Health inspection·October 20, 2025

The following reflects the findings of the California Department of Public Health during the investigation of: Facility Reported incident (FRI) CA002611303. Representing the Department, HFEN 51452 and HFEN 51374. These findings occurred during a visit to the facility on 11.3.25 conducted for the purpose of correcting a citation. 22 CCR § 72523. Nursing Service-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. 22 CCR § 72311. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. On 9/24/25, the facility was issued a citation related to the facility's failure to protect the other residents in the Behavioral Health Unit (BHU) from Resident 1. The facility's Plan of Correction (POC) included the following: 1. On 9/12/25, the Director of Nursing (DON) or designee initiated daily audits, Monday through Friday, of all residents receiving psychotropic medications (drugs that affect mood, behavior and mental processes) to ensure behavior monitoring is resident-specific, IM (intramuscular - administered into a muscle) medications are administered within the prescribed time frame, and documentation and care plan revisions are complete. 2. Upon Resident 1's return to the facility from inpatient psychiatric facility, Resident 1 will be reassessed by the interdisciplinary team (IDT - a group of professionals from different fields who collaborate to address patient need), and appropriate behavioral and supervision interventions will be determined and implemented at that time. On 11/3/25 at 9 A.M., a visit to the facility was conducted for the purpose of correcting a citation. The facility failed to correct the citation when: 1. The facility did not provide proof of psychotropic medication review for Resident 2. 2. The facility did not provide proof of daily audit for the behavior monitoring of all residents on psychotropic medications. 3. The facility did not provide clear evidence that the IDT reviewed Resident 1's plan of care upon return from the hospital according to their POC. On 11/3/25 at 10:20 A.M., an interview and record review with the Mental Health Case Manager (MHCM) and the DON were conducted. The MHCM reviewed the Credible Allegation Binder and acknowledged that Resident 2's psychotropic medication review was missing. The MHCM stated Resident 2's review was missed because she longer lived in the BHU. The MHCM acknowledged that the facility's POC indicated, "all residents receiving psychotropic medications". The MHCM stated the review was done for the BHU residents only and missed the other residents in the non-BHU unit of the facility. On 11/3/25 at 4:32 P.M., an interview was conducted with the Director of Clinical Services (DCS), the Clinical Consultant (CC), the DON, and the Administrator. The DCS reviewed the binder for the facility's psychotropic medication review and verified that Resident 2's review was not included in the binder. The CC stated that Resident 2's psychotropic medication review was not in the binder because the resident moved out of BHU and now lived in another unit of the facility. The CC was reminded that their POC statement indicated the daily audit was initiated for "all residents receiving psychotic medications." When the DCS was asked about the facility's audit tool for the psychotropic medication review, she stated that a report was generated from Point Click Care (PCC - a computer program) daily. The DCS stated that report was used for the psychotropic medication review audit and shredded after. The DCS stated they do not retain the audit result, therefore no proof of the audits performed existed. When asked about the POC statement regarding Resident 1 being assessed by the facility's IDT upon return from the hospital, the CC stated that the behavioral health assessment was IDT-driven and occurred at the time of admission, along with collaboration with the physician. The CC pointed to Resident 1's clinical document written on 10/22/25 titled Skilled Nursing - Behavioral Health Eval - V2 and indicated the IDT documentation was incorporated in the evaluation form. The evaluation form indicated "...9. IDT art the facility decided to continue 1:1 supervision and no roommate during her readjustment period. IDT will monitor progress and re-assess stability and care needs throughout her stay...." However, the facility was not able to provide documented evidence of the IDT meeting that occurred at the time of Resident 1's re-admission. A review of the facility's policy titled Interdisciplinary Process revised March 2022, indicated, "...4. The designated staff members responsible for coordination shall ... ensure documentation of meeting discussions and follow-up actions. 