Health inspection·January 2, 2026

Amended 1/8/2026 §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. §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. §72523. Patient Care Policies and Procedure (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 10/21/2025, the California Health Department of Public Health (CDPH) received a Facility Reported Incident (FRI) reporting a resident (Resident 1) alleged her roommate (Resident 2) attempted to drown her. On 10/22/2025 CDPH received a complaint alleging Resident 1's new roommate (Resident 2) attempted to drown her on 10/14/2025. On 10/21/2025, CDPH conducted an unannounced visit to the facility to investigate the FRI and complaint allegation. During the investigation, CDPH determined Resident 2 poured a pitcher of water on Resident 1 on 10/14/2025. The facility failed to: 1. Ensure Resident 1 was not subject to abuse when Resident 2, who had history of schizophrenia (a mental illness that is characterized by disturbances in thought), and sudden mood changes threw water on Resident 1. 2. To follow the facility's undated Policy and Procedure (P/P) titled "Abuse, Neglect and Exploitation" that indicated each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The P/P indicated a resident must not be subject to abuse by anyone, including but not limited to other residents These deficient practices resulted in Resident 1 feeling like she was drowning when Resident 2 threw water on her face which entered her mouth and throat. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 58-year-old female, was admitted to the facility on 7/13/2025 with a diagnosis of hypertensive heart disease, lack of coordination, contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the muscle of the right and, and contracture of the left ankle. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/10/2025, indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 1 had a functional limitation in range of motion ([ROM] the direction a joint can move to its full potential) to the upper [arm] and lower [leg] extremities on one side of his body and required substantial/maximal assistance (helper does more than half of the effort) with lying to sitting on side of the bed, and rolling from left to right. A review of Resident 2's Admission Record (Face Sheet) indicated Resident 2 was admitted to the facility on 9/21/2025 with a diagnosis of schizophrenia. A review of Resident 2's MDS dated 10/2/2025 indicated Resident 2's cognition was severely impaired, and Resident 2 required partial/moderate assistance from staff to complete her ADLs. During an observations and interview on 10/21/2025 at 9:04 a.m., Resident 1 stated while she was receiving ADL care (10/14/2025 time unknown) from Certified Nursing Assistant (CNA) 1, Resident 2 came over and poured water on her face, and the water went down her throat. During the interview Resident 1 was observed crying and stated she felt like she was drowning when the water was going down her throat. Resident 1 stated Resident 2 did not like her voice and had told her in the past, to "shut the f*ck up" and facility staff were present in the room when this happened. During an interview on 10/21/2025 at 9:45 a.m., Resident 3 stated she saw Resident 2 pouring water on Resident 1's face (10/14/2025). Resident 3 stated it looked like attempted murder, and it was intentional, like Resident 2 was drowning someone who could not move. Resident 3 stated the facility should have called the police, but they did not. During an interview on 10/21/2025 at 9:56 a.m., and a subsequent interview at 12:24 p.m., CNA 1 stated while providing ADL care to Resident 1 (10/14/2025, time unknown), she (CNA 1) left the room to follow up on Resident 1's treatment. CNA 1 stated when she returned to the room (time unknown) she heard Resident 1 screaming. CNA 1 stated Resident 1 informed her that Resident 2 threw water on her. CNA 1 stated Resident 1 was crying, and her upper body was soaking wet. CNA 1 stated there were times when Resident 1 feared Resident 2 because when Resident 1 watched her television, Resident 2 would get mad at Resident 1 for having the volume up. CNA 1 stated on the same day (10/14/2025), before the incident with the water pitcher occurred, she saw Resident 2 move Resident 1's bedside table to her (Resident 2) side of the room, which made Resident 1 upset and caused her to cry. CNA 1 stated she reminded Resident 2 that it was not her bedside table. During an interview on 10/21/2025 at 11:43 a.m., the Director of Nursing (DON) stated she was not aware of any incident occurring between Resident 1 and Resident 2. The DON stated if Resident 2 poured water on Resident 1, that would be considered abuse and had the potential for Resident 1 to be harmed. During a review of the facility's undated P/P titled "Abuse, Neglect and Exploitation" the P/P indicated each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The P/P indicated a resident must not be subject to abuse by anyone, including but not limited to other residents. The facility failed to: 1. Ensure Resident 1 was not subject to abuse when Resident 2, who had history of schizophrenia and sudden mood changes threw water on Resident 1. 2. To follow the facility's undated P/P titled "Abuse, Neglect and Exploitation" that indicated each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The P/P indicated a resident must not be subject to abuse by anyone, including but not limited to other residents These deficient practices resulted in Resident 1 feeling like she was drowning when Resident 2 threw water on her face which entered her mouth and throat. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security and welfare of Resident 1.