Health inspection·December 4, 2025

Code of Federal Regulations, Title 42, Section 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. California Code of Regulations, Title 22, Section 72311. Nursing Service – General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, 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, Title 22, 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 10/22/2025 at 9:30 am, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to investigate a Facility Reported Incident (FRI) regarding resident-to-resident physical abuse. The facility failed to protect Resident 1’s right to be free from physical abuse (any intentional act causing injury or trauma to another person) as indicated in the facility’s Policy and Procedure (P&P) titled, “Resident-to-Resident Altercations,” and Resident 2’s Care Plan (CP) intervention to observe Resident 2 closely. As a result, on 10/21/2025, Resident 2 pushed Resident 1 during an altercation and Resident 1 fell to the floor. Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 10/21/2025 for treatment of Resident 1’s laceration to the back of the head and to evaluate Resident 1’s complaint of right elbow pain. Resident 1’s laceration to the back of the head was repaired with one staple and Resident 1 sustained a fracture of the right elbow. a. A review of the facility’s “Midnight Census Report (MCR),” dated 10/20/2025, indicated Residents 1 and Resident 2 were roommates in the same room while at the facility. A review of Resident 1's Admission Record (AR) indicated Resident 1, a 78-year-old female, was admitted to the facility on 8/21/2024 with diagnoses which included type 2 diabetes mellitus, Alzheimer’s disease, and anxiety disorder. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/18/2025, indicated Resident 1 had moderately impaired cognitive skills. The MDS indicated Resident 1 required partial/moderate assistance from staff for toileting, personal hygiene, and dressing. A review of Resident 1’s Change in Condition Evaluation (CIC), dated 10/21/2025, indicated, “Resident (Resident 1) with roommate (Resident 2) argued in their room…when CNA (Certified Nursing Assistant 4) and charge nurse (Licensed Vocational Nurse 1) heard the sound and came to check immediately. Resident (Resident 1) [fell] on floor due to roommate (Resident 2) pushing (Resident 1). (Resident 1) got a small cut on back of head and with…minimal bleeding… (Resident 1) also reported (Resident 1’s) left elbow and left thigh hurting.” The CIC indicated Resident 1’s physician ordered for Resident 1 to be transferred to GACH 1. A review of Resident 1’s GACH 1 Emergency Department (ED) Note Physician (ED Note), dated 10/21/2025, indicated Resident 1 presented to GACH 1 ED on 10/21/2025 with a laceration to the back of the head. The ED Note indicated Resident 1 was pushed by Resident 1’s roommate, fell, and hit the back of Resident 1’s head. The ED Note indicated Resident 1 complained of right elbow and right hip pain. The ED Note indicated Resident 1’s laceration to the head was repaired with one staple (specialized staples that are used instead of sutures to mend skin wounds). The ED Note indicated Resident 1 was placed in a right long-arm splint (a medical device used to immobilize and support the arm after an injury) and was given a sling (a supportive device used to immobilize and protect an injured arm or shoulder). A review of Resident 1’s Diagnostic Radiology (DR) report, dated 10/21/2025, indicated Resident 1’s right elbow was x-rayed due to pain and status post assault with blunt trauma. The DR indicated Resident 1 had a fracture at the back of the right elbow. b. A review of Resident 2's AR indicated Resident 2, a 90-year-old female, was admitted to the facility on 8/26/2025 with diagnoses which included dementia, encephalopathy, and anxiety disorder. A review of Resident 2's MDS, dated 1/30/2024, indicated Resident 2 had severely impaired cognitive skills. The MDS indicated Resident 2 required partial/moderate assistance from staff for toileting, personal hygiene, lower body dressing, and bathing. A review of Resident 2's untitled Care Plan Report (CPR), indicated the facility initiated a care plan on 9/2/2025 with the focus being, “The resident is/has potential to be physically aggressive r/t (related to) throwing items on the floor,” and “The resident is/has potential to be verbally aggressive r/t screaming/yelling at staff.” The care plan indicated an intervention was to closely observe Resident 2. A review of Resident 2’s CIC, dated 10/21/2025, indicated on 10/21/2025 “Resident (Resident 2) with roommate (Resident 1) argued in their room… (CNA 4) and charge nurse (LVN 1) came to check immediately, resident (Resident 2) pushed roommate (Resident 1) out of the room on the ground.” During an interview on 10/22/2025, at 10:30 AM with Resident 2, Resident 2 stated Resident 1 would always open Resident 1’s privacy curtain. Resident 2 stated Resident 1 was taking Resident 2’s clothes out of the closet. Resident 2 stated Resident 1 was trying to take Resident 2’s blanket from Resident 2 so Resident 2 pushed Resident 1. Resident 2 stated Resident 1 also pushed Resident 2 and Resident 1 fell. During an interview on 10/22/2025, at 3:30 PM with CNA 4, CNA 4 stated that at around 8:30 PM on 10/21/2025, CNA 4 heard what sounded like arguing coming from the direction of Resident 1 and Resident 2’s room. CNA 4 stated CNA 4 was heading toward the room when CNA 4 saw Resident 1 falling backward out of Resident 1’s room. CNA 4 stated Resident 1 fell backward and hit Resident 1’s head on the floor. CNA 4 stated CNA 4 saw blood on the back of Resident 1’s head. CNA 4 stated Resident 2 informed CNA 4 that Resident 2 had pushed Resident 1 because Resident 1 was trying to push Resident 2. During an interview on 10/23/2025, at 10:20 AM with CNA 5, CNA 5 stated Resident 2 had a behavior of “losing (Resident 2’s) temper.” CNA 5 stated Resident 2 would get mad at residents (in general) when they walked past Resident 2 in the hallway. CNA 5 stated Resident 2 would also yell angrily at residents (in general) who were sitting in chairs when Resident 2 walked past the residents. CNA 5 stated Resident 2 would argue with other residents (in general). A review of the facility’s P&P titled, “Resident-to-Resident Altercations,” revised September 2022, indicated, “Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to the staff…Behaviors that may provoke a reaction by residents or others include: a. verbally aggressive behavior. such as screaming, cursing, bossing around/demanding, insulting race or ethnic group, intimidating; b. physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects; … d. taking, touching, or rummaging through others property, and e. Wandering into others rooms/space.” The facility failed to protect Resident 1’s right to be free from physical abuse as indicated in the facility’s P&P titled, “Resident-to-Resident Altercations,” and Resident 2’s Care Plan (CP) intervention to observe Resident 2 closely. As a result, on 10/21/2025, Resident 2 pushed Resident 1 during an altercation and Resident 1 fell to the floor. Resident 1 was transferred to GACH 1 on 10/21/2025 for treatment of Resident 1’s laceration to the back of the head and to evaluate Resident 1’s complaint of right elbow pain. Resident 1’s laceration to the back of the head was repaired with one staple and Resident 1 sustained a fracture of the right elbow. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.