5. The IDT meets: ... b.) Upon resident ... readmission...." On 11/3/25 at 17:22, the administrator was informed of the facility's failure to correct the citation. The administrator stated that the deficiencies will be corrected on 11/6/25. The following reflects the findings of the California Department of Public Health during the investigation of: Facility Reported incident (FRI) CA002611303. Representing the Department, HFEN 51452 and HFES 39111. State Citation B was written. 42 C.F.R. § 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) (1): The facility must-Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; 42 C.F.R. § 483.40 Behavioral health services. Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. 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 § 72523. Nursing Service-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. 22 CCR § 72311. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. On 9/10/25 at 9:09 A.M., an onsite visit was conducted to investigate an allegation of physical abuse that occurred on 9/5/25 between Resident 1 and Resident 2. It was determined the facility failed to ensure: Eighty-two residents on the behavioral health unit (BHU, an area of the building that housed residents with mental and psychosocial disorders [syndromes characterized by a clinically significant disturbance in an individual's cognition, emotion, regulation, or behavior]) were protected from physical abuse when: 1) Resident 1 stopped taking her Zyprexa (an antipsychotic medication [medication that helps to reduce the symptoms of psychosis, such as hallucinations, delusions, and disorganized thinking]) on 8/25/25 and a written plan of care was not developed to monitor and prevent potential inappropriate and aggressive behaviors resulting from stopping Zyprexa. 2) Resident 1 slapped Resident 2 in the face on 9/5/25 and a written plan of care was not developed timely to prevent further incidents of abuse. 3) Resident 1 made threatening gestures and threw her lunch tray at her roommate (Resident 3) on 9/9/25 while unsupervised. 4) Resident 1 continued to have escalating physically aggressive and threatening behaviors on 9/7 and 9/9/25 and interventions to closely supervise the resident and prevent further behavioral escalations were not developed and implemented. 5) Facility policies titled: Abuse and Neglect -Clinical Protocol; Resident -to- Resident Altercations; Unmanageable Residents; Behavioral Assessment, Intervention and Monitoring; Behavioral Health Services; and Care Plans, and Comprehensive Person-Centered were not implemented. As a result: Resident 2 and Resident 3 expressed fear of Resident 1 and stated they did not feel safe. Furthermore, these failures to provide adequate supervision to Resident 1 while she experienced escalating behaviors and demonstrated impulsive physical aggression posed a risk to the safety and well-being of the other 82 residents on the BHU. A review of the facility's Census dated 9/10/25 indicated, there were 83 residents in the BHU. A review of Resident 1's Admission Record dated 9/10/25, indicated the resident was admitted to the facility on 2/9/24 with diagnosis that included schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder), bipolar type (a chronic mental health condition characterized by extreme mood swings between manic and depressive episodes). A review of Resident 2's Admission Record dated 9/10/25, indicated the resident was admitted to the facility on 8/27/24 with diagnosis that included paranoid schizophrenia (a subtype of schizophrenia characterized by persistent delusions and hallucinations, primarily of a persecutory or threatening nature). A review of Resident 3's Admission Record dated 9/11/25, indicated the resident was admitted to the facility on 4/24/24 with diagnosis that included paranoid schizophrenia and schizoaffective disorder, bipolar type. A review of Resident 1's physician orders indicated the resident was to receive: Zyprexa 20 mg (milligrams) by mouth at bedtime (order dated 2/21/25). Zyprexa 10 mg by mouth twice a day, give intramuscular (IM) injection if resident refused oral dose (order dated 8/28/25). Zyprexa 10 mg to be given IM every 24 hours if resident refuses oral dose (order dated 8/28/25). Zyprexa 10 mg to be given IM every 12 hours if resident refuses oral dose (order dated 9/2/25). A review of Resident 1's Medication Administration Record (MAR) for August and September 2025 for Zyprexa indicated: 8/1 through 8/24/25 the resident took her Zyprexa as ordered. 