Health inspection·November 26, 2025

F600 §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; 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 CCR § 72527 Patient’s 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: (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 10/8/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility report incident regarding a resident touching another resident inappropriately, that a visitor had witnessed on 10/7/2025. The facility failed to implement its own policies and procedures title “Resident’s Rights” when it failed to protect Resident 1 from sexual abuse (non-consensual [without the person's permission] touching of one person for the sexual gratification of another) when Resident 2 was observed on video surveillance and by a family member (Visitor 1), pushing Resident 1 down the hallway in a wheelchair and started to touch, caress and squeeze Resident 1's right and left breast while Resident 1 repeatedly pushed Resident 2's hand away on 10/7/2025 at around 12:17 PM. This deficient practice resulted in Resident 1 being sexually abused by Resident 2 while Resident 1 repeatedly pushed Resident 2’s hands away from touching her breasts. This had the potential to result in Resident 1 experiencing psychosocial effects (a person's mental, emotional, social, and spiritual health) and humiliation and placed other residents in the facility at risk for sexual abuse from Resident 2. Based on the reasonable person concept (refers to a tool to assist the survey team’s assessment of the severity level of negative, or potentially negative, psychosocial outcome [psychosocial effects] of the deficiency may have had on a reasonable person in the resident’s position), due to Resident 1’s severely impaired cognitive skills (severely impaired (never/rarely made decisions), an individual subjected to abuse may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for yourself). A review of Resident 1’s Admission Record, indicated Resident 1 is a 98- year-old- female resident who was originally admitted to the facility on 5/24/2019, and readmitted on 2/5/2025 with diagnoses that included dementia (a progressive state of decline in mental abilities), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and metabolic encephalopathy (disease affecting how brain works). A review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool), dated 8/6/2025, indicated Resident 1’s cognitive skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) with oral hygiene, toileting hygiene, shower, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) once seated in wheelchair and while wheeling herself at least 150 feet. A review of Resident 1's Change of Condition (COC, significant change in resident's status that requires intervention) assessment form dated 10/7/2024, timed 1:30 PM, indicated a family member (Visitor 1) reported to nursing staff that Visitor 1 had witnessed another resident inappropriately touching Resident 1. A review of Resident 1’s Psychiatry Progress note dated 10/7/2025, reason for consult indicated urgent for abuse allegations. The note indicated per reports from other resident’s family member (Visitor 1), Resident 2 touched Resident 1 inappropriately while Resident 1 is sitting in the wheelchair. A review of Resident 2’s Admission Record, indicated Resident 2 is a 89- year-old- male who was admitted to the facility on 4/26/2024 with diagnoses that included dementia, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing. A review of Resident 2’s MDS, dated 7/23/2025, indicated Resident 2’s cognitive skills for daily decision making were moderately impaired (decisions poor, cues/supervision required). The MDS indicated Resident 2 was independent (resident completes the activity by themselves with no assistance from a helper) with oral hygiene and personal hygiene. The MDS indicated Resident 2 required set up or clean up assistance (helper sets up or cleans up, resident completes activity) with eating, upper body dressing, lower body dressing, putting on/taking off footwear and walking at least 50 feet to 150 feet in a corridor or similar space. A review of Resident 2's COC dated 10/7/2025, timed at 1:25 PM, indicated a situation of allegedly inappropriate touching another resident (details not specified). Licensed Vocational Nurse 1 (LVN 1) documented LVN 1 was notified by Visitor 1 that Resident 2 was seen touching another resident's breast in the hallway. A review of Resident 2’s order listings for the month of October 2025, an order of one-to-one monitoring, every shift was ordered on 10/7/2025 at 5:22 PM. A review of undated Visitor 1’s documented witness statement, the witness statement indicated the following: On 10/7/2025, Tuesday, around 12:30 PM, when Visitor 1 was feeding another resident (Visitor 1’s mom), Visitor 1 was standing beside the mom’s chair, then Visitor 1 saw a guy (Resident 2) pushing an “old lady’s” (Resident 1) wheelchair, his (Resident 2) hand was on the lady’s (Resident 1) shoulder and then slid down the breast. Visitor 1’s written witness statement also indicated, “then the lady (Resident 1) was pushing away the guy’s (Resident 2) hand”. During a concurrent observation and interview with the ADM on 10/8/2025 at 1:40 PM, the facility’s video surveillance dated 10/7/2025, timed between 12:15 PM and 12:20 PM was reviewed. Video surveillance showed a recording of Resident 2 standing in the hallway where Resident 1 was passing by while the resident