Health inspection·December 2, 2024

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 protect one of three sampled residents (Resident 1) from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another that results in bodily injury) and verbal abuse (harsh and insulting language directed at a person) when on 11/17/2024 at 7 a.m. Resident 2 struck Resident 1, pushed the bedside table towards Resident 1 causing him (Resident 1) to fall on the floor as he attempted to get up from the bed to move out of his (Resident 2) way, and yelling profanities (a type of language that includes dirty words and ideas) at Resident 1. This deficient practice resulted in Resident 1 sustaining injuries including abrasion (a minor injury where the top layer of your skin is scraped off, usually caused by rubbing against a rough surface) to Resident 1's left forearm (the part of the human arm between the elbow and the wrist), abrasion to Resident 1's lower back, bruise to Resident 1's right thigh, abrasions to Resident 1's left posterior (the back side of things) leg, and scattered discoloration on Resident 1's right thigh. On 11/18/2024, the facility sent Resident 2 to the General Acute Care Hospital (GACH) for psychiatric evaluation (a mental health assessment that helps diagnose and treat mental health issues). Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 11/7/2014 with diagnoses that included metabolic encephalopathy (a brain disorder that occurs when an underlying condition causes a chemical imbalance in the blood, which affects brain function), bipolar disorder (a mental health condition that causes extreme mood swings, or episodes, that can affect a person's energy, mood, and ability to function), and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/4/2024, the MDS indicated Resident 1 had the ability to understand and be understood. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) with toileting, showering, lower body dressing and putting on and taking off footwear and required partial assistance (helper does less than half the effort) with oral (mouth) hygiene, upper body dressing, and personal hygiene. During a review of Resident 1's Change in Condition (COC - a significant change in resident's health status) Evaluation, dated 11/17/2024 at 7 a.m., the COC indicated Licensed Vocational Nurse 1 (LVN 1) heard Resident 1 yelling for help and, upon entering the room, LVN 1 observed Resident 1 lying on the floor his right side. LVN 1 saw Resident 2 standing in front of Resident 1 yelling and attempting to strike Resident 1. The COC indicated Resident 1 said that Resident 2 physically assaulted him Page 1 of 4 555011 555011 12/02/2024 Vineland Post Acute 10830 Oxnard Street North Hollywood, CA 91606

F 0600 Level of Harm - Minimal harm or potential for actual harm (Resident 1) using the bedside table. The COC indicated the physician ordered to transfer Resident 1 to the GACH, however Resident 1 refused. The COC Evaluation indicated Resident 1's skin changes that included the following: 1. Abrasion of the upper mid-vertebrae (small circular bones that form the spine of a human being) Residents Affected - Few 2. Discoloration of the front right thigh 3. Scattered discoloration of the front left lower leg (front) with 2 lumps (pieces or masses of solid matter without regular shape or of no particular shape) 4. Abrasions of the rear left lower leg (Sites 1 and 2) During a review of Resident 1's Progress Notes, dated 11/17/2024 at 8 a.m., the progress notes indicated LVN 1 responded to Resident 1's call for help and observed Resident 1 on the floor in a right-side lying position near his (Resident 1) bed. The progress notes indicated LVN 1 observed Resident 2, who was near Resident 1, saying profanities and making attempts to strike at Resident 1. The progress notes indicated Resident 1 stated that Resident 2 started striking him for no reason. The progress notes indicated Resident 1 sustained the following injuries: 1. Abrasion on the left forearm. 2. Abrasion on the lower back. 3. Bruise/discoloration on the right thigh. 4. Scattered discoloration on the right thigh. 5. Abrasion on the left posterior leg (Site 1). 6. Abrasion on the left posterior leg (Site 2). During a review of Resident 1's care plan, created on 11/17/2024, titled, Victim of resident altercation, the care plan indicated interventions that included maintaining safety by keeping aggressor (a person who attacks first) away from resident and assure resident that staff members are available to help and department heads. During a review of the facility's five-day follow up report, dated 11/21/2024, the report indicated that on 11/17/2024 at 7 a.m., LVN 1 responded to Resident 1's call for help and found Resident 1 on the floor lying on his right side near his (Resident 1) bed with Resident 2 saying profanities and making attempts to strike at Resident 1. The report indicated Resident 1 stated that Resident 2 started striking him (Resident 1) for no reason and pushed the bedside table towards him (Resident 1) causing him (Resident 1) to fall as he (Resident 1) attempted to get up from bed and move out of his (Resident 2) way. The report indicated Resident 1 sustained injuries. The report indicated Resident 2 was in agitated (angry) state and continued to say profanities. The report indicated Resident 2 was not able to give an explanation as to what provoked the incident but admitted that he was physically aggressive towards Resident 1. The report indicated the physician ordered to send Resident 2 to the GACH for psychiatric evaluation. 555011 Page 2 of 4 555011 12/02/2024 Vineland Post Acute 10830 Oxnard Street North Hollywood, CA 91606

