Health inspection·May 21, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their care plan for one of three sampled residents (Resident 1). This failure resulted in Resident 1 physically touching Resident 2 on the jaw with a closed fist. Findings: During a review of Resident 1's admission RECORD (AR), dated 5/6/25, the AR indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder (a mental health condition in which the person experiences hearing voices, hallucinations and/or false beliefs) bipolar (a mental health condition that causes extreme shifts in mood, energy, and activity levels) type, and adjustment disorder (an emotional or behavioral reaction to a stressful life event or change) with mixed anxiety (a feeling of worry, fear, or nervousness about something that's happening or might happen) and depressed mood (consistently feeling sad, empty, or hopeless, and losing interest in activities you once enjoyed). During a review of Resident 2's AR dated 1/24/25, the AR indicated, Resident 2 was admitted to the facility on [DATE] with a diagnosis of development disorder of scholastic skills (a person who has difficulty learning and using specific academic skills, like reading, writing, or math), anxiety disorder, panic (a sudden episode of intense fear or discomfort that can feel like a physical attack, even though there's no real danger) disorder, Bipolar disorder, and insomnia (a sleep disorder where you have trouble falling asleep, staying asleep, or both). During an interview on 5/21/25 at 11:58 a.m. with Administrator in training (AIT), AIT stated on 5/5/25 a family member (not specified who) reported seeing Resident 1 touched Resident 2's jaw with a closed fist in the dining area. AIT interviewed Resident 1 who stated he did not recall the incident. AIT interviewed Resident 2 who stated he was touched on his shoulder (not specific which) by Resident 1. AIT stated Resident 1 had a history of physical altercation with Resident 2 (no date given) and other residents. AIT stated due to Resident 1's multiple altercation with residents, there was a care plan in place that staff were to keep Resident 1 separated from other residents in the dining area. During a review of Resident 1's Care Plan Report (CP), dated 9/19/24, the CP indicated, Resident 1 was physically aggressive with another resident (not specified who) when he elbowed the other resident in the upper arm. An intervention listed on 9/19/24 was to monitor Resident 1's behavior and, If resident (Resident 1) is in the dining room Please (sic) make sure to keep him away from other residents due to behaviors. Page 1 of 2 555053 555053 05/21/2025 Valley View Care Center 729 Browning Road Delano, CA 93215

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 2's Interdisciplinary (ideas and methods from different fields or areas of study to solve problems or understand something better) Post Event Note (IPEN), dated 5/7/25, the IPEN indicated, on 5/5/25, Visitor (not identified) reports that she saw another resident (Resident 1) calling (Resident 2) names and rolling close to him and with a closed fist gently tap (Resident 2) in the jaw. Visitor (sic) got up and let a Certified Nursing Assistant (CNA) [not identified] know and they were immediately separated. No (sic) injuries noted. During an interview on 5/21/25 at 12:10 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 5/5/25 she was in the dining area during lunch assisting residents. CNA 1 stated a family member (not identified) approached her and reported Resident 1 had touched Resident 2 on the cheek (side not recalled) with a closed fist. CNA 1 stated the incident occurred in the dining area. CNA 1 stated there had been previous physical and verbal altercations with Resident 1 and Resident 2. CNA 1 stated she was aware there was a CP that Resident 1 was to be kept separated from other residents in the dining room due to behaviors. CNA 1 stated if Resident 1 was able to touch Resident 2 with a closed fist then he was not monitored and kept separated from other residents by staff as he should have been. During an interview on 5/21/25 at 12:18 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 1 had an altercations with other residents (not specific who) in the past. LVN 1 stated when in the dining area Resident 1 was to be monitored by staff to prevent altercations. LVN 1 stated when Resident 1 touched Resident 2's cheek with a closed fist he was not being monitored by staff as he should have been. During an interview on 5/21/25 at 12:53 p.m. with Director of Nursing (DON), DON stated Resident 1 was to be monitored and keep separated from other residents in the dining area due to behaviors. DON stated when Resident 1 touched Resident 2's cheek with a closed fist on 5/5/25, the staff had not followed the intervention to monitor and keep Resident 1 separated from other residents. During an interview on 5/21/25 at 12:55 p.m. with AIT, AIT stated the intervention to monitor and keep Resident 1 separated from other residents in the dining room was not implemented by staff when Resident 1 was able to touch Resident 2's cheek with a closed fist. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, dated 7/2021, the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 555053 Page 2 of 2