Health inspection·October 24, 2025

F600 Federal Code Regulations §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. California Code of Regulations, Section 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. California Code of Regulations, Section 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. California Code of Regulations, Section 72527. Patient 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 9/9/2025, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a Facility Reported Incident regarding resident abuse. As a result of the investigation, the CDPH determined the facility failed to protect the resident’s right to be free from physical abuse for Resident 1 when on 9/2/2025, Registered Nurse 1 (RN 1) threw a cup of juice on Resident 1’s face. This failure resulted in Resident 1 being subjected to physical abuse by RN 1 while under the care of the facility. Resident 1 cried and did not answer how Resident 1 felt when RN 1 threw juice on Resident 1’s face. A review of Resident 1’s Admission Record indicated the facility admitted Resident 1, a 53-year-old male on 3/3/2025 with diagnoses including intellectual disability, schizoaffective disorder-bipolar type and unspecified anxiety disorder. A review of Resident 1’s untitled Care Plan (CP) initiated on 3/4/2025 indicated Resident 1 had the potential to be physically aggressive related to schizoaffective disorder, intellectual disabilities and poor impulse control. The CP interventions indicated for staff to provide physical and verbal cues to alleviate anxiety. A review of Resident 1’s untitled CP initiated on 3/4/2025 indicated Resident 1 had impaired cognitive function related to developmentally delay and schizoaffective disorder. The CP interventions indicated for staff to provide Resident 1 with necessary cues, to stop and return to Resident 1 if Resident 1 was agitated. A review of Resident 1’s untitled CP revised 4/6/2025 indicated Resident 1 had a behavioral problem. The CP intervention indicated for staff to provide positive interaction and attention, stop and talk with Resident 1 when passing by Resident 1’s room, explain all procedures to Resident 1 before starting, and allow Resident 1 to adjust to changes. A review of Resident 1’s untitled CP revised 4/9/2025 indicated Resident 1 had behavioral symptoms manifested by resistance to care. The CP interventions indicated for staff to approach Resident 1 in a calm manner. A review of Resident 1’s Minimum Data Set (MDS) dated 6/9/2025 indicated Resident 1 had severely impaired cognition. The MDS indicated Resident 1 had a history of verbal behaviors that included threatening, screaming, and/or cursing toward others. The MDS indicated Resident 1 had lower extremity impairment and required substantial/maximal assistance with toileting hygiene, showering/bathing, lower extremity dressing, putting on and taking off footwear, and personal hygiene. During an observation and concurrent interview with Resident 1 in Resident 1’s room on 9/9/2025 at 1:21 p.m., Resident 1 was lying in bed and did not respond to questions regarding the altercation between Resident 1 and RN 1. Resident 1 was crying intermittently. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 9/9/25 at 2:17 p.m., LVN 1 stated Resident 1 displayed anger at times, but those behaviors fluctuated. LVN 1 stated Resident 1’s aggressive behavior was intervened by staff by attempting to respond to Resident 1’s needs, administering prescribed medications, or by talking with Resident 1 calmly. LVN 1 stated if the above interventions were not effective, staff would give Resident 1 time alone and return to Resident 1 at a later time. LVN 1 stated Resident 1 was only aggressive verbally and was not physically. During an interview on 9/9/25 at 3:31 p.m. and review of a text message sent to RN 2 from RN 1, RN 2 stated the text message was dated 9/8/2025 at 10:53 p.m. RN 2 stated RN 2 did not see the text message from RN 1 until 9/9/2025 while driving to work. RN 2 stated RN 2 contacted the Administrator (ADM) and reported the text message from RN 1. The text message read as follows, “I actually got mad when (Resident 1) threw juice to my face that I went back to the cart to pour more juice and threw it back at (Resident 1).” During an interview with Certified Nursing Assistant 2 (CNA 2) on 9/9/2025 at 4:31 p.m., CNA 2 stated Resident 1 was agitated in the morning of 9/2/2025 (unable to give exact time), threw Resident 1’s medication on the floor and threw juice on CNA 2 and RN 1. CNA 2 stated CNA 2 picked up the cup and returned it to RN 1, then RN 1 returned to the medication cart for another cup of juice, returned to Resident 1’s room, and threw the juice in Resident 1’s face and chest. Resident 1 was yelling and screaming profanities, then RN 1 left the room. During a phone interview with RN 1 on 9/9/2025 at 4:43 p.m., RN 1 stated (on 9/2/2025, unable to recall the time) Resident 1 was cursing when Resident 1 saw RN 1 outside Resident 1’s room so RN 1 decided to give medications to another resident and returned to Resident 1 later. RN 1 stated Resident 1 continued cursing when RN 1 gave Resident 1 juice to take Resident 1’s medications. RN 1 stated Resident 1 threw the juice at RN 1’s face and on RN 1’s clothes, then slapped the medications from RN 1’s hand. RN 1 stated, since the therapeutic medication was not working for Resident 1, RN 1 thought “mirroring” Resident 1’s behavior would discourage Resident 1 from repeating the behavior. RN 1 stated RN 1 realized that throwing the cup of juice on Resident 1 was not allowed. During an interview with the Assistant Vice President for Operations (AVPOP) on 9/10/2025 at 11:30 am, the AVPOP stated what happened to Resident 1 was a “horrible experience” and RN 1 should not have thrown juice at Resident 1. The AVPOP stated Resident 1 should not have experienced abuse from RN 1. A review of the facility’s undated policy titled, “Abuse Prevention/Prohibition Policy, (APP)” indicated abuse is defined as the willful inflictions of injury, involuntary seclusions, physical, or chemical restraint not required to treat the residents’ symptoms, intimidation or punishment with resulting physical harm, pain, or mental anguish. The APP policy indicated understanding behaviors and symptoms of residents that may increase the risk of abuse and neglect can assist staff how to respond; these symptoms, include but are not limited to aggressive and/or catastrophic reactions of residents, and outbursts or yelling out. A review of the facility’s policy titled, “Resident Rights Policy (RRP)” dated 2/2021 indicated employees shall treat all residents with kindness, respect, and dignity. The RRP indicated federal and state laws guarantee certain basic rights to all residents of the facility and these rights included the resident’s right to: c) be free from abuse, neglect, misappropriation of property, and exploitation. The facility failed to protect the resident’s right to be free from physical abuse for Resident 1 when on 9/2/2025, RN 1 threw a cup of juice on Resident 1’s face. This failure resulted in Resident 1 being subjected to physical abuse by RN 1 while under the care of the facility. Resident 1 cried and did not answer how Resident 1 felt when RN 1 threw juice on Resident 1’s face. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.