F 0600 Level of Harm - Minimal harm or potential for actual harm b. A review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 7/6/2021 and readmitted on [DATE] with diagnoses including encephalopathy (any disorder or damage that affects the brain's structure or function which can be cause by a number of things, including injury, disease, drugs, or chemicals), schizophrenia (a mental illness that is characterized by disturbances in thought), and muscle weakness (general). Residents Affected - Few During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 required substantial assistance with lower body dressing and putting on and taking off footwear, required partial assistance with toileting, showering, and upper body dressing. During a review of Resident 2's COC, dated 11/17/2024 at 7 a.m., the COC indicated LVN 1 upon entering the room observed Resident 2, standing over Resident 1 who was lying on the floor, being verbally aggressive and attempting to strike Resident 1. The COC indicated Resident 2 continued to say profanities to Resident 1. During a review of Resident 2's Progress Notes, dated 11/17/2024 at 8:30 a.m., the Progress Notes indicated that on 11/17/2024 at 7:05 a.m. Resident 2 was asked and was not able to give a reason as to what provoked him (Resident 2) to strike and yell at Resident 1. The Progress Notes indicated Resident 2 admitted he was physically aggressive (using physical actions like hitting, kicking, pushing, or otherwise causing bodily harm to someone else) towards Resident 1. During a review of Resident 2's Physician Orders, dated 11/17/2024 at 1:02 p.m., the Physician Orders indicated Resident 2 may be transferred to the GACH 1 due to resident-to-resident altercation. During a review of Resident 2's Skilled Nursing Facility (SNF) to Hospital Transfer Form, dated 11/18/2024 at 9 a.m., the transfer form indicated the facility transferred Resident 2 to the GACH because of behavioral symptoms like agitation (a feeling of irritability, restlessness, or mental distress) and psychosis (a mental health condition that causes a person to lose touch with reality, making it difficult to tell what is real and what is not). The transfer form indicated Resident 2 was transferred to GACH for monitoring of behavioral change due to aggressive behavior with another resident (Resident 1). During an interview on 12/2/2024 at 10:16 a.m. Resident 1 stated he cannot recall the day of the incident but said it happened in the morning when his roommate (Resident 2) physically hit him (Resident 1) with his (Resident 2) fists like in a boxing manner. Resident 1 stated he dropped to the floor. Resident 1 stated he had bruises due to the hits Resident 2 gave him (Resident 1) in the arms and legs. Resident 1 stated Resident 2, who was crazy and was fuming (to be very angry), attacked him (Resident 1) in a mad state. During an interview on 12/2/2024 at 11:14 a.m., Resident 2 stated he had an argument with Resident 1 but cannot recall what it was all about. Resident 2 stated, I handled it and I took care of it. During an interview on 12/2/2024 at 1p.m., Restorative Nursing Assistant 1 (RNA 1) stated she cannot recall the exact date, was like about 2 weeks ago, around 7 a.m., when she overhead LVN 1 saying something happened in Resident 1 and Resident 2's room. RNA 1 stated when she walked into Resident 1's room she observed Resident 1 on the floor, with his hand on the siderail head facing the head of the bed and Resident 2 was sitting in his bed. RNA 1 stated LVN 1 had already separated Resident 1 and Resident 2 when RNA 1 entered the room. RNA 1 stated Resident 1 had a bump on his left leg, a 555011 Page 3 of 4 555011 12/02/2024 Vineland Post Acute 10830 Oxnard Street North Hollywood, CA 91606

F 0600 scratch on his back, and another scratch on his right arm. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/2/2024 at 1:43 p.m., LVN 1 stated the altercation between Resident 1 and Resident 2 occurred at 7 a.m. but cannot recall the exact date. LVN 1 stated she heard Resident 1 screaming for help, so she ran to Resident 1's room and observed Resident 1 lying on his right side and Resident 2 standing over Resident 1 with Resident 2 trying to strike at Resident 1. LVN 1 stated that after she separated the residents (Resident 1 and Resident 2), she assessed Resident 1 who had several lesions (an area of abnormal or damaged tissue caused by injury) on the leg (did not indicate which leg) that were bleeding, scratch on the arm, and scratch on the back was bleeding. LVN 1 stated Resident 1 said his back was hurting but said he was fine and refused pain medication. LVN 1 stated Resident 1 said he (Resident 1) was physically attacked by Resident 2. LVN 1 stated she asked Resident 2 what occurred, and Resident 2 said a lot of profanities and stated Resident 1 deserved it (the attack). LVN 1 stated Resident 2 confirmed he hit Resident 1 but did not specify. LVN 1 stated this would be considered a resident-to-resident abuse. Residents Affected - Few During an interview on 12/2/2024 at 2:30 p.m., the Director of Nursing (DON) stated LVN 1 notified her (DON) on 11/17/2024 at around 7:15 a.m. that there was an altercation between Resident 1 and Resident 2. The DON stated she interviewed Resident 1 who stated the incident occurred out of nowhere. The DON stated Resident 2 did not want to talk about it but said he (Resident 2) hit Resident 1 and got into a fight. The DON stated Resident 1 had injuries and abrasions on the arm and legs (did not give details). The DON stated that based on the facility's policy this incident was considered a resident-to-resident altercation between Resident 1 and Resident 2. The DON stated this is considered abuse. A review of the Facility's policy and procedure titled, Abuse, Neglect (failed to care for properly) and Exploitation (illegal or improper use of a person's resources), last reviewed on 4/17/2024 indicated it is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation (unauthorized, improper, or unlawful use) of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Willful means the individual must have acted deliberately, not that the individual must have intended 555011 Page 4 of 4