Health inspection·September 3, 2025

A citation. 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. California Code Regulations, Title 22, Section 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. California Code of Regulations, Title 22, Section 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: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (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. 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, Title 22, 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. On 8/1/25, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate one Facility Reported Incident regarding abuse. The Department determined the facility failed to provide one to one supervision (a designated staff to provide constant monitoring to prevent or redirect residents from engaging in harmful acts) for one of three sampled residents (Resident 2, with known behavioral issues), to prevent the physical altercation between Resident 1 and Resident 2 on 6/7/25. This failure resulted in Resident 2 suffering multiple bruises and a laceration to the right side of his face and Resident 1 suffering two fractures in his left hand. Review of Resident 1's "ADMISSION RECORD" indicated that Resident 1 was admitted to the facility with diagnoses that included but were not limited to unspecified mental disorder to known physiologic condition (a clear link between a physical condition and the mental symptoms, but the exact nature of the mental disorder is not clear), unspecified other stimulant abuse (continued use of amphetamine-type substances, cocaine, and other stimulants that can impact health), and cognitive communication deficit. Review of Resident 1's "...Change in Condition Evaluation," dated 6/7/25, indicated that Resident 1 was involved in a resident-to-resident physical altercation and indicated the following, "...AFTER THE RESIDENT WAS PUNCHED IN THE FACE, HE PROCEEDED TO GET UP FROM HIS WHEELCHAIR AND PUNCH ANOTHER RESIDENT X 5 ON THEIR FACE...RESIDENT HAD SWELLING TO HIS R [Right] EYE AND SWELLING TO HIS LEFT KNUCKLES..." Review of Resident 1's "Interdisciplinary [IDT - a group of professionals from various disciplines who work together to provide comprehensive care to a patient or group of patients] Care Conference Note...," dated 6/8/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a test used to get a snapshot of how well you are functioning cognitively at the moment the test is taken; with a range of scores from 0-15, higher scores represent higher cognitive function) score of 12, indicating Resident 1 had mildly impaired cognitive function. Review of Resident 2's "ADMISSION RECORD" indicated that Resident 2 was admitted to the facility with diagnoses that included but were not limited to cerebral infarction (a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it), hemiplegia and hemiparesis following a cerebral infarction on the left, non-dominant side (paralysis and weakness of left side of the body after stroke), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), unspecified psychosis not due to a substance or known physiological condition (condition with symptoms that involves a disconnection from reality and the world, but does not fit into established categories of mental health disorders), and anxiety disorder. Review of Resident 2's "...Change in Condition Evaluation," dated 6/7/25, indicated that Resident 2 was involved in a resident-to-resident physical altercation and indicated the following, "...STAFF WITNESSED SEEING THE RESIDENT GETTING PUNCHED X 5 ON THE FACE BY ANOTHER RESIDENT...RESIDENT HAD IMMEDIATE SWELLING AND CONTUSION [bruise]..." Review of Resident 2's "Interdisciplinary Care Conference...," note completed on 6/8/25, indicated that Resident 2 had a BIMS score of 13, indicating that Resident 2 was cognitively intact. During a concurrent observation and interview on 8/1/25, at 9:55 a.m., Certified Nursing Assistant (CNA) 1 was noted to be sitting outside of Resident 2's bedroom within visual sight of Resident 2, who was asleep in his bed. CNA 1 stated she was providing one-to-one supervision for Resident 2. CNA 1 stated that Resident 2 was receiving one-to-one supervision on all shifts due to Resident 2's history of physical and verbal aggressive behaviors with other residents. CNA 1 stated the risk of not having Resident 2 on one-to-one supervision, was that Resident 2 could become aggressive with another resident and there would be no one closely monitoring him to step in and redirect Resident 2 before the altercation escalated. CNA 1 stated that her role in providing Resident 2 with one-to-one supervision was to monitor and ensure she watched Resident 2, "to make sure he didn't start a fight with anyone." During an interview with Resident 2 on 8/1/25, at 11:15 a.m., Resident 2 was sitting on the right side of his bed. Resident 2 was noted to have a small area of discoloration under his right eye. Resident 2 stated that the eye was still tender and painful at times. Resident 2 stated that he was in the hallway when Resident 1 came up to him and asked him for a cigarette. Resident 2 stated that when he told Resident 1 that he did not have any cigarettes, Resident 1 said to him "f... y..." so Resident 2 said he said the same thing back to Resident 1. Resident 2 stated that when he did that, Resident 1 stood up and hit him. Resident 2 stated he then hit Resident 1 back but could not remember where he hit him. Resident 2 stated that Resident 1 then started to hit him repeatedly, causing a right black eye. Resident 2 stated that Resident 1 was a bad man, and he was glad Resident 1 was no longer in the facility. During a phone interview on 8/1/25, at 11:48 a.m., Licensed Nurse (LN) 1 stated that on 6/7/25 at approximately 11 p.m. she heard a loud commotion in the hallway while she was at the center nurse's station. LN 1 