8/25/25 the resident refused her Zyprexa. 8/26/25 the resident refused her Zyprexa. 8/27/25 the resident refused her Zyprexa. 8/28/25 the resident refused her Zyprexa. 8/29 through 9/11/25 the resident took some Zyprexa on and off but did not consistently take the full ordered dosage in a 24-hour period. A review of Resident 1's MAR for May, June, and July 2025 indicated the resident was monitored for behavioral manifestations. Resident 1 was monitored for "abrupt change in mood (anger outbursts)," "constant refusal of care," and "auditory hallucinations (voices telling to hurt herself)." Resident 1 had zero incidents of behavioral manifestations in May, June, July, and August 1 through 27 2025. A review of Resident 1's August and September 2025 MAR indicated the following behavioral manifestations on: 8/28/25 Four incidents of constant screaming/yelling profanities at others and two incidents of refusing care. 8/29/25 Four incidents of constant screaming/yelling profanities at others, three incidents of anger outbursts, and five incidents of refusing care. 8/30/25 Two incidents of screaming/yelling profanities and one incident of anger outbursts. 8/31/25 Three incidents of screaming/yelling profanities and two incidents of anger outbursts. 9/1/25 Two incidents of screaming/yelling profanities and two incidents of anger outbursts. 9/2/25 One incident of screaming/yelling profanities and one incident of anger outbursts. 9/3/25 Three incidents of screaming/yelling profanities and three incidents of anger outbursts. 9/4/25 Five incidents of screaming/yelling profanities, six incidents of anger outbursts, and five incidents of refusing care. 9/5/25 Thirteen incidents of screaming/yelling profanities, twelve incidents of anger outbursts, seven incidents of refusing care, and seven incidents of auditory hallucinations. 9/6/25 Two incidents of screaming/yelling profanities and four incidents of anger outbursts. 9/7/25 Nine incidents of screaming/yelling profanities and nine incidents of anger outbursts. 9/8/25 Two incidents of screaming/yelling profanities and four incidents of anger outbursts. 9/9/25 Three incidents of screaming/yelling profanities and two incidents of anger outbursts. 9/10/25 Seven incidents of screaming/yelling profanities, seven incidents of anger outbursts, and six incidents of refusing care. 9/11/25 Five incidents of screaming/yelling profanities, five incidents of anger outbursts, two incidents of refusing care, and three incidents of combative features striking at others. A review of Resident 1's clinical record indicated the resident did not have a written Plan of Care to address her refusal to take Zyprexa as ordered and interventions that were put in place to monitor and address potential behavioral manifestations resulting from not taking her Zyprexa. A review of Resident 1's Progress Notes indicated: On 8/25/25 at 8:14 A.M., "Resident is refusing her medications...." On 8/28/25 at 9:57 A.M., (Change of condition note) "... [Resident 1] refusing all medications and exhibiting manic behavior, yelling at other residents...." On 9/1/25 at 9:16 P.M., "Resident noted with increased agitation, yelling and hitting staff, refused her psychotropic medication, Zyprexa, despite of explanation [sic] of risks and benefits...." On 9/5/25 at 9:15 P.M., Resident 1 "unprovokingly" slapped Resident 2 in the face. Resident 1 denied her action to Resident 2. "[Resident 1] has been frequently refusing scheduled PO [oral] medications despite education on risks and benefits." On 9/6/25 at 7:19 A.M., "... [Resident 1] has calmed down and has stopped harassing patients...." On 9/6/25 at 9:57 P.M., Resident refused all medications, remained "hostile" throughout the shift. On 9/7/25 at 10:43 P.M., Resident 1 struck Certified Nursing Assistant (CNA) 2 with her walker when Resident 1 was by the nurses' station and CNA 2 was trying to exit the nurses' station. Resident 1 was still trying to hit CNA 2 when another employee tried to intervene, putting herself between the two. On 9/8/25 at 2:12 A.M., Resident 1 continued to be aggressive, by throwing cups, yelling, and screaming and had episodes of paranoia (a mental health condition characterized by intense and irrational distrust and suspicion of others, despite a lack of evidence to support these beliefs). On 9/11/25 at 3:11 A.M., "[Resident 1] observed with episodes of provoking the MHW [Mental Health Worker], yellin