Health inspection·February 19, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of six sample residents (Resident 1) was not physically assaulted by another resident while under the facility ' s care. This deficient practice resulted in Resident 1 being assaulted by her roommate (Resident 2) when during an unprovoked attack, Resident 2 hit Resident 1 with her fist then her shoe. Resident 1 sustained a contusion (a bruise) to her left upper and lower eyelid. Resident 1 was transferred to a General Acute Care Hospital (GACH) on 2/4/2025 for evaluation and treatment where an ice pack was applied. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with unspecified dementia (loss of cognitive [thinking process] functioning, remembering, and reasoning to such an extent that it interferes with a person ' s daily life and activities) and schizophrenia (a mental illness which can affect a person ' s thoughts, mood and behavior). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/1/2024, the MDS indicated Resident 1 had severe cognitive impairment. During review of Resident 1 ' s History and Physical (H&P) dated 1/17/2025, the H&P indicated Resident 1 was alert and oriented to person only, with episodes of confusion. During a review of Resident 1 ' s Nursing Progress note dated 2/4/2025 and timed at 2:07 p.m., the Nursing Progress note indicated Resident 1 was lying in bed asleep when Certified Nursing Assistant (CNA) 1 walked by Resident 1 ' s room and saw Resident 1 ' s roommate (Resident 2) assault Resident 1. The Nursing Progress note indicated Resident 1 was noted with a bruise on her left upper and lower eyelid. During a review of Resident 1 ' s Skin assessment dated [DATE] and timed at 2:33 p.m., the Skin Assessment indicated Resident 1 had a contusion on her left upper and lower eyelid. During a review of Resident 1 ' s Physician ' s Order Summary dated 2/4/2025, the Physician ' s Order Summary indicated to transfer Resident 1 to a GACH for further evaluation. During a review of Resident 1 ' s Nursing Note dated 2/4/2025 and timed at 10:59 p.m., the Nursing Note indicated Resident 1 was transported by ambulance to the GACH on 2/4/2025 at 6:05 p.m. Page 1 of 3 056313 056313 02/19/2025 Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia, anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation) and paranoid schizophrenia (a type of mental illness where someone experiences intense beliefs that others are actively trying to harm them, often accompanied by delusions [false beliefs] and hallucinations [seeing or hearing things that aren't there], making it difficult for them to distinguish reality from their distorted perceptions). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had moderate cognitive impairment. During a review of Resident 2 ' s undated H&P, the H&P indicated Resident 2 had a fluctuating capacity to understand and make decisions. During a review of the GACH ' s Emergency Department (ED) Physician ' s note dated 2/19/2025 and timed at 12:10 p.m., the ED Physician ' s note indicated Residents 1 presented to the emergency room (ER) for head trauma secondary to being assaulted by another resident at her facility. The ED Physician ' s note indicated Resident 1 was evaluated for a minor isolated blunt head trauma and left periorbital (the area surrounding the eye socket) ecchymosis (bruising). The ED Physician ' s note indicated Resident 1 was treated with an ice pack. During a review of GACH ' s Clinical Discharge summary dated [DATE] and timed at 12:30 p.m., the Clinical Discharge Summary indicated Resident 1 had a contusion of the left orbital (eye socket) tissue and was provided with discharge instructions to apply ice on the injury for 20 minutes two to three times daily for the first one to two days. During a review of Resident 1 ' s Nursing Note dated 2/5/2025 and timed at 9:24 a.m., the Nursing Note indicated Resident 1 was readmitted to the facility from the GACH on 2/5/2025. During an interview on 2/18/2025 at 3:20 p.m., CNA 1 stated she was walking down a hallway when she saw Resident 2 sitting in a wheelchair near Resident 1, hitting Resident 1 in her face with her fist. During an interview on 2/19/2025 at 9:27 a.m., Resident 1 stated Resident 2 hit her in the face with her shoe, it was unprovoked, and she (Resident 1) had no idea why Resident 2 assaulted her, she must have been having a bad day. During an interview on 2/19/2025 at 3:14 p.m., the Director of Nursing (DON) stated the day of the incident (2/4/2025) CNA 1 called for her help. The DON stated when she entered Resident 1 ' s room she observed Resident 1 with a red mark to her left eye. The DON stated CNA 1 informed her Resident 1 was hit by Resident 2. During an interview on 2/19/2025 at 4:20 p.m., the Administrator (ADM) stated it was impossible to monitor all corners of the facility and it was the responsibility of all facility staff to ensure resident safety. During a review of the facility's Policy and Procedure (P&P) titled, Abuse, Neglect and Exploitation with no date, the P&P indicated that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by 056313 Page 2 of 3 056313 02/19/2025 Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807

F 0600 anyone including but not limited to; facility staff, other residents, consultants, contractors, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056313 Page 3 of 3