Health inspection·October 2, 2024

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents involved in multiple altercations (physical fight) (Residents 1 and 2) were separated and distanced away from each other as indicated in the care plan. This failure resulted in Resident 1 being grabbed and pulled out from a chair which led to a closed clavicle fracture (broken collarbone). Findings: On October 2, 2024 at 8:30 a.m., an unannounced visit to the facility was conducted to investigate an allegation of physical abuse (the intentional use of physical force to cause injury or harm to another person). On October 2, 2024, Resident 2's admission record was reviewed. Resident 2 was admitted to facility on February 9, 2024, with diagnoses which included schizophrenia (a severe mental disorder affecting a person's emotions and perception of reality). A review of Resident 2's History and Physical, dated September 20, 2024, indicated Resident 2 does not have the capacity to understand and make decisions. A review of Resident 2's COC(Change of Condition)/Interact Assessment Form, indicated the following: - On September 13, 2024 at 6:34 p.m., indicated, .At 1834 (6:34 p.m.) outside .Staff heard a commotion between two residents .Resident (Resident 2) pushed another resident (Resident 1) on his right side of his head .; and - On September 14, 2024 at 2:00 p.m., indicated, .Resident on 1:1 (one on one) monitoring for aggressive behavior .Around 10:45 a.m .One resident (Resident 1) passed by his room and resident (Resident 2) suddenly attacked and hit the other resident (Resident 1) . A review of Resident 2's Care Plan, dated September 13-14, 2024, indicated .Focus: Resident to resident interaction on 9/13/2024 and 9/14/2024 .Resident is the aggressor .Interventions: Keep the 2 (two) involved residents apart from each other .Provide redirection when needed . A review of Resident 2's Progress Notes, dated September 30, 2024 at 11:01 a.m., indicated, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 555135 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Springs Care Center 1441 Michigan Avenue Beaumont, CA 92223 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)