Health inspection·August 8, 2025

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 protect residents right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1), who was physically attacked by Resident 2, who had a known history of agitation and aggressive behaviors toward others. The facility failed to:1. Implement its policy and procedure (P&P) titled, Abuse, Neglect and Exploitation which indicated each resident had the right to be free from abuse and neglect.2. Implement its P&P titled Behavior Management Plan, which indicated, residents with behavioral concerns will have a behavioral management plan to ensure they received appropriate services and interventions to meet their needs. These deficient practices resulted in Resident 2 punching Resident 1 on the right side of the face causing Resident 1 to sustain a hematoma (broken blood vessels) on the head and left ear bleeding, that required hospitalization in a general acute care hospital (GACH), where he was diagnosed with a right frontal (to the front and adjacent to the forehead) scalp (the skin covering the head) hematoma. Resident 1 underwent a repair of a one-centimeter ([cm] - unit of measurement) laceration (skin cut) to the left ear that required sutures (a basic wound closure technique where individual stitches are placed and tied separately along the length of the wound). Resident 1 was still admitted to the GACH as of 8/20/2025.Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and major depressive disorder ([MDD] - a mood disorder that cause a persistent feeling of sadness and loss of interest). During a review of Resident 1's History and Physical (H&P), dated 4/22/2025, the H&P indicated, Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 6/26/2025, the MDS indicated, Resident 1's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 1 sometimes had the ability to make self-understood and understand others. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) from staff with activities of daily living (ADL's - routine tasks/activities) such as oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 1's Change in Condition Evaluation ([COC] - a communication tool used to communicate a resident's change of condition), dated 7/28/2025, the COC indicated Resident 1 was found on the floor with Resident 2 on top of him. The COC indicated Resident 1 stated Resident 2 hit him and pushed him to the floor. The COC indicated Resident 1 was bleeding from the left ear and had a hematoma on the right side of his face. The COC indicated Resident 1 was transferred to the GACH for evaluation and treatment. During a review of Page 1 of 4 555368 555368 08/08/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0600 Level of Harm - Actual harm Residents Affected - Few Resident 1's GACH Emergency Report (ER), dated 7/28/2025, the report indicated Resident 1 presented to the ER with injuries to his head, hand, neck, and a left ear laceration. The ER Report indicated Resident 1's Computed Tomography scan ([CT] process of taking pictures of body parts to diagnose and treat disease and injury) of the head indicated Resident 1 had a right frontal hematoma. The ER Report indicated Resident 1 had a 1-centimeter ([cm] - unit of measurement) laceration to his left ear that required sutures (a basic wound closure technique where individual stitches are placed and tied separately along the length of the wound). During a review of Resident 2's Face Sheet, the Face Sheet indicated, Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). During a review of Resident 2's H&P, dated 6/28/2025, the H&P indicated Resident 2 could make needs known but could not make medical decisions. During a review of Resident 2's MDS assessment, dated 7/10/2025, the MDS indicated Resident 2's cognitive skills for daily decision making were intact. The MDS indicated Resident 2 was independent (Resident completes the activity by themself with no assistance from a helper) on ADLs such as eating, toileting hygiene, and upper body dressing. During a review of Resident 2's GACH Psychiatric Evaluation Notes prior to admission to the facility, dated 6/14/2025, the notes indicated Resident 2 was admitted to the GACH on a 5150 (an involuntary 72-hour psychiatric hold, allowing law enforcement or designated mental health professionals to detain individuals who, due to a mental health disorder, are deemed a danger to themselves or others) for danger to others. The Psychiatric Evaluation Notes indicated, Resident 2 was involved in a physical altercation with another resident and had been increasingly agitated and aggressive toward others without any provocation (an action or statement that is intended to make someone angry). During a review of Resident 2's Initial Psychiatric Evaluation in the facility, dated 7/14/2025, The initial Psychiatric Evaluation indicated, Resident 2 was agitated, paranoid (unjustified suspicion and mistrust of other people or their actions) and anxious. The Initial Psychiatric Evaluation indicated a treatment plan to observe Resident 2 for deterioration in function, increase socialization to prevent isolation and compliance of medication. During a review of Resident 2's Progress Notes, dated 7/28/2025, the Progress Notes indicated Resident 2 had experienced an auditory hallucination (perceptions of sound when no actual sound is present) commanding him to fight. The progress Notes indicated Resident 2 went to Resident 1's room and physically attacked Resident 1 and put him on the floor. During a review of the facility's Five Day Follow Up Investigative Report, dated 8/1/2025, the report indicated on 7/28/2025 CNA 1 witnessed Resident 2 hitting Resident 1 across the face and both residents lost their balance and fell to the ground. The report indicated Residents 1 and 2 were separated immediately and assessed by staff. The report indicated Resident 1 was transferred to the GACH for further evaluation. During a telephone interview on 8/6/2025 at 12:19 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated on 7/28/2025 at approximately 5 a.m., she heard a staff calling for help from Resident 1's room, she ran to the resident room and observed Resident 2 coming out of Resident 1's room. LVN 1 stated she found Resident 1 lying on his back on the floor with a hematoma on the right side of his forehead. LVN 1 stated she observed a moderate amount of blood coming from Resident 1's left ear. During an interview on 8/6/2025 at 3:02 p.m., with CNA 1, CNA 1 stated on 7/28/2025 at around 5:00 a.m., she was assisting another resident and heard a loud noise coming from Resident 1's room. CNA 1 stated she ran to Resident 1's room, observed Resident 1 on the floor and Resident 2 on top of him. CNA 1 stated she observed Resident 