Health inspection·March 25, 2026

42CFR§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. 22CCR § 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. 22CCR § 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. On 1/26/2026, the California Department of Public Health (CDPH) received a facility reported incident regarding abuse between Residents 1 and 2. On 2/6/2026 CDPH conducted an unannounced abbreviated survey at the facility. The facility failed to: 1. Ensure Resident 1 did not kick Resident 2 out of the bed and onto the floor on 1/26/2026 at 2:15 p.m., so that Resident 2 remained free from abuse from Resident 1. 2. Ensure Resident 1 did not throw a pitcher of water and Resident 2's urinal containing urine on Resident 2, on 1/26/2026 at 2:15 p.m. 3. Implement the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation", indicating residents had a right to be free of physical abuse. These deficient practices resulted in Resident 1 physically kicking Resident 2 out of Resident 2's bed and soaking Resident 2 in water and urine. On 1/26/2026 at 4:55 p.m. Resident 2 was transferred to a General Acute Care Hospital (GACH) for further evaluation where he was diagnosed with a left maxillofacial (jaw and the face) contusion (bruise). Resident 2, a 74-year-old male, was admitted on 9/24/2025, with diagnoses including encephalopathy (broad term for any disease, damage, or malfunction of the brain), heart failure (heart cannot pump enough blood to the body), dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) mood disorder (mental health conditions involving long-term, extreme disturbances in emotional state, such as intense sadness or high energy elevated periods of emotional highs), and anxiety (mental health condition characterized by pervasive worry and fear) disorder. A review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 1/2/2026, indicated Resident 2 had severe cognitive (thought process) impairment. Resident 2 needed supervision when eating, partial assistance (helper does less than half the effort to complete the task) with oral hygiene, substantial assistance (helper does more than half the effort to complete the task) with personal hygiene, showering, and toileting hygiene. A review of Certified Nurse Assistant (CNA) 1's signed statement, undated, indicated (on 1/26/2026 at 2:15 p.m.) Resident 1 was standing on the left side of Resident 2's bed while Resident 2 was lying on the bed. Resident 1 kicked Resident 2 on the left side and Resident 2 rolled and fell off the right side of the bed. CNA 1 attempted to intervene between Resident 1 and Resident 2, and Resident 1 pushed CNA 1 away from him. CNA 1 called for help. Resident 1 then reached for and threw a water pitcher containing water. The water pitcher and the water landed on Resident 2's face. Resident 1 then grabbed and threw a urinal, filled with urine on Resident 2's chest. A review of Resident 2's Progress Notes dated 1/26/2026 at 2:15 p.m., indicated Resident 2 was hit by another resident (Resident 1). Resident 2 presented with slight swelling on the left temporal (side of the head) area and redness on the left shin (front of the leg below the knee), right knee, and chest area. On 1/26/2026 at 4:55 p.m., an ambulance transported Resident 2 to a GACH for further evaluation. A review of Resident 2's Emergency Department (ED) Notes, Final Report, dated 1/26/2026 at 10 p.m., indicated on 1/26/2026 at 2:30 p.m., Resident 2 was brought in by ambulance secondary to acute traumatic left facial tenderness this afternoon from a physical altercation with another resident. Computerized Tomography scan ([CT] type of imaging to create detailed images of the body) of the brain without contrast (special dye to highlight specific tissues) and CT of facial bones without contrast revealed Resident 2 sustained a left maxillofacial contusion. Resident 1, a 40-year-old male, was admitted to the facility on 3/1/2025, with diagnoses including encephalopathy, schizoaffective disorder, and anxiety disorder. A review of Resident 1's MDS, dated 12/30/2025 indicated Resident 1 had severe cognitive impairment. Resident 1 needed set-up assistance for activities of daily living (ADL) such as eating, oral hygiene, and personal hygiene. During an interview on 2/6/2026 at 11:40 a.m., Resident 1 stated he (Resident 1) kicked Resident 2 because Resident 2 "stunk"; Resident 1 stated he (Resident 1) then threw a water pitcher and a container of urine at Resident 2. During an interview on 2/6/2026 at 12:20 p.m., CNA 1 stated on 1/26/2026 at about 2:15 p.m., Resident 1 was standing on the left side of Resident 2's bed when Resident 1 kicked Resident 2 on the left side while Resident 2 was lying down. Resident 2 fell off the bed to the right side and landed on the floor mat. CNA 1 attempted to intervene but Resident 1 pushed her (CNA 1) away, and CNA 1 called for help. Resident 1 threw a water pitcher, and the water pitcher and the water landed on Resident 2's face. Resident 1 also threw a urinal at Resident 2, and urine landed on Resident 2's chest. During an interview on 2/6/2026 at 12:43 p.m., Licensed Vocational Nurse (LVN ) 2, stated Resident 2 was a victim of physical abuse when Resident 1 kicked him, threw a water pitcher containing water and a urinal with urine on Resident 2. On 1/26/2026, she (LVN 1) heard CNA 1 calling for help and by the time LVN 2 was in the room Resident 2 was on all fours on the fall mattress on the floor. LVN 2 stated Resident 1 was pacing in the room very agitated saying, "I beat him up. I beat him up." There were fluids (water and urine) on the floor and on Resident 2. During an interview on 2/9/2026 at 1:23 p.m., the Director of Nursing (DON), stated residents have the right to be free from abuse. Resident 1 physically abused Resident 2. Facility staff should have physically separated Resident 2 from Resident 1 when Resident 1 first kicked Resident 2. Resident 2 should not have been able to kick Resident 2, throw a water pitcher and urine on Resident 1. A review of the facility's P&P titled, "Abuse, Neglect, Exploitation", undated, indicated residents had the right to be free from physical abuse. The P&P indicated the facility will make efforts to protect all residents after alleged abuse by responding to the needs of the resident and protect them from further incidents. The P&P indicated to prevent residents' abuse, the facility will train staff in appropriate interventions to deal with aggressive and/or catastrophic reactions by residents. The facility failed to: 1. Ensure Resident 1 did not kick Resident 2 out of the bed and onto the floor on 1/26/2026 at 2:15 p.m. so that Resident 2 remained free from abuse from Resident 1. 2. Ensure Resident 1 did not throw a pitcher of water and Resident 2's urinal containing urine on Resident 2, on 1/26/2026 at 2:15 p.m. 3. Implement the facility's P&P titled, "Abuse, Neglect, Exploitation", indicating residents had a right to be free of physical abuse. These deficient practices resulted in Resident 1 physically kicking Resident 2 out of Resident 2's bed and soaking Resident 2 in water and urine. On 1/26/2026 at 4:55 p.m. Resident 2 was transferred to a GACH for further evaluation where he was diagnosed with a left maxillofacial contusion. These violations had a direct or immediate relationship to the health, safety, or security of Resident 2.