stated that she heard what sounded like a "POW" and when she came out from behind the station, she saw Resident 1 and Resident 2 in front of each other and yelling at each other. LN 1 stated that she and two other LNs ran towards the two residents and separated them upon arrival. LN 1 stated that Resident 2 had an obvious injury to his face as his right eye started to swell and was red and there was blood on his face. LN 1 stated she did not see any injury to Resident 1. LN 1 stated that Resident 1 was not on any specific monitoring prior to the altercation but was placed on one-to-one supervision after the altercation. LN 1 stated that Resident 2 was on one-to-one supervision but only on the morning and evening shifts due to his history of being verbally and physically aggressive with other residents, but that level of supervision was not in place on the night shift. LN 1 stated that the altercation might not have happened had Resident 2 been receiving one-to-one supervision on the night shift. During a phone interview on 8/1/25, at 12:04 p.m., LN 2 stated that she heard yelling and screaming while she was at the facility's north nurses' station. LN 2 stated she and two other LNs started running to the area. LN 2 stated while enroute to the altercation, she could see Resident 1 standing over Resident 2, who was in his wheelchair, and Resident 1 was punching Resident 2. LN 2 stated that when they arrived at the scene Resident 1 was still hitting Resident 2. LN 2 stated that one of the other LNs got in between the two residents and LN 2 pulled Resident 2 back from Resident 1. LN 2 stated Resident 2 had swelling to his right eye, redness around the orbital area (eye socket) and blood coming from a cut over his eye, while Resident 1 had a red face and knuckles but no indication of bleeding anywhere. LN 2 stated that Resident 2 did have a history of becoming physically and verbally aggressive with other residents. LN 2 stated Resident 2 had been receiving one-to-one supervision on the morning and evening shifts but not the night shift. LN 2 stated that the altercation might not have happened had Resident 2 been receiving one-to-one supervision on the night shift. During a phone interview on 8/1/25, at 12:39 p.m., LN 3 stated that the altercation between Resident 1 and Resident 2 occurred on 6/7/25 around 11 p.m. LN 3 stated she did not see the event or respond to the event but was the receiving nurse for Resident 1 when one of the other LNs brought him back to his primary nurses' station. LN 3 stated that Resident 1 stated that "the guy swung at me, so I swung back." LN 3 stated that Resident 1 had no bruise or cuts on his face, but there was redness to his knuckles. LN 3 stated that Resident 1 had no history of aggressive behaviors prior to this altercation, but Resident 2 did have a history of physical and verbal aggression towards other residents. LN 3 stated that Resident 1 and Resident 2 were placed on one-to-one supervision after the altercation. During a concurrent interview and record review with the Administrator (ADM) on 8/1/25, at 10:48 a.m., the ADM stated that the Director of Nurses notified her of the altercation between Resident 1 and Resident 2. A review of Resident 1's radiology report (a medical document that describes the results of an imaging test), dated 6/8/25, the ADM confirmed that Resident 1 sustained "... a fracture involving the 5th metacarpal [finger] and 5th proximal phalanx [the bone at the base of the little finger] distally with minimal callus [a temporary formation of new bone and cartilage that develops at the fracture site during initial stages of healing] and displacement. There is associated soft tissue swelling..." The ADM stated that Resident 2 had a history of physical and verbal aggressive behaviors towards other residents and had been placed on one-to-one supervisor on the morning and evening shifts because of those behaviors. The ADM stated that Resident 2 had not received one-to-one supervision on the night shift prior to the 6/7/25 event. The ADM stated that the altercation might have been avoided had Resident 2 been receiving one-to-one supervision on the night shift prior to 6/7/25. Review of Resident 2's "Care Plan Report," with a last care plan review completed date of 7/15/25, indicated Resident 2 had resident to resident altercation on the following dates: 1/24/25; 1/29/25; 2/26/25; 3/5/25; 3/10/25; 3/19/25; 3/24/25; 4/17/25; 4/23/25; 5/9/25; and 6/7/25. Review of a facility policy titled, "Safety of Residents," dated 6/27/22, indicated, "...maintain one-on-one supervision of the resident until the behavior has subsided..." Review of a facility policy titled, "Resident Rights," revised 12/21, indicated, "...Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to...be free from abuse..." Review of a facility policy titled, "Abuse Prohibition - Administrative Policies," revised 10/25/24, indicated, "Health Care Center prohibits abuse...for all residents...Physical abuse includes hitting, slapping, pinching, kicking, etc....Identifying, correcting and intervening in situation in which abuse...is more likely to occur...The Center will provide adequate supervision when the risk of resident-to-resident altercation is suspected. The Center is responsible for identify residents who have a history...or who exhibit other behaviors that make them more likely to be involved in an altercation..." Therefore, the Department determined the facility failed to provide one to one supervision to Resident 2, with known behavioral issues, to prevent the physical altercation between Resident 1 and Resident 2 on 6/7/25. This failure resulted in Resident 2 suffering multiple bruises and a laceration to the right side of his face and Resident 1 suffering two fractures in his left hand. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents and results in an A citation.