is in her wheelchair. The video surveillance showed Resident 2 started to walk behind and started pushing Resident 1’s wheelchair. The video surveillance showed Resident 2 caressed Resident 1’s right breast at 12:17:00 PM, and at 12:17:03 PM, Resident 1 was observed pushing off Resident 2’s right hand away from Resident 1’s right breast. The video surveillance also showed Resident 2 was caressed Resident 1’s left breast at 12:17:07 PM, and at 12:17:08 PM, Resident 1 was observed pushing off Resident 1’s left hand away from Resident 1’s left breast. The ADM verified, the female resident in the wheelchair in the video surveillance is Resident 1, and the male resident behind the wheelchair and pushing Resident 1’s wheelchair was Resident 2. The ADM also verified that the family member seen in the video surveillance from 12:17:07 to 12:17:08 was Visitor 1 who witnessed the incident between Resident 1 and 2 and reported the incident to CNA 1. During a concurrent observation in Resident 1’s room and an attempt for an interview with Resident 1 on 10/8/2025 at 1:59 PM, Resident 1 was nonverbal. When approached and asked about the incident, Resident 1 could not answer and the resident with a flat affect (a reduced or absent display of emotions in a person's facial expressions, tone of voice, and body language.  It is a symptom that can be associated with various mental health conditions). During an attempt for an interview with Resident 2 on 10/8/2025 at 2:02 PM, Resident 2 did not answer the question when asked about the incident on 10/7/2025 with Resident 1. During an interview on 10/8/2025 at 2:37 PM with SSD, SSD stated, yesterday (10/7/2025), the ADM informed SSD that CNA 1 stated Visitor 1 witnessed Resident 1’s right breast was touched in circular motion by Resident 2. During an interview on 10/8/2025 at 3:15 PM with LVN 1, LVN 1 stated, on 10/7/2025 (unable to recall time), CNA 1 reported to LVN 1 that Resident 1 was touched on the resident’s breast by Resident 2, and Resident 1 pushed it off. During a concurrent record review and interview with the DON on 10/8/2025 at 4:30 PM, facility’s video surveillance dated 10/7/2025, timed between 12:15 PM and 12:20 PM was reviewed. The DON stated the video surveillance showed that Resident 1 pushed away Resident 2’s hand when Resident 2 touched or massaged Resident 1’s right and left breast. The DON stated, this showed Resident 1 was not comfortable or does not want Resident 2 touching or massaging Resident 1’s breasts. During an interview with Visitor 1 on 10/9/2025 at 12:40 PM, Visitor 1 stated, on 10/7/2025 at approximately 12:30 PM, Visitor 1 witnessed a female (Resident 1) resident’s chest area was being touched by a male resident (Resident 2). Visitor 1 stated she witnessed the female resident (Resident 1) removed the male resident’s (Resident 2) hand from the female resident’s chest, and Visitor 1 added “So, I think she (Resident 1) did not like it.” Visitor 1 also stated it is not normal and appropriate for a male resident to touch a female’s chest area that is why Visitor 1 reported what she witnessed to CNA 1. During a concurrent record review and interview with MDSN on 10/9/2025 at 1:25 PM, facility’s video surveillance dated 10/7/2025, timed between 12:15 PM and 12:20 PM was reviewed. MDSN stated Resident 2’s action of pushing Resident 1’s wheelchair and touching and squeezing Resident 1’s breasts several times was not appropriate and normal. MDSN stated according to the video, Resident 2 was observed squeezing and trying to feel Resident 1’s private area (part of the body that is usually covered by clothing) which was Resident 1’s breast. MDSN stated this behavior is considered sexual abuse by Resident 2 to Resident 1 and can cause psychosocial effects on Resident 1. During a concurrent observation and interview with the DON on 10/10/2025 at 4:39 PM, the facility’s video surveillance dated 10/7/2025, timed between 12:15 PM and 12:20 PM was reviewed. The DON stated according to the video surveillance, Resident 2 was observed caressing Resident 1’s breast two times. The DON stated this incident is not acceptable, because there is dignity issue and invasion of privacy. The DON stated this incident is an abuse and can cause decline with Resident 1’s wellbeing and can affect Resident 1’s mood. A review of the facility’s Policy and Procedure (P&P) titled Resident Rights, revised in February 2021, indicated Federal and State laws guarantee certain basic rights to all residents of the facility and these rights include the resident’s right to be treated with respect, kindness and dignity. The P&P also indicated, resident has the right to be free from abuse. A review of the facility’s P&P titled Abuse, Neglect, Exploitation (taking advantage of a resident for personal gain) and Misappropriation Prevention Program, revised in April 2021, indicated “Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The P&P also indicated, this includes but is not limited to freedom from corporal punishment (which is physical punishment, is used as a means to correct or control behavior, includes, but is not limited to, pinching, spanking, slapping of hands, flicking, or hitting with an object), involuntary seclusion (separation of a resident from other residents or from her/his room or confinement to her/his room against the resident’s will, or the will of the resident representative), verbal, mental, and sexual or physical abuse. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.