Health inspection·October 23, 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. (a) The facility must— (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Code of Federal Regulations, Title 42, Section 483.12 Reporting of Alleged Violations. (b) The facility must develop and implement written policies and procedures that: (5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i)(A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (i)(B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. 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 8/28/2025, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility to investigate a complaint regarding resident-to-resident physical abuse. The facility failed to protect Resident 2’s rights to be free from physical abuse and failed to report a physical abuse incident for Resident 2 to the Department as indicated in the facility’s policy and procedure (P&P) titled, “Abuse, Neglect, Exploitation and Misappropriation Prevention Program.” As a result, on 8/23/2025, Resident 1 pushed Resident 2 and Resident 2 fell to the floor. Resident 2 was transferred to General Acute Care Hospital (GACH) 1 for an assessment and evaluation due to an unwitnessed fall. Resident 2 sustained an acute comminuted fracture of the right 5th metacarpal (the bone in the hand that connects the little finger to the wrist). The failure to report the incident to the Department had the potential to result in Resident 2 and other residents residing at the facility to be subjected to further abuse. a. A review of Resident 2’s Admission Record (AR) indicated Resident 2 was admitted to the facility on 9/6/2024 with diagnoses which included schizoaffective disorder and legal blindness. A review of Resident 2’s Minimum Data Set (MDS), dated 6/19/2025, indicated Resident 2’s cognition was severely impaired. The MDS indicated Resident 2 needed partial to moderate assistance with activities of daily living and with walking. A review of Resident 2’s Situation, Background, Assessment and Recommendation (SBAR) Communication Form, dated 8/23/2025 and timed at 12:18 pm, indicated on 8/23/2025 at 11:30 am, Resident 2 was having a verbal conversation with Resident 1 when suddenly Resident 2 fell on the floor unwitnessed. The SBAR indicated Resident 2 told staff, “He [Resident 1] pushed me, and [I] ended [on] the floor; my back is painful.” The SBAR indicated Resident 2’s pain was rated 1 out of 10 (pain scale 0 to 10, 0 means no pain and 10 means the worst possible pain felt). The form indicated Medical Doctor (MD) 1 was notified on 8/23/2025 at 12 pm, and the facility received a new order for laboratory [blood] work. A review of Resident 2’s Progress Notes (PN), dated 8/23/2025 and timed at 2 pm, indicated Resident 2 was transferred to GACH 1’s Emergency Department (ED) for an assessment due to an unwitnessed fall. A review of Resident 2’s PN, dated 8/23/2025 and timed at 11:40 pm, indicated Resident 2 returned to the facility from GACH 1 with a right-hand 5th metacarpal fracture. A review of Resident 2’s GACH 1’s right wrist X-ray results, dated 8/23/2025 and timed at 2:28 pm, indicated an acute comminuted (broken into more than two fragments) fracture of the right 5th metacarpal beginning in the distal diaphysis (the main or midsection (shaft) of a long bone) and extending to the distal epiphysis (the end of a long bone farthest from the center of the body) with suspected intra-articular extension (extending into the wrist joint). b. A review of Resident 1’s AR indicated Resident 1 was admitted to the facility on 6/8/2025 with diagnoses which included type 2 diabetes and essential hypertension. A review of Resident 1’s History and Physical (H&P) Examination, dated 6/9/2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1’s SBAR Communication Form, dated 8/23/2025, indicated Resident 1 had a disagreement with Resident 2 and Resident 1 pushed Resident 2. During an interview on 8/28/2025 at 11 am, Resident 1 stated on 8/23/2025 (could not remember the time), Resident 1 had an altercation with Resident 2. Resident 1 stated Resident 2 was sitting across the hall and Resident 1 was walking into Resident 1’s room when Resident 2 said something to Resident 1. Resident 1 told Resident 2 to “shut up and mind [Resident 2’s] own business.” Resident 1 stated Resident 2 was walking toward Resident 1 and, “I [Resident 1] pushed and dropped [Resident 2] to the ground, and [Resident 2] started yelling [Resident 1] hit me.” During an interview on 9/2/2025 at 1 pm, Licensed Vocational Nurse (LVN) 3 stated on 8/23/2025 at 11:30 am, LVN 4 yelled out Resident 2 was “on the floor.” LVN 3 stated LVN 3 ran toward LVN 4 and when LVN 3 arrived on the scene, Resident 2 was lying on Resident 2’s left side on the floor and Resident 1 was standing over Resident 2. LVN 3 stated Resident 1 told Resident 2, “That is what you get, they should have kicked you out a long time ago.” LVN 3 stated Resident 2 did not respond to Resident 1. Resident 2 turned to LVN 3 and stated, “My back and arm are hurting [pain unrated], call an ambulance because I do not feel I can get up from the floor.” LVN 3 stated Resident 2 complained of 7 out of 10 pain on Resident 2’s back and [right] arm. During an interview on 9/2/2025 at 2:33 pm, LVN 4 stated LVN 4 heard a staff (unidentified) say “Mister [Resident 2] fell.” LVN 4 stated LVN 4 rushed down the hallway and observed Resident 1 standing by Resident 1’s room yelling and laughing at Resident 2. Resident 1 stated, “That is what you get, you should not be here, yea I pushed him so what, I pushed him.” Resident 2 was lying on the floor and stated, “Help me, I can’t get up.” LVN 4 stated LVN 4 notified the Administrator (ADM) and the Director of Nursing (DON) of the incident and stated LVN 3 told LVN 4 not to fill out the abuse reporting form because the ADM and the DON told LVN 3, the ADM and the DON would fill out the form and report the incident to the Department. LVN 4 stated, LVN 4 was a mandated reporter, and abuse should be reported within 2 hours to the State Agency (the Department), the Ombudsman, and the police department. During a concurrent interview and record review on 9/3/2025 at 3:30 pm with the DON, the facility’s P&P titled, “Abuse, Neglect, Exploitation and Misappropriation Prevention Program,” dated April 2021, was reviewed. The P&P indicated residents have the right to be free from verbal, mental, or physical abuse. The P&P indicated a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse by anyone including but not necessarily limited to…other residents. The P&P indicated for staff to identify and investigate all possible incidents of abuse, and to investigate and report any allegations within timeframes required by federal requirements. The DON stated the facility did not report the incident that occurred between Resident 1 and Resident 2 on 8/23/2025 to the Department. The facility failed to protect Resident 2’s rights to be free from physical abuse and failed to report a physical abuse incident for Resident 2 to the Department as indicated in the facility’s P&P titled, “Abuse, Neglect, Exploitation and Misappropriation Prevention Program.” As a result, on 8/23/2025, Resident 1 pushed Resident 2 and Resident 2 fell to the floor. Resident 2 was transferred to GACH 1 for an assessment and evaluation due to an unwitnessed fall. Resident 2 sustained an acute comminuted fracture of the right 5th metacarpal. The failure to report the incident to the Department had the potential to result in Resident 2 and other residents residing at the facility to be subjected to further abuse. The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 2.