Health inspection·January 28, 2026

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. 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 CFR § 72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be implemented to ensure that patient related goals and facility objectives are achieved. § 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. (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. On 12/11/2025, the California Department of Public Health (CDPH) received a complaint regarding Certified Nurse Assistant's (CNA) bad conduct towards Resident 1. On 12/12/2025, the CDPH conducted an unannounced visit at the facility to investigate allegations about a CNA's bad conduct towards Resident 1. The facility failed to: 1). Investigate and report to the CDPH when CNA 1 allegedly yelled at Resident 1 on 12/11/2025 at around 2:30 a.m. 2). Implement its policy and procedure (P&P) titled, "Abuse and Neglect Prohibition (prevention) Policy," dated 6/2022, which indicated the facility must initiate an investigation within 24 hours of an allegation of abuse and report all alleged violations immediately to the Licensing and Certification Program District Office. These failures resulted in a delay of investigation by the CDPH and placed Resident 1 and other residents at risk for abuse. Resident 1 was a 55-year-old male, originally admitted to the facility on 6/25/2021 and readmitted on 9/1/2021. Resident 1's diagnoses included hypertension (high blood pressure), and legal blindness (a specific level of vision impairment defined by government standards. Visual acuity of 20/200 or less in the good eye). A review of Resident 1's History and Physical (H&P) dated 9/1/2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 9/12/2025, indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance which may be provided throughout the activity, or intermittently) for eating, upper/lower body dressing and putting off footwear. The MDS indicated Resident 1 required setup assistance (helper sets up or cleans up; resident completes activity/ helper assists only prior to or following the activity) for oral hygiene, toileting hygiene, shower/bathe self and personal hygiene. The MDS indicated Resident 1 was independent (Resident completes the activity by themself with no assistance from a helper) with rolling from left to right, for sitting to lying, lying to sitting on side of the bed, sitting to standing, for chair/bed to chair transfer, walking 10 feet, walk 50 feet with two turns and to walk 150 feet. The MDS indicated Resident 1 needed set up for toilet transfer, and tub/shower transfer. A review of Resident 1's Progress Notes dated 12/11/2025 at 3:00 a.m., indicated Resident 1 showed signs of aggression (not specified [violent behavior]) when he went to the nurses' station. The progress notes indicated Resident 1 had an argument (not specified) with Certified Nurse Assistant (CNA) 1. The progress notes indicated Resident 1, and CNA 1 used indecent (unacceptable) words (not specified) towards each other. The progress notes did not indicate an investigation was initiated regarding the argument between Resident 1 and CNA 1. During an interview on 12/12/2025 at 10:45 a.m., with Resident 1, Resident 1 stated on 12/11/2025 around 2:30 a.m., he asked Registered Nurse (RN) 1 at the nurse's station about a medical issue (unspecified). Resident 1 stated CNA 1 interrupted his conversation with RN 1 and Resident 1 told CNA 1 not to butt in (interrupt) his conversation. Resident 1 stated CNA 1 yelled at him and told him that she was going to "get some raid on his ass." Resident 1 stated CNA 1 needed to behave professionally, instead of yelling. Resident 1 stated CNA 1 talked like she was on the streets. During a phone interview on 12/12/2025 at 12:26 p.m., with RN 1, RN 1 stated Resident 1 came to the nurse's station on 12/11/2025 at around 3 a.m. and asked to switch CNA 1 with another CNA because he (Resident 1) did not like black women. RN 1 stated CNA 1 said something (not sure what was said) to Resident 1 while she (RN 1) was assisting the resident. RN 1 stated Resident 1 started to insult CNA 1 and CNA 1 started to talk loudly to the resident. RN 1 stated she reported the incident (CNA 1 talking loudly at Resident 1) to the incoming morning shift RN 2 (time not specified). RN 1 stated, at that moment, she thought reporting it to the incoming RN 2 on 12/11/2025 7am- 3pm shift was sufficient. RN 1 stated yelling at residents could be a form of abuse because the resident could feel threatened. RN 1 stated she should have reported the incident (staff yelling at resident) to the Administrator (ADM) immediately on 12/11/2025 so the incident could have been investigated. RN 1 stated not reporting the incident to the ADM delayed the facility's investigation and could have led to another verbal incident and physical confrontation. RN 1 stated she should have reported the incident (staff yelling at resident) to the Department of Health by filing the Report of Suspected Dependent Adult/Elder Abuse (SOC 341- documentation of information given by the reporting party on the suspected incident of abuse or neglect of an elder or dependent adult). During a phone interview on 12/12/2025 at 1:46 p.m., with CNA 1, CNA 1 stated on 12/11/2025 at around 2:30 a.m., she did not call Resident 1 names, disrespect nor said anything inappropriate like "spraying bug killer" to Resident 1. CNA 1 stated she only intervened when Resident 1 started to yell at RN 1 and called RN 1 a "dumb bitch." CNA 1 stated Resident 1 disliked black women. CNA 1 stated staff should not yell at a resident. During a phone interview on 12/26/2025 at 11:57 a.m., with LVN 1, LVN 1 stated he was at the nursing station when CNA 1 and Resident 1 yelled at each other. LVN 1 stated he did not report it to the ADM because the RN Supervisor (RN 1) was already aware. During a phone interview on 12/29/2025 at 11:02 a.m., with the ADM, the ADM stated the verbal altercation between CNA 1 and Resident 1 occurred on 12/11/2025 between 2:30 a.m. to 3:00 a.m. The ADM stated he was not aware of the verbal altercation between Resident 1 and CNA 1 until 12/12/2025 around 11:00 a.m. and that was the reason the facility did not start the investigation within 24 hours as per the facility's P&P. The ADM stated the delay in the investigation put Resident 1 at risk for further verbal abuse. A review of the facility's policy and procedure (P&P) titled, "Abuse and Neglect Prohibition (prevention) Policy," dated 6/2022, indicated anyone who witnessed an incident of suspected abuse should report the incident to the supervisor immediately. The P&P indicated upon receiving information concerning a report of suspected or alleged abuse, the Administrator or designee should report all alleged violations immediately and submit a written report using the California Report of Suspected Dependent Adult/ Elder Abuse Form (SOC 341) to the Licensing and Certification Program District Office. The P&P indicated the facility must initiate an investigation within 24 hours of an allegation of abuse and thoroughly document in the facility's investigation form and log. The facility failed to: 1). Investigate and report to the CDPH when CNA 1 allegedly yelled at Resident 1 on 12/11/2025 at around 2:30 a.m. 2). Implement its P&P titled, "Abuse and Neglect Prohibition Policy," dated 6/2022, which indicated the facility must initiate an investigation within 24 hours of an allegation of abuse and report all alleged violations immediately to the Licensing and Certification Program District Office. These failures resulted in a delay of investigation by the CDPH and placed Resident 1 and other residents at risk for abuse. These violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to the resident.