Health inspection·June 25, 2025

State Citation B was written Code of Federal Regulations, Title 42, Section §483.12 483.12(a)(1) Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by anyone. Cal. Code Regs. Tit. 22, § 72527 - Patients' 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. Cal. Code Regs. § 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. Cal. Code Regs. Tit. 22, § 72311. Nursing Service--General. (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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. Cal. Code Regs. Tit. 22, § 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. On 4/14/25, at 11:05 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a Facility Reported Incident regarding a resident-to-resident altercation. The department determined the facility failed to consistently implement Resident 1's one-to-one care intervention (1:1, involves a nurse or caregiver providing support specifically to one individual) to prevent Resident 1 from striking the left side of Resident 2's face on 3/10/25. This failure removed Resident 2's right to be free from abuse and had the potential to result in psychosocial outcomes. During an interview on 4/14/25, at 1:14 p.m., Certified Nurse Assistant (CNA) 1 stated, Resident 1 had been on one-to-one care. CNA 1 further stated Resident 1 had anger issues and Resident 1 used to fight with other residents before being placed on one-to-one care. CNA 1 stated Resident 1 tried to hit other residents in the past. During an interview and concurrent record review on 5/22/25, at 1:49 p.m., the Assistant Director of Nursing (ADON) confirmed Resident 1 was placed on one-to-one care from 3/5/25 to 5/9/25. The ADON stated Resident 1 was on one-to-one care to provide safety to other residents and to make sure other altercations did not occur. The ADON stated during one-to-one care staff was assigned to always stay with Resident 1 and to make sure Resident 1's behavior was being managed. The ADON stated facility staff did not follow one-to-one care interventions with Resident 1 when the altercations had happened. During an interview on 5/22/25, at 4:10 p.m., the Administrator (ADM) stated the expectation was to always have staff have their eyes on Residents when one-to-one care was being done. The ADM stated staff providing one-to-one care did not keep their eyes on Resident 1 which resulted in altercations. The ADM stated, "...injury to either one of them could occur if staff providing one-to-one care is not present or keeping a visual on them..." Review of Resident 2's "IDT NOTE," dated 3/11/25, written by the Social Services Director (SSD), indicated, " ...On 3/10/2025 Activities Director witnessed this resident was involved in an altercation as the victim. It was reported that the resident and another resident (the perpetrator) were in the hallway when the perpetrator struck the victim on the left side of the face..." Review of Resident 2's "Social Service Progress Note," dated 3/11/25, written by SSD indicated, " ...Resident met with SSD following an altercation with another resident. Resident was visibly upset but denied ongoing fear or anxiety. Expressed frustration, stating, I didn't deserve that..." Review of Resident 1's "IDT NOTE," dated 3/11/25, written by the Director of Nursing (DON), indicated, " ...Resident has a history of being verbally and physical aggressive with both staff and other residents. Resident involved in multiple physical altercations with peers...during a scheduled smoke break where he physically struck out at another resident following a verbal exchange...Current Interventions in Place: 1:1 Supervision..." Review of Resident 1's "Care Plan," initiated on 3/5/25, the interventions indicated, " ...placed resident on 1:1 to closely monitor for behaviors and prevent further altercations..." During a review of a facility policy and procedure (P&P) titled "Abuse and Neglect - Clinical Protocol," revised 3/2018, the document indicated, " ...Treatment/Management...1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect...Monitoring and Follow-up...2.... basic medical, functional, and psychosocial needs are being met and that potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately..." During a review of an undated facility lesson plan titled "What is 1 to 1 Care?" indicated, "...1 to 1 care involves a nurse or carer providing support specifically to one individual...1:1 SUPERVISION...The patient must be within your line of vision and within reach at all times. The patient must not be left alone..." Therefore, the department determined the facility failed to ensure Resident 2 remained free from abuse when Resident 1, whom was on one-to-one care at the time of the incident, struck the left side of Resident 2's face on 3/10/25. This failure removed Resident 2's right to be free from abuse and had the potential to result in psychosocial outcomes. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 2.