555368 Page 2 of 4 555368 08/08/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0600 Level of Harm - Actual harm Residents Affected - Few 2 punching Resident 1's head and right side of the resident's face with both fists. CNA 1 stated she observed bruises on Resident 1's face and left ear was bleeding. CNA 1 stated she tried to stop Resident 2 from punching Resident 1 but Resident 2 tried to hit her (CNA 1). CNA 1 stated she left Resident 1 and Resident 2 in the room while Resident 2 continued hitting Resident 1, went outside and screamed for help. CNA 1 stated there was a lot of blood on the floor. During an interview on 8/6/2025 at 3:54 p.m., with the Minimum Data Set Nurse (MDSN), the MDSN stated Resident 2 had a history of aggressive behavior and physical altercation with another resident prior to admission to the facility. The MDSN stated there was no comprehensive care plan developed addressing Resident 2's potential to be physically aggressive to others because Resident 1's aggressive behavior was only a history. The MDSN stated he did not develop a care plan for Resident 2's history of physically aggressive behavior until Resident 2 displayed the actual behavior by attacking Resident 1 on 7/28/2025. During an interview on 8/6/2025 at 4:10 p.m., with the Director of Staff Development (DSD), the DSD stated residents with a history of physical aggressive behavior should have a comprehensive care plan so staff could identify any triggers and better manage the resident's behaviors, provide supervision, and implement other interventions to ensure the safety and well-being of the residents in the facility. The DSD stated she had no answer why the MDSN did not develop a care plan with measurable interventions related to Resident 2's history of physical altercation prior to admission to the facility. The DSD stated without a care planning there was a chance to escalate Resident 2's aggressive behavior. During an interview on 8/8/2025 at 2:26 p.m., with the Social Service Director (SSD), the SSD stated failure to develop a comprehensive care plan for a resident with a known history of physical aggression could lead to a resident-to-resident altercation and physical abuse. The SSD stated the physical abuse Resident 1 suffered from Resident 2 could have been prevented if the facility had provided close monitoring and supervision to Resident 2, given the resident's history of physical altercation with other residents prior to admission to the facility. During an interview on 8/8/2025 at 3:36 p.m., with the Administrator (ADM), the ADM stated all residents had the right to be free from any forms of abuse. The ADM stated Resident 2 should have been closely monitored given his history of agitation and aggressive behavior. The ADM stated that since Resident 1 sustained an injury, the facility did not prevent Resident 1 from physical abuse by Resident 2. During a review of the facility's undated P&P, titled Abuse, Neglect and Exploitation, the P&P indicated, Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The P&P indicated Physical abuse includes, but not limited to hitting, slapping, punching and kicking. The P&P indicated, Prevention of Abuse, Neglect, and Exploitation - the facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of resident: l. Assess, monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors. During a review of the facility's undated P&P, titled Behavior Management Plan, the P&P indicated, Residents who exhibit behavioral concerns may require a behavioral management plan to ensure they are receiving appropriate services and interventions to meet their needs. 555368 Page 3 of 4 555368 08/08/2025 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an accurate Minimum Data Set ([MDS] - a resident assessment tool) was completed accurately for one of three sampled residents (Resident 2) by failing to:1. Ensure Resident 2's Depakote (an anticonvulsant used to treat seizure disorder and other psychiatric conditions) medication was encoded as anticonvulsant and reflected in the MDS assessment under Section N (N0415 High-Risk Drug Classes) medication. This deficient practice resulted in incorrect data transmitted to Center for Medicare and Medicaid Services (CMS) related to inappropriate MDS care screening and assessment tool practices. Findings:During a review of Resident 2's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). During a review of Resident 2's History and Physical (H&P), dated 6/28/2025, the H&P indicated, Resident 2 could make needs known but cannot make medical decisions. During a review of Resident 2's MDS assessment, dated 7/10/2025, the MDS indicated, Resident 2 was independent (decisions consistent/reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 2 was independent (Resident completes the activity by themself with no assistance from a helper) with eating, toileting hygiene, and upper body dressing. During a review of Resident 2's Order Summary Report (a document containing active orders), dated 8/6/2026, the Order Summary Report indicated, the physician placed a telephone order on 6/27/2025 for Resident 2 to start on Depakote 500 milligrams ([mg] - metric unit of measurement, used for medication dosage/and or amount) by mouth to give 1 tablet by mouth every 12 hours (9 a.m. and 9 p.m.) for bipolar disorder manifested by fluctuation in mood as evidenced by sudden angry outburst due to responding to internal stimuli for no form of provocation. During a concurrent interview and record review on 8/6/2025 at 1:21 p.m., with the Minimum Data Set Nurse (MDSN), Resident 2's MDS assessment, dated 7/10/2025, was reviewed. The MDSN stated Resident 2 was taking Depakote which is considered as anti-convulsant medication. The MDSN stated there should a check marked on MDS Section N0415 under anticonvulsant medication. The MDSN stated the MDS assessment was completed inaccurately. The MDSN stated per Resident Assessment Instrument ([RAI] - a guide that helps nursing home staff use to assess residents and develop care plans) manual coding of medications should be based on the pharmacological (relating to the use of drugs to treat a condition) classification of the medication not based on the reason it was prescribed. The MDSN stated he had not been coding Depakote medication as anticonvulsant in the past and it was not a red flagged. The MDSN stated accuracy of assessment in the MDS was important because it entails the condition and needs of the resident and for continuity of care. During a review of the facility's undated policy and procedure (P&P), titled Conducting an Accurate Resident Assessment, the P&P indicated, The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Residents Affected - Few 555368 Page 4 of 4