident 1 stated CNA 1 was not professional and yelled at him. Resident 1 stated CNA 1 made him feel like he was in the “hood” with his aggressive behavior and intimidation. Resident 1 stated a nurse should not make him feel that way. Resident 1 stated he did not get along with CNA 1 for at least six months and did not want CNA 1 to be assigned to him. Resident 1 stated he previously informed LVN 2 and the Administrator (ADM) not to assign CNA 1 to him. Resident 1 stated continuing to have CNA 1 assigned to his care made him feel bad and as if the facility did not care about him. During a telephone interview on 9/5/2025 at 10:20 a.m., CNA 1 stated she informed RN 2 of Resident 1’s CNA assignment preferences a month prior because Resident 1 verbalized not liking CNA 1. CNA 1 stated she was assigned to Resident 1 on the evening of 8/24/2025. CNA 1 stated on 8/24/2025 at 11 p.m., she tried to honor Resident 1’s preferences and inform LVN 2 that Resident 1 did not want her as his assigned CNA and nothing was done. CNA 1 stated Resident 1 became verbally aggressive when he was assigned a nurse he did not want. CNA 1 stated on 8/25/2025, Resident 1 was screaming at her in the hallway outside his room, because Resident1 wanted CNA 1 to “put everything back” the way it should be in the room. During a telephone interview on 9/5/2025 at 11:11 a.m., RN 1 stated on 8/25/2025 around 4:30 a.m., Resident 1 was in the hallway outside his room loudly making accusations that CNA 1 disrespected his rights. RN 1 stated Resident 1 informed her that CNA 1 did not pull the curtain all the way nor close the bathroom door. RN 1 stated while in the hallway, CNA 1 said some “insulting” words to Resident 1, but RN 1 did not remember the exact words. RN 1 stated he instructed Resident 1 to return to his room and he asked CNA 1 to back off, but CNA 1 refused to back off. RN 1 stated if he was aware Resident 1 did not want CNA 1 to be assigned to him, he would not have assigned CNA 1 to Resident 1’s room at all. RN 1 stated he was made aware by Resident 1 of his care preferences after the verbal altercation with CNA 1 on 8/25/2025. RN 1 stated it would be best for the RN and staff assigned to Resident 1 to know of the resident’s care preferences to prevent allegations and incidents between the staff and resident. During an interview on 9/5/2025 at 3:50 p.m., the Director of Nursing (DON), stated it was not acceptable for any staff to yell at a resident because the resident had the right to be treated with respect. The DON stated it was not acceptable for CNA 1 to aggressively exchange words with Resident 1. The DON stated the incident was a violation of Resident 1’s rights to be free from abuse. The DON stated on 8/25/2025 around 4:30 a.m., CNA 1 should have stopped and left the scene without exchanging words with Resident 1. The DON stated the staff were expected to be professional. During a telephone interview on 9/10/2025 at 9:40 a.m., the ADM stated he expected staff to be professional and provide customer service regardless of what the residents were doing or saying. The ADM stated it was important to know Resident 1’s care preferences when making nursing assignments. The ADM stated the nursing assignment should be readjusted so the residents were not assigned staff they did not prefer. A review of the facility’s Policy and Procedure (P&P) titled “Quality of Life-Dignity,” dated 4/2018, indicated residents shall be treated with dignity and respect at all times. The P&P indicated staff shall speak respectfully to residents at all times. The P&P further indicated that demeaning practices and standards of care that compromise dignity are prohibited. A review of the facility’s P&P titled “Quality of Life- Accommodation of Needs,” dated 4/2018, indicated that the resident's individual needs and preferences shall be accommodated to the extent possible. The P&P indicated that in order to accommodate individual needs and preferences, staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. A review of the facility’s P&P titled “Abuse and Neglect Prohibition Policy,” dated 6/2022, indicated to ensure that facility staff were doing all that was within their control to prevent occurrences of abuse for all the residents. The P&P indicated that the facility should be identifying, correcting, and intervening in situations in which abuse was more likely to occur, and it included analysis of the supervision of staff to identify inappropriate behaviors. The P&P indicated that the facility should analyze the assessment, care planning, and monitoring of the residents with needs and behaviors which might lead to conflict. The P&P further indicated that “Verbal Abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend, or disability.” The facility failed to: 1. Follow its P&P titled “Abuse and Neglect Prohibition Policy,” which indicated the facility would identify, correct, and intervene in situations in which abuse was more likely to occur. As a result, Resident 1 was subjected to CNA 1’s verbal abuse. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.